Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Apostolic Christian Home during CMS and state inspections, most recent first.
Dignity During Meal Service: The Dietary Manager referred to residents needing feeding assistance as "all the feeders" in a loud voice facing the dining room, and the comment was heard by residents eating lunch. The staff member confirmed the remark was about residents on pureed and mechanical soft diets, while most residents were present in the dining room.
Food items were found without expiration or delivery dates, sanitizer test strips were expired, and dishwasher temperature test strips were unavailable during a dietary tour. During lunch service, a staff member repeatedly touched her clothing with gloved hands, handled food and equipment without changing gloves or performing hand hygiene, and plated meals in an unsanitary manner while the DM observed.
Controlled substance administration records were not updated when medications were given. An LPN administered a resident’s Lyrica without signing it out on the controlled substance record, and reconciliation later found multiple count discrepancies for several residents’ Pregabalin, Hydrocodone-Acetaminophen, and Lorazepam medication cards versus the documented counts. The LPN confirmed the counts and records were only updated at the end of the shift.
Incomplete Dialysis Care Plan and Unremoved Diuretic Information: A resident who was cognitively intact and dependent on renal dialysis had a care plan that lacked required dialysis details, including monitoring, access site care, emergency contacts, ESA monitoring, BP arm guidance, and medication timing around dialysis. The care plan also still referenced a diuretic that had already been discontinued and should have been removed.
Hand hygiene was not performed between glove changes during suprapubic catheter care for a resident with urinary retention, suprapubic catheter status, prior prostate cancer, and a history of ischemic stroke. An RN removed gloves and put on new gloves without hand hygiene while cleansing the suprapubic site and again before applying skin barrier and a dressing; the RN and DON both acknowledged hand hygiene should have been performed between glove changes.
Failure to address weight loss for a resident on a regular diet and liquids. The resident had a high nutritional risk score and lost 10.66% of body weight, dropping from 137 pounds to 122.4 pounds. Snacks were offered but the resident was often unavailable, no nutritional supplements had been tried, and an invalid RD note documented recommendations for weekly weights, an appetite stimulant, and meal alternatives when intake was low.
Oxygen Cannula Storage and Liter-Flow Order Deficiency: A resident with COPD, CHF, and SOB had an oxygen order to titrate for pulse ox >89% per NC, but the chart did not include a specific liter-flow order. Staff stated the resident used O2 at night on 2 L, while the RN and DON confirmed the cannula should be stored in a cloth bag when not in use; however, it was observed draped over the concentrator instead.
An LPN failed to perform hand hygiene, use gloves, and clean/disinfect a shared blood glucose monitor while checking blood sugar and giving insulin to a resident, then handled clean and soiled items with contaminated hands. CNAs also failed to change gloves or perform hand hygiene during incontinence care for the same resident, placed soiled items on the bed, and handled a trash bag with bare hands after care.
The facility failed to use McGeers Criteria for determining infections, affecting all 48 residents. The DON and IP were responsible for reviewing antibiotics, but some orders were made without meeting infection criteria. The DON confirmed no documentation of McGeers Criteria was followed, and nurses needed education on its use.
A resident's skin issue was not properly documented or monitored according to facility policy. An LPN discovered a dark brown area on the resident's heel but failed to document it or notify the responsible parties. The Wound Nurse classified it as a callous and did not perform weekly measurements, as the facility only tracks pressure ulcers. The DON confirmed the lack of documentation and reliance on visual assessments for non-pressure ulcer skin issues.
A facility failed to ensure proper hand hygiene during glove changes while performing wound care for a resident with multiple ulcers. The LPN did not perform hand hygiene between glove changes, contrary to the facility's Standard Precautions Policy. The resident had a history of metabolic encephalopathy, chronic ulcers, diabetes, and chronic kidney disease. The LPN admitted confusion about hand hygiene requirements, and the DON confirmed the policy mandates hand hygiene with every glove change.
Dignity During Meal Service
Penalty
Summary
The facility failed to refer to residents who needed assistance with feeding in a dignified manner during the lunch meal service. During the lunch meal pass at the steam table in the kitchen, directly across from the serving window to the dining room, the Dietary Manager told another staff member in a loud voice, facing the dining room residents, "All the feeders are ready!" when referring to the residents who needed help with their meals. The statement was heard by residents in the dining room, which was full of residents eating lunch at the time. The staff member verified that the Dietary Manager was referring to the residents who needed feeding assistance, including two residents on pureed diets and 10 residents on mechanical soft diets. Facility records showed there were 47 residents in the facility, with five receiving room trays and one out for dialysis at the time, leaving 41 residents in the dining room.
Food Storage, Sanitizer Testing, and Meal Service Not Maintained Sanitarily
Penalty
Summary
Food items were stored without required dating, as six packages of 12-count hamburger buns and 16 loaves of white bread did not have an expiration or delivery date marked on them during the dietary tour. The Dietary Manager stated she did not know the items lacked dates and acknowledged they should have an expiration or delivery date. The report also noted that the facility's sanitizer test strips had expired in June 2025, and staff were unsure how to use them when the sanitizer bucket was checked at the three-compartment sink. During the same tour, the Dietary Manager and dietary staff were unable to locate dishwasher temperature test strips and stated they had never used them before. They were unable to verify the dishwasher temperature for sanitizing dishes and the Dietary Manager stated new sanitizer and dishwasher test strips needed to be ordered. During lunch meal service, kitchen staff were observed plating food in an unsanitary manner when a staff member repeatedly touched her clothing with gloved hands, did not change gloves or perform hand hygiene, and used the same gloves while handling bread, plated meals, and opening the warmer oven for pureed/soft foods and alternative meals. The Dietary Manager observed the meal pass and reminded the staff member not to touch her clothing and to change gloves and perform hand hygiene if she did.
Controlled substance administration records were not updated at the time medications were given
Penalty
Summary
The facility failed to document administration of controlled medications on the Controlled Drug Receipt/Record Disposition forms for five residents reviewed for controlled substance medication administration documentation. During observation on 4/7/26, an LPN removed R4’s Lyrica 25 mg from the locked narcotic drawer and administered it without signing it out on the controlled substance record. The LPN confirmed that Lyrica is a controlled substance, that the narcotic count was not updated, and that there were no controlled substance records on or in the medication cart at the time of administration. Record review and controlled substance reconciliation on 4/7/26 and 4/8/26 showed discrepancies between the amounts documented on the Controlled Drug Receipt/Record Disposition forms and the actual amounts in the medication cards for R4, R20, R23, R40, and R45. The LPN confirmed that controlled substance counts were not updated and medications were not signed out at the time they were administered during the shift, stating the counts and records were updated at the end of the shift before reconciliation with the oncoming nurse. The reconciliation identified differences for Pregabalin, Hydrocodone-Acetaminophen, and Lorazepam medication cards compared with the documented counts.
Incomplete Dialysis Care Plan and Unremoved Diuretic Information
Penalty
Summary
The facility failed to revise R7’s care plan to include required dialysis-related information and failed to remove a discontinued diuretic from the care plan. R7 was observed alert and oriented, stated she receives hemodialysis three days a week on Monday, Wednesday, and Friday, and showed her right upper arm fistula for dialysis. Her MDS documented that she was cognitively intact and dependent on renal dialysis, and current physician orders documented dialysis on Monday, Wednesday, and Friday. Her diagnoses included End Stage Renal Disease and Dependence on Renal Dialysis. R7’s dialysis care plan did not include documentation for monitoring vital signs, weights, nutrition, or who to notify with concerns; the specific type and location of dialysis services; interventions and goals based on the type of dialysis; ESA therapy monitoring requirements; which arm to use for BP monitoring; who to contact for dialysis-related emergencies, concerns, or complications; monitoring and reporting for hemorrhage, access site infection, and hypotension; access site assessment and care, including PPE and infection control measures; or the approach to administering medications before, during, or after dialysis according to practitioner orders. In addition, the care plan still included a history of weight loss due to a daily diuretic even though the diuretic furosemide had been discontinued and the resident was no longer taking it.
Hand Hygiene Not Performed Between Glove Changes During Suprapubic Catheter Care
Penalty
Summary
The facility failed to perform hand hygiene with glove changes during suprapubic catheter care for one resident reviewed for catheter care. The resident’s record showed a history of urinary retention, a suprapubic catheter status, a past prostate cancer history, and a prior ischemic stroke. Physician orders directed monthly suprapubic catheter changes with an 18 French catheter and daily stoma care with wound cleanser, collagen sheet application, and a border dressing. During observation of catheter care, the RN performed hand hygiene, donned gown and gloves, and prepared supplies on a clean surface. While caring for the resident’s suprapubic site, the RN removed gloves and put on a new pair without performing hand hygiene, then cleansed around the insertion site and washed the catheter from the insertion site away from the body. The RN again removed gloves and applied new gloves without hand hygiene before placing skin barrier and a clean dressing. The RN later stated she should have performed hand hygiene between glove changes, and the DON verified that hand hygiene should be performed between glove changes.
Failure to Address Resident Weight Loss
Penalty
Summary
The facility failed to implement interventions to prevent weight loss for one resident reviewed for weight loss. The resident was on a regular diet and liquids, had a nutritional risk indicator score documented as high, and had a care plan entry to follow the ordered diet and encourage good food and fluid intake with meals. The resident’s record showed a weight of 137 pounds on 11/05/2025 and 122.4 pounds on 04/08/2026, a 10.66% weight loss, with a BMI of 21.01. The resident’s record also showed snacks were offered during March 2026, but the resident was unavailable most of the time and did not reject any snack offered from the snack cart when available. A dietitian note dated 4/2/26 was marked invalid and documented that the resident remained on a regular/general diet, had a BMI of 21.3, and recommended weekly weights for four weeks, offering an appetite stimulant, and offering alternatives if the resident ate less than 50% at meals. On 4/09/2026, an LPN stated the resident had not been tried on nutritional supplements, received chocolate milk with meals, had lost three pounds in the past month, went to the dining room for meals, and slept more. The DON stated the dietitian note was grayed out because it was not finished and that the resident had weight loss and the family had been contacted.
Oxygen Cannula Storage and Liter-Flow Order Deficiency
Penalty
Summary
The facility failed to appropriately store an oxygen nasal cannula when it was not in use and failed to ensure the physician order included a specific liter flow for oxygen for one resident, R43. The facility policy on oxygen administration states that when a resident is not using the O2 cannula, it should be stored in cloth bags provided and that staff should check the physician order for liter flow. R43’s record showed diagnoses including COPD, chronic diastolic CHF, and shortness of breath, and the physician order dated 1/21/25 directed staff to titrate oxygen for pulse ox greater than 89% consistently per nasal cannula every shift, but no order in the medical record specified the oxygen liter flow. During observation on 4/07/2026 and 4/08/2026, R43’s oxygen nasal cannula was seen draped over the oxygen concentrator in the room rather than stored in a bag. On 4/07/2026, R43 was reclining in a recliner and in no distress and stated he wore oxygen at night but was unsure of the liter flow. On 4/08/2026, the RN stated R43 wore oxygen at night on 2 liters and confirmed there was no specific liter-flow order, stating she would start at 2 liters but would need to check the policy for the set starting flow. The DON also stated that if the order only reads to titrate, it would be standard of care to administer at 2 liters, and confirmed the cannula should be kept in the bag on the concentrator when not in use, although R43 was known to take it out sometimes.
Infection Control Failures During Blood Glucose Monitoring, Insulin Administration, and Incontinence Care
Penalty
Summary
The facility failed to ensure staff performed hand hygiene, used appropriate PPE, and properly cleaned and disinfected resident medical equipment during blood glucose monitoring and insulin administration for two residents. One resident had diagnoses including congestive heart failure and a sacral pressure ulcer and was frequently incontinent of bowel and bladder. During blood glucose monitoring, an LPN obtained a fingerstick blood sample without performing hand hygiene or donning gloves, placed a blood-soiled test strip, alcohol pad, and blood glucose monitor into the monitor case used for multiple residents, did not perform hand hygiene after the blood glucose check, touched the resident’s clean spoon with soiled hands, and then administered insulin without performing hand hygiene or donning clean gloves. The LPN also did not perform hand hygiene after the insulin was given and placed the case containing used supplies and the soiled monitor on top of the medication cart. The facility also failed to ensure appropriate infection prevention practices during incontinence care for the same resident. Two CNAs provided incontinence care without hand hygiene or glove changes after removing the soiled brief, after cleaning the peri area and anal area, and before drying the resident and applying a clean brief. Soiled briefs and washcloths were placed on the resident’s bed, and a positioning wedge was handled with the same gloves used during care. After care, one CNA removed gloves and performed hand hygiene, then handled the trash bag containing soiled items and the brief with bare hands, tied the bag shut without gloves, held it against his chest, and left the room. The DON verified that hand hygiene and glove changes are to be done after incontinence care and before clean procedures are started, and that soiled briefs should not be placed on the resident’s bed.
Failure to Utilize Infection Criteria for Antibiotic Use
Penalty
Summary
The facility failed to utilize a set standard to determine infections, which has the potential to affect all 48 residents currently residing in the facility. The facility's Antibiotic Stewardship policy outlines commitments and activities to optimize infection treatment and reduce adverse events associated with antibiotic use. However, the facility's Infection Control monitoring logs for the year 2024 did not include documentation of McGeers Data for determining infections. The Director of Nursing (DON) and the Infection Preventionist (IP) were responsible for reviewing antibiotics, but it was found that some antibiotic orders were obtained for residents who did not meet the criteria for an infection. The DON confirmed that there was no documentation of McGeers Criteria being followed for any of the facility's infections. The Infection Preventionist stated that nurses were supposed to use McGeers Criteria when communicating with doctors about infections, but some infections did not meet the criteria to be considered infections. The DON acknowledged the need to educate floor nurses on McGeers Criteria, as antibiotics were often started before the review process by the DON and IP. This lack of adherence to established criteria and documentation led to the deficiency identified in the report.
Failure to Document and Monitor Skin Issue
Penalty
Summary
The facility failed to adhere to its policy for documenting and monitoring a skin issue for a resident, identified as R7, who was reviewed for skin issues. The facility's policy requires skin assessments to be conducted on admission, weekly, and daily by CNAs, with any changes reported to the nurse on duty. Additionally, all treatments should be monitored daily and documented in the Electronic Treatment Record (ETAR). However, the facility did not document R7's right foot measurements or wound description in the Wound Summary Report, Progress Notes, or Treatment Record from December 10, 2024, through January 21, 2025. A Skin Incident Report dated December 22, 2024, noted a right heel skin incident but failed to document that R7's physician or family were notified. On December 22, 2024, an LPN discovered a dark brown area on R7's right heel but did not document the finding or notify the responsible parties. The LPN applied a barrier ointment and provided pressure ulcer boots but did not complete the required documentation or follow-up. The Wound Nurse later classified the area as a callous and did not perform weekly measurements, as the facility only tracks pressure ulcers. The Director of Nursing confirmed the lack of documentation and stated that the facility does not track measurements for non-pressure ulcer skin issues, relying on visual assessments instead.
Failure to Perform Hand Hygiene During Glove Changes
Penalty
Summary
The facility failed to ensure proper hand sanitation during glove changes while performing pressure ulcer dressing changes for a resident. The facility's policy on Standard Precautions, revised on 11/3/2025, mandates hand hygiene each time gloves are removed. However, during an observation on 1/22/25, a Licensed Practical Nurse (LPN) did not perform hand hygiene between glove changes while providing wound care to a resident with multiple ulcers and skin conditions. The resident, admitted on 8/7/23, had a history of metabolic encephalopathy, non-pressure chronic ulcer, Type 2 diabetes mellitus with a foot ulcer, a stage three pressure ulcer, and chronic kidney disease. During the dressing change, the LPN was observed not performing hand hygiene between glove changes while treating different body sites, including the suprapubic catheter site, bilateral buttocks, and right heel. The LPN admitted to being confused about when hand hygiene should be performed and acknowledged that gloves should be changed between treatments to different body sites to prevent cross-contamination. The Director of Nursing (DON) confirmed that the facility's Standard Precautions Policy requires hand hygiene with every glove change, highlighting a discrepancy between practice and policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Roanoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loft Rehabilitation & Nursing | 5.6 mi | ★★★★★ | 2 | 1 |
| Snyder Village | 7.3 mi | ★★★★★ | 0 | 0 |
| Apostolic Christian Home Of Eureka | 7.7 mi | ★★★★★ | 0 | 0 |
| Arc At El Paso | 11.4 mi | ★★★★★ | 5 | 0 |
| El Paso Rehabilitation And Health Care Center | 11.4 mi | — | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.