Church Home of the Protestant Episcopal Church

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey, it was determined that for three (Employees #2, #4, and #5) of seven newly hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and/or misappropriation of resident property related to screening of prospective employees. Specifically, a nurse aide registry abuse screening was not completed for newly hired employees prior to starting work.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for one of one main kitchen the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, potentially hazardous foods were not cold held at or below 45 degrees Fahrenheit (°F), and a refrigerator was not maintained in good working order.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey it was determined that for one (Resident #12) of six residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the Activities of Daily Living services required to maintain good nutrition. Specifically, Resident # 12 was not consistently provided with the amount of assist required during mealtimes. This is evidenced by the following: Resident #12 had diagnoses that included adult failure to thrive, macular degeneration (an eye disease that causes vision loss), and hearing loss. The Minimum Data Set assessment dated [DATE], revealed the resident was severely impaired cognitively, that their vision was highly impaired, and they required substantial/maximal (helper does more than half the effort) assistance with eating. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for one (Resident #109) of one resident reviewed, the facility did not manage the resident's pain to the extent possible in accordance with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Specifically, there was insufficient evidence that the resident's pain was effectively monitored and treated despite numerous complaints of pain. Additionally, Resident #109's Comprehensive Care Plan did not include that the resident had chronic pain with goals and interventions related to pain management. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey, it was determined that for two (Residents #8 and #79) of 12 residents reviewed, the facility did not provide special eating equipment for residents who need them to maintain or improve the residents' ability to eat and drink independently. Specifically, Resident #8 and Resident #79 were observed on multiple occasions consuming soup from a bowl instead of a mug as recommended by Occupational Therapy. This is evidenced by the following: 1. Resident #8 had diagnoses including stroke with hemiplegia (paralysis and weakness on one side of the body), adult failure to thrive, dementia, and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observations, interviews and record reviews, conducted during the Recertification Survey, completed on 3/11/22, it was determined that for one of one main kitchen, the facility failed to store, prepare, distribute and serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there were multiple undated and unlabeled food items, dented cans, and a high temperature automatic dishwashing machine that did not meet temperature sanitizing standards. This is evidenced by the following: The undated facility policy titled 'Food Storage', included that plastic containers with tight-fitting covers must be used for storing cereals, cereal products, and broken lots of bulk foods and must be accurately labeled and dated. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey, completed on 3/11/22, it was determined for one (Resident #2) of one resident reviewed for communication, the facility did not ensure the resident had the right to be informed of, and participate in their treatment in a language that they could understand. Specifically, Resident #2 who had little understanding of the English language was not provided with the opportunity to communicate and be communicated with in a language they could consistently understand.

Inspectors wroteBased on observations, interviews and record review, conducted during the Recertification Survey, completed on 3/11/22, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment for one of twenty-four residents reviewed. Specifically, Resident #120 was observed on multiple days in a soiled Broda (type of geriatric positioning chair) chair. This is evidenced by: Resident #120 had diagnoses that included vascular dementia, hemiplegia (loss of muscle function on one side of the body) and adult failure to thrive. The Minimum Data Set Assessment, dated 2/15/22, documented that per staff assessment, Resident #120 had poor memory, poor recall and severely impaired decision-making skills. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey, completed on 3/11/22, it was determined that for two (Resident #2 and Resident #60) of seven residents reviewed for investigations, the facility did not thoroughly investigate injuries of unknown origin in order to rule out abuse, neglect or mistreatment. The issues involved the lack of an investigation for bruises of unknown origin for Resident #60 and lack of a thorough investigation of a fractured heel of unknown origin for Resident #2. This was evidenced by the following: 1. Resident #60 had diagnoses that included dementia, a history of falls, and was legally blind. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #33 and #51) of five residents reviewed for non-pressure related skin conditions, the facility did not thoroughly investigate skin injuries in order to rule out abuse, neglect or mistreatment. Specifically, the facility was unable to provide documentation that a thorough investigation was completed to support the probable causes for unwitnessed skin injuries. This is evidenced by the following: Review of the undated facility policy, Investigation of Unwitnessed Injury, revealed that all unwitnessed resident injuries involving bruises will be investigated to determine if the elements of abuse or mistreatment are present. The injury is to be assessed by a Registered Nurse (RN) to rule out possible abuse, neglect, or mistreatment. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of two residents reviewed for hospice, the facility did not ensure that a Significant Change in Status Minimum Data Set (MDS) Assessment was completed. Specifically, Resident #81 did not have a Significant Change Assessment completed following the start of hospice services, and Resident #59, did not have a Significant Change Assessment completed within the required timeframe following the start of hospice services. This is evidenced by the following: The Facility Resident Assessment Instrument 3.0 User's Manual Version 1.16, dated October 2018, reveals that a Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for enteral nutrition (tube feeding), the facility did not provide appropriate treatment and services to prevent complications and or have a mechanism in place to ensure periodic evaluation of the amount of tube feeding being administered. Specifically, Resident #95's tube feeding orders were incomplete and did not include the total volume of tube feeding to be administered, and daily intakes were not recorded or consistently monitored. This is evidenced by the following: Resident #95 was admitted to the facility on [DATE] and had diagnoses that included cerebral vascular accident with left hemiparesis (weakness), dysphagia (difficulty swallowing) and vascular dementia. [...]