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Complaint Investigation

Christian Care Nursing Center

November 21, 2025 · Muskegon, MI · 2053 South Sheridan Drive
Citations 4
CMS Rating 1/5
Beds 49
Provider ID 235656
Healthcare Facility
Christian Care Nursing Center
Muskegon, MI  ·  View full profile →
Inspection Summary

Christian Care Nursing Center in Muskegon, MI — inspection on November 21, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0604
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

Review of Nursing Home Guide: Restraints education provided to facility staff from 8/22/25 - 9/16/25 revealed the following is considered a physical restraint, Lap belts, bed rails, locked chairs, wrist/ankle ties.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Christian Care Nursing Center

2053 South Sheridan Drive Muskegon, MI 49442

SUMMARY STATEMENT OF DEFICIENCIES

made or suspicion is formed. d.

Any reasonable suspicion of a crime against a resident will also be reported to the local Law Enforcement Agency in addition to the State Agency.

Further review of the facility's Reporting of Incidents policy and procedure, revised 2/2024, reflected, 5.

The Administrator will complete the 24-hour report via the online reporting system established by [Name of State Survey Agency].

The following statement was reviewed on the bottom of the first page NOTE: WHEN IN DOUBT AS TO WHETHER THE INCIDENT/OCCURRENCE IS REPORTABLE TO THE STATE AGENCY/LAW ENFORCEMENT AGENCY THE FACILITY SHOULD REPORT THE EVENT.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Christian Care Nursing Center

2053 South Sheridan Drive Muskegon, MI 49442

SUMMARY STATEMENT OF DEFICIENCIES

better to help prevent a fall. RN D stated it wasn't even 10 minutes later when CNA E asked if I had saw the gait belt on R200. I thought she meant around his waist. I had not seen it around the wheelchair until she brought it to my attention.

The gait belt was around R200 and his wheelchair. I told the aides to take it off him immediately because it was being used as a restraint. R200 seemed fine, he was just at the table eating breakfast. I then called and left messages for the DON and the Unit Manager (UM) J and reported what happened. I talked to the Nursing Home Administrator (NHA). RN D stated a skin assessment was completed on R200 with no concerns.

She stated she had not talked to R200's family or physician about the incident. RN D clarified she had three aides in the dining room besides CNA E and none of them admitted to restraining R200 with a gait belt. RN D revealed she reported the incident because she considered it to be abuse.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Christian Care Nursing Center

2053 South Sheridan Drive Muskegon, MI 49442

SUMMARY STATEMENT OF DEFICIENCIES

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2628080Based on interview and record review, the facility failed to ensure the medical records for 1 of 3 residents (R200) was complete and accurate.Findings include:R200A review of R200's admission Record, dated 9/25/25, revealed R200 was an [AGE] year-old resident initially admitted to the facility on [DATE] with multiple diagnoses that included Alzheimer's Disease and Dementia.A review of R200's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/19/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 3 which revealed R200 was severely cognitively impaired.A review of the Facility Reported Incident (FRI) revealed the incident occurred on 8/10/25 at approximately 8:30 AM. [Name of R200] was observed in the dining room by staff with a gait belt around his waist and his wheelchair.A review of R200's Electronic Medical Record (EMR), dated 8/07/25 to 9/22/25, failed to reflect documentation (e.g., a progress note, a physician note, assessment) that indicated on 8/10/25 R200 was observed being restrained by a gait belt to his wheelchair while he was in the dining room eating breakfast.

During an interview on 9/26/25 at 3:23 PM, the NHA (Nursing Home Administrator) revealed he did not see any documentation in R200's EMR that he had been being restrained by a gait belt to his wheelchair while he was in the dining room eating breakfast on 8/10/25.

The NHA further revealed they had completed an incident report. A copy of the incident report was requested from the NHA.A review of R200's incident report, dated 8/10/25 at 9:39 AM, revealed, It was reported to me [Unit Manager (UM) J] via Phone by nurse [Name of RN D] that resident had been progressively combative over the weekend peaking on Sunday, hitting, kicking, walking in the hallways and urinating, staff assisted him to a wheelchair and he was attempting to get out of w/c and hit staff. He was assisted to the dining room to eat and that is when it was observed by [Name of CNA E] that there was a gait belt around the resident's chair. In addition, the following statement on bottom of page one of the incident report revealed, Privileged and Confidential - Not part of the Medical Record - Do not Copy.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Muskegon, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Christian Care Nursing Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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