Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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.
The facility did not employ a full-time certified dietary manager for its 58 residents, risking inadequate nutrition. Dietary Staff BB had only partially completed a dietary manager course due to staffing shortages, and the Registered Dietician visited monthly. Administrative Staff A was aware of the certification issue. The facility's policy required a qualified dietitian to oversee services, which was not met.
The facility's assessment failed to specify staffing levels needed for each unit, shift, and per census, affecting all 58 residents. The assessment lacked details on the number of RNs, LPNs/LVNs, CMAs, and CNAs required, including for evenings and weekends. This deficiency was noted during an inspection, despite the assessment being revised in June 2024.
The facility failed to use foot pedals during wheelchair transports for several residents, including those who were severely cognitively impaired, leading to their feet sliding on the floor. Staff interviews revealed that foot pedals were only applied if residents could not lift their legs, contrary to the facility's policy requiring the safe use of assistive devices. This placed residents at risk for preventable accidents and injuries.
The facility failed to ensure the Consulting Pharmacist identified and reported irregularities in the use of antipsychotic medications for several residents, including those with Alzheimer's and dementia. The pharmacist did not recognize or report issues related to medication indications, placing residents at risk for unnecessary psychotropic medications and related complications. The facility's policy required monthly reviews and reporting of irregularities, which were not adhered to.
The facility failed to ensure appropriate indications or documented physician rationale for antipsychotic medications for several residents, including those with dementia and other mental health conditions. Residents were administered medications like Seroquel and Risperidone without documented rationale or evidence of non-pharmacological interventions, placing them at risk for unnecessary psychotropic medications and related complications.
A resident's PHI was exposed when a medication cart was left unattended in the dining room with an open laptop displaying sensitive information. A nurse left the screen unlocked, compromising privacy. Staff acknowledged the need for securing PHI, as per facility policy.
The facility failed to update care plans for two residents, one with increased aggressive behaviors and another with specific sleeping preferences and behaviors. Despite staff awareness, these changes were not documented, risking impaired care due to uncommunicated needs.
A facility failed to ensure a resident with a pressure injury on her left heel had pressure-reducing heel protectors and boots in place as ordered. Despite physician orders and care plans, the resident was observed without these devices while sitting in a Broda chair and lying in bed. Staff interviews revealed a lack of adherence to the prescribed care plan, with CNAs typically responsible for applying the devices. This oversight placed the resident at risk for further skin breakdown.
A resident with severe cognitive impairment and a history of falls was not provided with a Dycem mat in his wheelchair as required by his care plan, despite being at risk for falls. Observations showed the mat was missing during multiple inspections, and staff interviews revealed uncertainty about its placement, leading to a failure in ensuring a safe care environment.
The facility failed to sanitize shared medical equipment, such as blood pressure cuffs and pulse monitors, after each resident's use, as observed on multiple occasions in the main dining room. Despite having sanitizer spray available and a policy requiring equipment sanitization according to CDC guidelines, staff did not consistently follow these practices, placing residents at risk for infectious diseases.
The facility failed to offer the PCV20 vaccine or obtain informed declinations for two residents, despite their records showing previous vaccinations with PCV13 and PSV23. The facility relied on the WEB IZ system for immunization prompts and did not have an immunization policy, leading to this deficiency.
A resident with a history of pain and weakness was injured during transport in a facility van when the driver failed to secure her with a seatbelt. The resident, who was in a wheelchair, slid onto the van floor after the driver braked suddenly, resulting in fractures to her left tibia and fibula. The driver admitted to not using a seatbelt due to the resident's size and the short trip distance, highlighting a lack of training and adherence to safety protocols.
Lack of Certified Dietary Manager Puts Residents at Nutritional Risk
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for its 58 residents, which placed them at risk for inadequate nutrition. During an initial tour of the kitchen, Dietary Staff BB revealed that she had started a certified dietary manager course three years ago but had only completed three months due to staffing shortages that required her to return to full-time dietary duties. The Registered Dietician visited the facility monthly, but this was not sufficient to meet the facility's needs. Administrative Staff A acknowledged awareness of Dietary Staff BB's lack of certification and indicated an intention to investigate further. The facility's policy, revised in November 2024, required a qualified, competent, and skilled dietitian to oversee food and nutrition services, which was not adhered to, leading to the deficiency.
Inadequate Facility-Wide Assessment for Staffing Needs
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, which was revised in June 2024, did not specify the staffing levels required for each unit, shift, and per census, including the number of RNs, LPNs/LVNs, CMAs, and CNAs needed. This lack of detailed staffing information affected all 58 residents residing in the facility. During an inspection on December 18, 2024, it was noted that the facility's assessment did not include staffing levels for each shift, including evenings and weekends. Administrative Staff A mentioned that the assessment was completed annually based on guidelines, considering the resident population, acuity, census, and needs. However, the assessment was found to be insufficient in determining the resources necessary for competent care, impacting all residents in the facility.
Failure to Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure the use of foot pedals during wheelchair transports for several residents, including those who were severely cognitively impaired. Observations revealed that residents were being pushed in wheelchairs without foot pedals, causing their feet to slide along the floor. This was noted for multiple residents, including one who was repeatedly asked to keep their feet up while being transported. Staff interviews indicated that foot pedals were only applied if residents could not lift their legs, despite the facility's policy requiring the safe use of assistive devices. The facility's policy on assistive devices, revised in January 2024, mandates the supervision and safe use of equipment such as foot pedals. However, staff members, including CNAs and LNs, were observed not adhering to this policy, as they allowed residents' feet to slide on the floor during transport. An administrative nurse confirmed that foot pedals should always be applied for high fall risk residents, especially when being pushed long distances. The failure to utilize foot pedals placed residents at risk for preventable accidents and injuries due to unmet care needs.
Failure to Identify and Report Medication Irregularities
Penalty
Summary
The facility failed to ensure that the Consulting Pharmacist (CP) identified and made recommendations regarding the inappropriate indications for antipsychotic medications for several residents. Specifically, the CP did not recognize or report issues related to the medication indications for Residents 55, 8, 52, and 32. This oversight placed these residents at risk for unnecessary psychotropic medications and related complications. The facility's Medication Regimen Reviews policy, last revised in May 2024, required the CP to review each resident's medication regimen at least monthly and report any irregularities found during the review. Resident 55's records showed a diagnosis of Alzheimer's disease and other conditions, with a documented use of Seroquel for behavioral disturbances and paranoia related to dementia. However, there was no documented rationale for the use of Seroquel, and the Monthly Medication Reviews from August to December 2024 did not note any inappropriate indication of use. Similarly, Resident 8's records indicated the use of Seroquel for major depressive disorder without documented non-pharmaceutical interventions or informed consent, and the CP failed to report this irregularity. Resident 52's records documented the use of quetiapine fumarate for behavioral disorders associated with dementia, but there was no physician-documented rationale for its continued use. The CP's Monthly Medication Reviews did not address this issue. Resident 32 was prescribed risperidone for delusions, yet the EMR lacked a physician-documented rationale for its use. Again, the CP did not identify or report this irregularity. These deficiencies highlight the facility's failure to adhere to its own policies and procedures regarding medication regimen reviews, placing residents at risk for unnecessary medication administration and potential adverse effects.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure appropriate indications or documented physician rationale for the use of antipsychotic medications for several residents, placing them at risk for unnecessary psychotropic medications and related complications. Resident 55, diagnosed with Alzheimer's disease, was administered Seroquel for behavioral disturbances and paranoia related to dementia without documented rationale or evidence of non-pharmacological interventions. The care plan lacked documentation of behaviors and non-pharmacological interventions, and a gradual dose reduction was not completed. Resident 8, with diagnoses including diabetes mellitus, depressive disorder, and anxiety, received Seroquel for major depressive disorder without documentation of non-pharmaceutical interventions tried and failed prior to administration. The care plan lacked documentation related to the antipsychotic medication, and there was no evidence of informed consent for its use. Similarly, Resident 32, diagnosed with conditions including dementia and bipolar disorder, was prescribed Risperidone for delusions without a documented physician rationale for its continued use. Resident 52, with diagnoses such as cerebral infarction and vascular dementia, was given Quetiapine for behavioral disorders associated with dementia without a documented rationale. The facility's policy required that residents not receive medications without clinical documentation to treat specific conditions, yet this was not adhered to. The facility's failure to ensure appropriate indications or documented physician rationale for these medications placed the residents at risk for unnecessary psychotropic medications and related complications.
Resident PHI Exposed on Unattended Medication Cart
Penalty
Summary
The facility failed to maintain the privacy of a resident's protected health information (PHI) when a medication cart was left unattended in the main dining room. On December 17, 2024, at 07:37 AM, a laptop on the medication cart displayed the PHI of a resident, including medications, date of birth, allergy information, and code status, which was visible to anyone passing by. Licensed Nurse G left the computer screen unlocked and open, thereby compromising the resident's privacy. On December 18, 2024, Licensed Nurse H acknowledged that the medication cart should be double locked, the computer screen closed, or the PHI hidden from view. Administrative Nurse D confirmed that nursing staff are expected to close the computer screen before leaving the medication cart unattended. The facility's policy on confidentiality and personal privacy, last reviewed in August 2024, mandates the protection and safeguarding of resident confidentiality and personal privacy. The failure to adhere to this policy resulted in a breach of the resident's privacy.
Failure to Update Care Plans for Behavioral and Preference Changes
Penalty
Summary
The facility failed to revise the care plan for Resident 33 to reflect his increased behavioral episodes. Resident 33, who has severe cognitive impairment and multiple medical conditions including epilepsy and major depressive disorder, exhibited aggressive behaviors during care and transfers. Despite documented incidents of physical aggression and resistance to care, the care plan did not include interventions or triggers related to these behaviors. Staff interviews confirmed that Resident 33 could become aggressive and that the care plan should have reflected these behavioral concerns. Additionally, the facility did not update Resident 32's care plan to include her sleeping preferences and behavior of yelling for help. Resident 32, who has severe cognitive impairment and multiple diagnoses including dementia and bipolar disorder, was observed sleeping on couches in common areas and calling out for help. Staff were aware of these preferences and behaviors, but they were not documented in the care plan. Interviews with staff revealed that while they knew of Resident 32's habits, these were not formally included in her care plan. The facility's failure to update the care plans for both residents placed them at risk for impaired care due to uncommunicated care needs. The facility's policy requires that care plans reflect current conditions and changes, but this was not adhered to in these cases. The lack of updated care plans meant that important information about the residents' needs and preferences was not formally communicated to all staff, potentially impacting the quality of care provided.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that pressure-reducing heel protectors and boots were in place for a resident with a pressure injury on her left heel. The resident, who had diagnoses including a pressure ulcer, dementia, major depressive disorder, and anxiety, was observed without the necessary protective devices on multiple occasions. Despite physician orders and care plans specifying the use of bilateral heel protectors during the day and Thera-boots at night, the resident was seen without these devices while sitting in a Broda chair and lying in bed. This oversight was noted during observations on two consecutive days, with the resident's heels directly on the bed and a pressure-reducing boot found on the floor of her closet. Interviews with facility staff revealed a lack of adherence to the prescribed care plan. A CNA indicated that the presence of heel protectors would be known through the Kardex, charge nurse information, and if the devices were in the room. A licensed nurse stated that the devices were listed on the Treatment Administration Record and should be signed off every shift, but acknowledged that CNAs were typically responsible for applying them. An administrative nurse expressed an expectation that the devices should have been in place as ordered. The facility's Support Surface Guidelines policy, revised in September 2024, was intended to guide the use of pressure-reducing devices, but the failure to implement these measures placed the resident at risk for further skin breakdown and worsening of pressure ulcers.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure a safe care environment for a resident, identified as R35, who was at risk for falls due to severe cognitive impairment and a history of repeated falls. R35's care plan required the use of a Dycem mat in his wheelchair to prevent slips and falls. However, observations revealed that while a Dycem mat was present in R35's recliner, it was consistently missing from his wheelchair during multiple inspections. This oversight occurred despite the care plan's clear instructions and the facility's policy to provide ongoing monitoring and assessment of individuals at risk for falls. Interviews with staff, including a CNA and an administrative nurse, highlighted a lack of clarity and consistency in ensuring the Dycem mat was in place for R35's wheelchair. The CNA acknowledged R35's impulsive behavior and fall risk but was uncertain about the presence of a Dycem mat in his wheelchair. Similarly, the administrative nurse was unsure if R35 had two Dycem mats or if staff were expected to move the mat between his recliner and wheelchair. This lack of adherence to the care plan and facility policy placed R35 at risk for preventable falls and injuries.
Failure to Sanitize Shared Medical Equipment
Penalty
Summary
The facility failed to ensure proper sanitization of shared medical equipment, specifically blood pressure cuffs, pulse monitors, and oxygen saturation equipment, after each resident's use. This deficiency was observed on multiple occasions in the main dining room, where licensed nurses did not sanitize the equipment before or after use on residents. On December 16, 2024, a licensed nurse did not sanitize the pulse monitor or blood pressure cuff before or after taking a resident's measurements. Similar observations were made on December 17 and 18, 2024, where another licensed nurse failed to sanitize the equipment before and after use. Interviews with staff revealed that there was an expectation for all nursing staff to sanitize shared equipment after each use, and sanitizer spray was available for this purpose. However, the practice was not consistently followed, as evidenced by the observations. The facility's policy, dated September 2024, outlined the requirement for cleaning and disinfecting resident-care equipment according to CDC guidelines, categorizing items based on their risk of infection. Despite these guidelines, the failure to sanitize equipment placed residents at risk for infectious diseases.
Failure to Offer PCV20 Vaccine
Penalty
Summary
The facility failed to offer and administer or obtain informed declinations for the Pneumococcal Conjugate Vaccine (PCV20) for two residents, identified as R32 and R53. R32's clinical record showed that the PCV13 was administered on 11/30/17, and the PSV23 was administered on 08/30/13, but lacked documentation that the PCV20 was offered or declined, or that there was a historical administration or a physician-documented contraindication. Similarly, R53's clinical record indicated that the PCV13 was administered on 09/27/18, and the PSV23 on 09/02/19, but also lacked documentation regarding the PCV20. Administrative Nurse D stated that the facility relied on the WEB IZ system to prompt when an immunization was needed and did not offer the PCV20 if a resident had received PCV13 and PCV23. The facility did not provide an immunization policy, leading to the deficiency of not offering the PCV20 or obtaining informed declinations for these residents.
Failure to Secure Resident in Transport Leads to Injury
Penalty
Summary
The facility failed to provide a safe environment, free from preventable accidents, for a resident who was involved in an accident while being transported in the facility's van. The resident, who had a history of pain, fibromyalgia, and weakness, was using a wheelchair and required assistance with most activities of daily living. On the day of the incident, the resident was strapped into the van with the wheelchair secured, but a seatbelt was not placed around her. As a result, when the driver braked suddenly, the resident slid out of the wheelchair onto the van floor, sustaining fractures to her left tibia and fibula. The incident occurred when the transportation staff member, responsible for driving the van, did not secure the resident with a seatbelt, citing the resident's size and the short distance of the trip as reasons for the oversight. The driver admitted to not using a seatbelt because he was unsure if it could fit around the resident and did not consider it necessary for the short journey. This lack of proper restraint led to the resident sliding out of the wheelchair when the van braked suddenly, resulting in significant injuries. Interviews with staff revealed that there was a lack of training and awareness regarding the necessity of using seatbelts for residents in wheelchairs during transport. The facility's policy required that all residents be properly secured with seatbelts, but this was not adhered to in this case. The failure to follow established safety protocols and ensure the resident was adequately secured in the van directly contributed to the accident and the resident's subsequent injuries.
Removal Plan
- An OT evaluation for R1 was ordered.
- All facility transportation was suspended until training and competencies were completed by transportation staff.
- R1's Care Plan was updated.
- Transportation EE and Transportation FF completed transportation competencies.
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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 Sabetha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sabetha Manor | 0.5 mi | ★★★★★ | 7 | 0 |
| Crestview Nursing & Residential Living | 14.3 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Seneca | 15.1 mi | ★★★★★ | 0 | 0 |
| Falls City Care Center | 15.7 mi | ★★★★★ | 0 | 0 |
| Maple Heights Nursing & Rehabilitative Center | 15.8 mi | ★★★★★ | 1 | 0 |
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