Holy Trinity Eastern Orthodox N & R Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, the facility failed to provide adequate assistance for Activities of Daily Living (ADLs) for one Resident (#37) out of a total sample of 19 residents. Specifically, for Resident #37, the facility failed to ensure that fingernail care was provided when the Resident was dependent on staff for ADL care. Findings include: Review of the facility policy titled Fingernail Care-Personal Care Needs, updated 9/1/23, indicated: -The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. -Routine cleaning and inspection of nails will be provided on an ongoing basis. -Principles of nail care: >Nails should be kept smooth to avoid skin injury. >Only licensed nurses shall trim or file fingernails of residents with diabetes. Resident #37 was admitted to the facility in March 2024 with diagnoses including Cerebral Infarction, Hemiplegia affecting the right dominant side, and Type 2 Diabetes Mellitus. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record and policy review, and interview, the facility failed to ensure that a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASRR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) screen was submitted for one Resident (#73) out of a total sample of 18 residents. Specifically, for Resident #73, the facility staff failed to request a Level II PASRR evaluation when the Resident demonstrated an increase in behavioral, psychiatric, and mood-related symptoms resulting in a change to the Resident's plan of care. Findings Include: Resident #73 was admitted to the facility in August 2023, with diagnoses including Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations) and Depression (a mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to develop a care plan for the use of a positioning aid for one Resident (#6) out of a total sample of 18 residents. Specifically, for Resident #6, the facility failed to ensure a care plan was developed for the use of bilateral (both sides) wedge cushions (a triangular shaped cushion used to aid in positioning for health issues or comfort) while the Resident was in bed. Findings include: Review of the facility policy titled Body Positioning, released 1/17/17, indicated the following: -Positioning techniques should be used with residents with stroke and other neurological impairments for the following reasons: >Orthopedic enhancement of postural alignment >Increase stability -Documentation >In the care plan, document positioning needs and interventions and approaches to meet resident's needs. Resident #6 was admitted to the facility in March 2020, with diagnoses including a history of Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interview, the facility failed to ensure provided meals were palatable and of appropriate temperatures on two (Village Unit and Courtyard Unit), out of the two units observed. Findings include: During the initial pool process on 6/6/23 the survey team identified the following meal concerns: -Cold food -Bland food -Overcooked food 1. On 6/7/23 at 11:53 A.M., the surveyor observed the steam table arrive on Village Unit for lunch service. On 6/7/23 at 12:01 P.M., the surveyor observed the start of lunch trays being served to the residents in the Village dining room. On 6/7/23 at 12:32 P.M., the final meal had been delivered and the surveyor obtained the following temperatures and palatability with Activities Assistant #1: -pureed mac and cheese: 99 degrees Fahrenheit (F) tasted lukewarm, not hot, bland, with a runny consistency -pureed mixed vegetables:100 degrees (F), tasted lukewarm, not hot, bland, with a runny consistency -pureed stuffed peppers: 100 degrees (F), tasted lukewarm, not hot, with a runny consistency -regular consistency mixed vegetables: 98…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, policy reviews and interviews, the facility failed to ensure its staff adhered to Infection Control policies/practices by encouraging social distancing and mask wearing for residents who were negative for COVID-19 infection and who were in close contact with symptomatic COVID-19 positive Residents (#18 and #23). The facility also failed to ensure appropriate donning (putting on) and doffing (removing), use of personal protective equipment (PPE), conduct testing by staff in a manner to minimize the spread of COVID-19 infection during an active outbreak on two of three units observed. Findings include: Review of the facility policy titled Protective Attire Technique, revised 2022, indicated that employees wear appropriate protective attire when providing care to residents in isolation. The policy also included the following: -Order of protective attire application and removal: Application: 1. gown 2. mask/eyewear/face shield 3. gloves Removal: 1. gloves 2. gown 3. mask/eyewear/face shield Review of the facility policy titled Corona Virus (COVID-19) Transmission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility staff failed to ensure access to a call light (a device used to alert staff of a request/need) for one Resident (#4), out of a total sample of 19 residents. Specifically, Resident #4's call light was not accessible during meals when he/she was eating in his/her room without staff presence/supervision. Findings include: Resident #4 was admitted to the facility in April 2017 with diagnoses of Acute Respiratory Failure with Hypercapnia (where the lungs are unable to adequately oxygenate the blood and eliminate carbon dioxide, resulting in abnormally elevated carbon dioxide levels) and Dysphagia (difficulty with swallowing). Review of the Minimum Data Set (MDS) Assessment, dated 4/17/23, indicated Resident #4 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Review of the Activities of Daily Living (ADL) Care plan, revised 5/5/23, included the following intervention: -call light to be within reach On 6/6/23 at 9:00 A.M., the surveyor observed Resident #4 seated in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement the plan of care for four Residents (#4, #10, #18 and #75), out of a total sample of 19 residents. Specifically the facility failed to: 1) For Resident #4, implement the plan of care relative to Activities of Daily Living (ADLs) and swallowing. 2) For Resident's #10 and #18, ensure the Physician's Orders relative to medication parameters were implemented. 3) For Resident #75, ensure the plan of care relative to fall prevention was implemented. Findings include: 1. For Resident #4 the facility failed to ensure the plan of care and/or Physician's Orders were implemented relative the level of supervision and adaptive equipment as recommended by the Speech Language Pathologist (SLP- clinician who assess, prevent, diagnose and treat swallowing disorders) to reduce the risk of aspiration (inhalation of food/fluid/substances into the airway and lungs). Resident #4 was admitted to the facility in April 2017 with diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report out of range laboratory values to the Physician for Resident (#75), and to obtain Physician ordered laboratory services for one Resident (#4), out of a total sample of 19 residents. Specifically 1. For Resident #75, the facility failed to ensure its staff reported an out of range Valproic Acid level of 40 micrograms per milliliter (ug/ml), [normal range is 50-100 ug/ml], and 2. For Resident #4 the facility failed to provide Physician ordered laboratory services for liver function tests (LFTs- a test to help diagnose and monitor liver disease or damage) and Hemoglobin A1c (a test that measures the average blood sugar levels over the past three months) tests. Findings include: 1. Resident #75 was admitted to the facility in [DATE] with diagnoses including Alzheimer's Disease, Major Depressive Disorder and anxiety disorder. Review of the Valproic Acid (level of Valproic acid in the blood when taking Depakote- a medication used as a mood stabilizer;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to maintain complete and accurate medical records for one Resident (#10), out of a total sample of 19 Residents. Specifically, the facility staff failed to ensure: a) Residuals (amount of liquid drained from the stomach following administration of enteral feeding [a form of nutrition that is delivered into the digestive system as a liquid via a feeding tube]) were documented in the clinical record. b) The order to obtain residuals was discontinued when the Resident transitioned to taking all meals by mouth. Findings include: Resident #10 was admitted to the facility in December 2021 with diagnoses including Cerebral Infarction (stroke), Dysphagia and Gastrostomy (G-tube: a feeding tube surgically inserted through the abdomen and into the stomach to deliver liquid food/fluids/medications). Review of the MDS Assessment, dated 2/6/23, indicated Resident #10 was severely cognitively impaired as obtained from staff interview, was dependent on staff with eating, and had a feeding tube which provided greater then 51%…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.