Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Christian Care Retirement Community during CMS and state inspections, most recent first.
Improper Food Labeling and Kitchen Sanitation: Surveyors found multiple open food items in dry storage, the freezer, and the refrigerator that were undated and lacked open or expiration dates, including salad dressing, bread, fish, and other items. The DM stated some items were not routinely labeled and could not tell when they had been opened. Surveyors also observed the ice machine flap with black dots and pink lines and heavy buildup and debris behind and beside the stove and ovens; the DM said the area had not been cleaned for months and there was no current cleaning schedule for that area.
Protected health information was left unsecured for 15 residents when a wooden wall unit in the hallway was observed open with papers visible on a shelf. The papers included resident names, treatment orders, shower schedules, and CNA care instructions. CNA 2 and the DON both identified the information as PHI and stated the unit should be closed when not in use. Facility policies stated health records should not be left unattended or unsecured.
Opened medications in two med carts were found without open dates during observation with the DON. Missing labels were noted on inhalers, laxatives, a chewable antacid, and levetiracetam solution for multiple residents with active orders, and the DON stated that all opened medications need to be labeled with an open date.
The facility failed to document physician orders for the DNR status of two residents, despite having signed declarations. Interviews with staff confirmed the requirement for such documentation, which was not met according to the facility's policy.
A resident with dementia and a history of exit-seeking behavior eloped from the facility's courtyard after being left unattended by an Activity Aide. The resident exited through an unlocked gate and was later found at another entrance. The facility's policy on preventing elopement was not effectively implemented, as the gate lacked a code alert alarm and the staff was unaware of the resident's need for supervision.
Improper Food Labeling and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in the kitchen and stock areas. During observation, surveyors found multiple open and undated items in dry storage, including individual pouches of salad dressing, cherry gelatin, cream soup base, and graham cracker crumbs. In the freezer and refrigerator areas, open boxes of parmesan crusted salmon and chicken breast filets, a loaf of bread, and a bag of fish pieces were also found without open dates or expiration dates. During interview, the Dietary Manager stated the facility typically labels and dates food when opened, but said the salad dressing and bread were not usually labeled, and she could not tell when those items had been opened when they were not marked. The facility policy stated food items should be labeled and dated, and items without expiration dates should be dated when opened. The facility also failed to maintain sanitation in the kitchen. During observation, the ice machine had black dots and pink lines on the plastic flap, which were removed when the Dietary Manager wiped it with a cleaning rag. The floor on the sides and behind the stove and stacked ovens had brown buildup, pasta, and other unidentifiable debris. The Dietary Manager stated the floor behind and between the stove and oven had last been cleaned about 2 to 3 months earlier, and later stated there was no current cleaning schedule for that area. The Dietary Manager and Administrator in Training stated cleaning schedules were typically done once a month, the ice machine was cleaned monthly, and staff cleaned it between monthly cleanings, but the Dietary Manager overlooked the cleaning and it was not cleaned. The Administrator in Training stated 58 of 58 residents ate from the kitchen and 22 of 58 residents received ice from the ice machine.
Protected Health Information Left Visible at CNA Station
Penalty
Summary
The facility failed to ensure protected health information was kept secured for 15 of 58 residents residing in the facility. During an observation on 08/19/2025 at 10:00 AM, a wooden wall unit was open with a shelf protruding about 12 inches into the hallway. The shelf held papers listing 16 resident names and information including treatment orders, shower schedules, and instructions for CNA care. One resident was hospitalized, leaving 15 residents on the hall. During an interview at 10:03 AM, CNA 2 stated the papers included shower schedules, linen changes, and shift report information used by CNAs to communicate resident care needs, and she identified the information as protected health information that should not be visible to individuals not providing care to the resident. During an interview at 1:44 PM, the DON stated the drop-down shelf served as an informational CNA station and contained CNA assignment sheets, shower schedules, and special instructions for resident care. She stated the information inside was protected health information and the unit should be closed when not in use. A policy titled Information Security Policy Overview, dated 10/23, stated health records should not be left on desks or unattended. A policy titled Policy and Procedure on Physical Security, undated, stated health records should not be left on desks or cabinets unattended and that records pulled from cabinets for future treatment should be left in secured areas until needed by staff members.
Opened Medications Found Without Open Dates in Medication Carts
Penalty
Summary
The facility failed to ensure that opened medications were labeled with open dates in 2 of 2 medication carts reviewed. During an observation of the 221-233 medication cart with the DON, opened medications for Resident 45, Resident 60, Resident 44, Resident 52, and Resident 45 again were found without open dates, including Airsupra 90-80 mcg inhaler, Wixela 250-50 inhaler, milk of magnesia suspension, polyethylene glycol 3350 powder, and Cal-Gest 200 (500) mg chewable tablets. During a separate observation of the 201-212 medication cart with the DON, opened medications for Resident 10 and Resident 29 were also found without open dates, including levetiracetam 100 mg/ml solution and polyethylene glycol 3350 powder. Record review confirmed the residents had active physician orders for the medications found in the carts. Resident 45 had diagnoses including cerebral infarction and orders for Airsupra inhaler and Cal-Gest chewable tablets; Resident 60 had hemiplegia and hemiparesis following cerebral infarction and an order for Wixela inhaler; Resident 44 had a diagnosis of presence of left artificial hip joint and an order for milk of magnesia; Resident 52 had COPD and an order for polyethylene glycol 3350; Resident 10 had nontraumatic intracerebral hemorrhage and an order for levetiracetam solution; and Resident 29 had dementia in other diseases classified elsewhere and an order for polyethylene glycol 3350. The DON stated that all opened medications need to be labeled with an open date.
Failure to Document DNR Orders for Residents
Penalty
Summary
The facility failed to ensure that physician orders were in place for the code status of two residents, leading to a deficiency. Resident 62, diagnosed with encephalopathy and generalized anxiety, did not have a physician order for their Do Not Resuscitate (DNR) status, despite having a signed out-of-hospital DNR declaration and order by a physician. Similarly, Resident 166, who had chronic obstructive pulmonary disease, lacked a physician order for their DNR status, even though their advance directives indicated a wish for no resuscitation, signed on a prior date. Interviews with Registered Nurse 5 and the Director of Nursing (DON) confirmed that code status should be documented on the face sheet, physician orders, and resident room doors, and that there should have been a physician order for the DNR code status. The facility's Medical Treatment Declaration Policy, provided by the DON, outlines the need for guidelines to ensure residents are given the necessary information to make informed medical treatment choices.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement interventions to prevent the elopement of a resident, identified as Resident B, who was one of four residents reviewed. On the date of the incident, Resident B was in the courtyard with an Activity Aide who left her unattended to use the restroom. During this time, Resident B exited the courtyard through an unlocked gate, walked around the building, and rang the doorbell at another entrance. The staff let Resident B back inside, and her nurse was notified. The gate from which Resident B exited did not have a code alert alarm, although Resident B had a wanderguard/code alert on her walker due to her history of exit-seeking behavior. Interviews and record reviews revealed that the Activity Aide was unaware that Resident B should not be left unattended outside, despite the facility's standard practice of not leaving certain residents alone. Resident B was noted to be normally confused, with diagnoses including dementia and anxiety disorder. The facility's policy on elopement, revised in March 2022, defined elopement as an unplanned exit of a resident and emphasized the need to educate staff about residents at risk and the interventions to prevent such incidents. However, this policy was not effectively implemented in the case of Resident B.
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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 Bluffton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Terrace Health Care Center | 2.6 mi | ★★★★★ | 30 | 0 |
| Ossian Health Care And Rehabilitation Center | 9.1 mi | ★★★★★ | 3 | 0 |
| Markle Health & Rehabilitation | 10.3 mi | ★★★★★ | 1 | 0 |
| Swiss Village | 11.9 mi | ★★★★★ | 8 | 0 |
| Envive Of Berne | 12.4 mi | ★★★★★ | 15 | 0 |
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