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 Christian Park Health Care Center during CMS and state inspections, most recent first.
Failure to report resident-to-resident altercation to SA: A CNA witnessed one resident enter another resident’s room during personal care and open the privacy curtain, exposing the resident. The affected resident later described being naked in bed, feeling embarrassed and afraid, and identified the other resident involved. The DON and NHA were unaware of the incident, and the event was not reported to the SA as required by facility policy.
A cognitively intact resident with chronic hypoxic respiratory failure and morbid obesity was transferred to a hospital with unclear and poorly documented reasons in the EMR, which only noted constipation and an O2 saturation in the low 80s. The ADON acknowledged that the discharge was not properly documented and that the reason for sending the resident out was unclear. After the resident became medically stable in an out-of-state hospital, the resident, hospital CM, and Ombudsman reported that the resident wished to return and had been educated on the risks of using BiPAP instead of AVAP, but the NHA repeatedly delayed or refused readmission, citing an inability to manage AVAP and daily ABGs despite a sister facility’s experience with AVAP. A hospital-arranged transport returned the resident to the facility after a long trip, but staff, reportedly under the NHA’s direction, did not open the door or accept the resident, forcing a return trip to the hospital. These actions conflicted with the facility’s own transfer/discharge policy requiring clear physician documentation, appropriate criteria for transfer, and proper notice and process.
A resident with chronic respiratory failure and intact cognition was transferred twice to hospitals, including an out-of-state facility for acute on chronic hypoxic respiratory failure, acute hypercapnic respiratory failure, and sepsis. Review of the EMR and interviews with the ADON showed there was no written transfer notice, no documentation that bed-hold and readmission policies were provided, and no required hospital transfer paperwork, despite facility policy requiring these actions for emergency transfers. This lack of required documentation and notification caused the resident worry, fear, and frustration and contributed to a delay in readmission after a prolonged hospitalization.
A resident with dementia and a history of constipation experienced prolonged periods without bowel movements, despite having scheduled and PRN medications available. Staff failed to administer PRN interventions or document timely assessments, leading to worsening abdominal pain, vomiting, and eventual hospitalization for small bowel obstruction, acute kidney injury, and sepsis. Facility staff later acknowledged documentation and communication failures regarding bowel management.
A resident with dementia and cognitive impairment, identified as being at risk for constipation, experienced prolonged periods without bowel movements despite having PRN medications available. The care plan was not updated or followed, and interventions were not implemented, resulting in the resident developing a small bowel obstruction, acute kidney injury, and sepsis, requiring hospitalization.
A resident with paraplegia and a history of depression was restricted from using his electric wheelchair inside the facility after a single incident, while other residents were not similarly restricted. The resident's requests, such as excluding the DON from his care conference, were disregarded by management, leading to increased anxiety and feelings of being targeted. Staff and the ombudsman confirmed the resident felt disrespected and that his rights to dignity and self-determination were not honored.
The facility failed to provide prescribed therapeutic diets to three residents, leading to potential health risks. One resident received a dinner roll against dietary instructions, another was served non-ground turkey despite needing ground meats, and a third received a salt packet despite a no-added-salt diet due to hypertension. Staff acknowledged these errors during observations.
Failure to Report Resident-to-Resident Altercation to State Agency
Penalty
Summary
The facility failed to notify the State Agency of a resident-to-resident altercation involving two residents who were both cognitively intact, with each scoring 15/15 on the BIMS. One resident entered the other resident’s room while personal care was being provided, opened the privacy curtain, and exposed the resident. The other resident later reported that a man burst into her room while she was being changed, pulled the privacy curtain open about 2 feet, and saw her naked while she was lying in bed. She stated she felt embarrassed, exposed, and afraid, and identified the other resident as the person involved. During interviews, the CNA reported witnessing the resident enter the room and open the curtain while the other resident was receiving personal care. The DON stated this was the first time she had read the charting and that no one had told her about the incident. The NHA reported being unaware of the event and stated they did not know what could be done to make staff report incidents to management. Facility policy required staff to immediately report allegations or suspicions of mistreatment, abuse, neglect, or exploitation to the Administrator and DON, and required the Administrator or DON to report incidents and accidents to the State Agency.
Failure to Properly Document Transfer and Timely Readmit a Cognitively Intact Resident After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to timely and appropriately readmit a cognitively intact resident after a hospital transfer, and failure to properly document and manage the original transfer/discharge. The resident had chronic hypoxic respiratory failure, morbid obesity (over 500 pounds), used 4 L O2 during the day, and BiPAP at night and for naps. The resident’s MDS and behavioral health documentation showed a BIMS score of 14/15, indicating intact cognition. The facility’s EMR documented that the resident was sent to the ED for “no BM for 3 days,” with a change in condition note showing an O2 saturation of 84% on oxygen via nasal cannula and a recommendation to send to the ER. The ADON stated that the EMR did not clearly or properly document the reason for the transfer, that the facility’s practice was not to send residents out solely for constipation, and that alternative measures should have been used. The ADON also reported being unsure why the resident was sent out and acknowledged that the discharge was not properly documented. The NHA reported that the resident was initially transferred to the local ED for a hypoxic episode and then to an out-of-state hospital, and later stated that the resident would not be readmitted until “stable,” citing a need for an AVAP machine and daily ABGs that the facility allegedly could not manage. However, the resident’s EMR from prior months showed baseline O2 saturations in the mid‑80s, with some readings as low as 69% and 71%, and the out-of-state hospital record described chronic hypoxic respiratory failure on 2 L O2 at baseline. The hospital admission record from the out-of-state facility stated that the resident presented from the nursing facility with acute worsening dyspnea and hypoxia, with O2 saturation dropping to 55% on BiPAP at the facility, but there was no corresponding documentation in the facility’s EMR of such a drop. The NHA acknowledged being unaware that the last EMR note before transfer only referenced no bowel movement for three days and confirmed that whatever was in the EMR was all the facility had regarding the discharge. After the resident became medically stable at the out-of-state hospital, the resident, the hospital CM, and the Ombudsman all reported that the resident wished to return to the facility and had been educated extensively on the risks of using BiPAP instead of AVAP. The Ombudsman and the hospital CM stated that the NHA repeatedly delayed readmission, asserting the facility could not care for someone on AVAP, despite the Ombudsman and a DON at a sister facility confirming that the sister facility had experience with AVAP and a resident using it. The Ombudsman and CM described an incident in which the hospital discharged the resident back to the facility, arranging a nearly five-hour transport; upon arrival, facility staff, reportedly under the NHA’s direction, did not open the door or accept the resident, and the driver had to return the resident to the out-of-state hospital after another long trip. The resident reported feeling fine on the day of the original transfer, not understanding why he was sent out, and later described the return trip and refusal at the door as feeling like being treated as “garbage” in a “meat wagon.” The facility’s own transfer and discharge policy required that transfers/discharges be necessary for the resident’s welfare, properly documented by a physician, and accompanied by written notice and appeal rights, but the record review and interviews showed unclear documentation of the reason for transfer, lack of proper discharge documentation, and delayed or refused readmission despite the resident’s expressed desire and documented capacity to return. The NHA also reported that the Ombudsman had filed an appeal with the State Agency alleging an involuntary discharge and that the State Agency requested an involuntary discharge form, but the NHA had not yet provided anything back. The hospital CM stated that the resident had been medically stable for several days, no longer required daily ABGs, and that the resident understood and accepted the risks of his choices. The CM further reported repeated denials of readmission, difficulties in communicating with the facility, and that progress notes and discharge summaries had been sent to the NHA, who at times claimed not to have received them. During the survey, the NHA initially provided only 9 of 54 pages of the hospital discharge summary, attributing this to the admissions coordinator’s printer running out of paper, and there were multiple delays in providing requested documents. Collectively, these actions and omissions resulted in the resident not being timely readmitted to his home facility, despite his wishes, his cognitive capacity, and the hospital’s assessment of medical stability, and were inconsistent with the facility’s own transfer and discharge policy requirements.
Failure to Provide Required Transfer Notices and Bed-Hold Information During Hospitalizations
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its transfer and discharge policy by not providing required written transfer notifications, bed-hold policy information, and hospital transfer documentation for a cognitively intact resident. The resident was originally admitted with diagnoses including respiratory failure and had a BIMS score of 14/15, indicating intact cognition. The resident’s EMR showed that he was sent to a local emergency department for no bowel movement for three days and had previously been transferred to an out-of-state hospital after the facility noted his oxygen saturation was 65% on his baseline 2 L oxygen, leading to admission for acute on chronic hypoxic respiratory failure, acute hypercapnic respiratory failure, and sepsis secondary to bilateral pneumonia, UTI, bacteremia, and cellulitis. During review, the ADON identified that the EMR reflected discharges from the facility and admissions to the hospital on two separate occasions. Despite these transfers, the EMR contained no evidence of a written notification of transfer to the resident or resident representative and no documentation that the facility’s bed-hold and readmission policies were provided, as required by the facility’s own policy. The facility’s policy specified that, for emergency transfers, notice of transfer must be provided to the resident and representative as soon as practicable, a physician’s order with date and reason for transfer must be obtained, written notice of bed-hold and readmission policies must be given at the time of transfer or within 24 hours, and a transfer form, medication list, and care plan goals must be sent to the receiving hospital, with nursing documenting the hospital transfer in the medical record. At the time of the survey exit, there was no required documentation in the resident’s EMR, including the bed-hold notice, written transfer notice, or hospital transfer paperwork, and this failure resulted in worry, fear, and frustration for the resident and delayed his readmission from a lengthy out-of-state hospitalization.
Failure to Prevent and Treat Constipation Resulting in Harm
Penalty
Summary
The facility failed to implement preventative measures, promptly assess, and treat constipation for a resident with dementia, resulting in actual harm. The resident had a documented history of constipation and was prescribed both scheduled and PRN medications for bowel management. Despite this, documentation showed prolonged periods without bowel movements, including a six-day and a ten-day interval with minimal or no bowel movements. During these periods, there was no evidence that PRN medications for constipation were administered, even though they were available and ordered. Nursing and CNA documentation indicated that the resident experienced increasing abdominal pain, decreased appetite, and eventually vomiting. Nursing staff noted the absence of regular bowel movements and administered a rectal suppository only after the resident began to show significant symptoms. The resident's condition deteriorated further, with continued abdominal pain, lethargy, fever, and abnormal vital signs. The on-call physician's assistant was contacted, and an abdominal X-ray was ordered, but the resident's status continued to decline, leading to transfer to the hospital. At the hospital, the resident was diagnosed with a small bowel obstruction, acute kidney injury, and sepsis. The hospital course included non-operative management due to the resident's advanced age and comorbidities, and the plan was shifted to comfort-focused care. The facility's own staff and leadership acknowledged issues with documentation and communication regarding bowel management, and the lack of timely intervention and follow-through on bowel protocols contributed to the resident's decline and subsequent hospitalization.
Failure to Revise and Implement Care Plan for Constipation Management
Penalty
Summary
The facility failed to implement, review, and revise the care plan and interventions for a resident at risk for constipation, resulting in a delay in treatment and subsequent medical complications. The resident, who had dementia and was cognitively impaired, was identified as being at risk for constipation due to decreased mobility, medication side effects, and opioid use. The care plan included interventions such as monitoring for signs and symptoms of constipation, administering medications as ordered, and reporting abnormal findings to the physician. However, documentation revealed that the resident went extended periods without bowel movements, specifically six days without a bowel movement and another ten-day period with only one medium bowel movement. Despite having PRN medications available for constipation relief, including stool softeners, laxatives, suppositories, and enemas, there was no documentation that any of these were administered during the periods of constipation. Progress notes indicated that the resident later experienced a large episode of dark brown emesis and was subsequently sent to the hospital for evaluation of fever and hypotension. Hospital records confirmed the development of a small bowel obstruction, acute kidney injury, and sepsis. Interviews and record reviews confirmed that the care plan was not followed or updated to reflect the resident's changing condition. The Director of Nursing acknowledged that the care plan should have been person-centered and interventions implemented to meet the resident's goals. Reference materials cited in the report emphasized the importance of revising care plans based on the resident's current status and needs, which was not done in this case.
Failure to Honor Resident Dignity and Rights
Penalty
Summary
A resident with paraplegia and a history of major depressive disorder was admitted to the facility and was cognitively intact, as evidenced by a BIMS score of 15/15. The resident had previously been involved in an incident where he accidentally bumped into another resident with his electric wheelchair, resulting in no injury but some pain. Following this incident, the facility restricted his use of the electric wheelchair within the building, allowing him to use it only when leaving the facility. The resident expressed that other residents were not similarly restricted after incidents, and he felt targeted and unfairly treated. Staff interviews confirmed that the resident had not been given a second chance to use his electric wheelchair inside the facility, and no education or interventions were provided to address the incident or prevent recurrence. The resident repeatedly voiced feelings of anxiety, frustration, and fear of retaliation or discharge due to the way management handled his situation. He reported that his requests, such as not having the DON present at his care conference, were disregarded by the former NHA, who insisted on the DON's attendance despite the resident's objections. Multiple staff members and the facility ombudsman corroborated that the resident felt disrespected, bullied, and that his rights were not honored. The resident also experienced additional distress when required to use a large orange flag on his wheelchair against his wishes and when his television access was disrupted without timely resolution from management. Documentation and interviews revealed that the facility failed to maintain the resident's dignity and respect his rights to self-determination and participation in care planning. Staff did not document or communicate the resident's grievances or emotional distress to management or the social worker, and interventions to establish a trusting relationship and maintain a non-threatening environment were not effectively implemented. The facility's own policies on resident dignity and rights were not followed, as the resident's preferences and autonomy were repeatedly overridden by management decisions.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that residents received food as prescribed by a physician and in accordance with their preferences, affecting three residents. For one resident, a lunch tray included a dinner roll despite instructions indicating no bread unless it was a sandwich. The resident did not consume the roll, which was returned untouched. The Certified Dietary Manager acknowledged that bread should not have been on the tray with manicotti, as per the resident's request. Another resident was observed attempting to cut a turkey slice with a fork, although their therapeutic diet required ground meats. The resident indicated a preference for ground turkey, and a Certified Nurse Aide recognized the error and sought to correct it by obtaining ground turkey from the dietary department. Additionally, a third resident received a breakfast tray with a salt packet, contrary to their prescribed diet of no added salt due to hypertension. A Registered Nurse confirmed the presence of salt was inappropriate for the resident's condition.
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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 Escanaba
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Park Village | 0.2 mi | ★★★★★ | 2 | 0 |
| Bishop Noa Home For Senior Citizens | 0.4 mi | ★★★★★ | 11 | 0 |
| Pinecrest Medical Care Facility | 21.6 mi | ★★★★★ | 0 | 0 |
| Roubal Care And Rehabilitation Center | 34.2 mi | ★★★★★ | 0 | 0 |
| Serenity Spring Senior Living At Scandia Village | 38.4 mi | ★★★★★ | 3 | 0 |
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