Church Home of the Protestant Episcopal Church

Based 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. The findings are: On 1/5/24 from 1:30 PM to 2:45 PM, newly hired employee files were provided to the surveyor for review and included the following: Employee #2 was hired on 9/20/23 as a Unit Secretary and the nurse aide registry screen for prior abuse findings was not completed until 1/5/24. Employee #4 was hired on 10/17/23 as a Food Service Worker and the nurse aide registry screen for prior abuse findings was not completed until 1/5/24. Employee #5 was hired on 12/4/23 as an Environmental Services Worker and the nurse aide registry screen for prior abuse findings was not completed until 1/5/24.…

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 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. The findings are: Observations in the main kitchen on 1/3/24 at 9:14 AM included a Hoshizaki brand stand up two door refrigerator marked with a #5 on the door and two thermometers inside of the left door displaying 48°F. At this time the kitchen thermometers and the surveyors' Thermapen were checked for proper calibration using a cup of ice and water and read 32°F. Observations on 1/3/24 at 9:28 AM included the temperatures of the following items within the Hoshizaki cooler were measured by the surveyor as follows: Carrots 49 °F, rice 48°F, vegetables soup 53°F, six hamburgers 51°F, gravy 48°F, bologna 48°F, a partial package of Turkey 51°F, eight…

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 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. Review of the Comprehensive Care Plan (CCP), revised on 12/18/23 revealed Resident #12 was at risk for alteration in nutrition with staff interventions that included to…

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 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: The facility's Pain Assessment and Management policy dated last reviewed December 2022, included the purpose of the policy was to help staff identify pain in a resident, to develop interventions that are consistent with the resident's goals and needs and address the underlying causes of…

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 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). The Minimum Data Set Assessment, dated 12/2/23, revealed that Resident # 8 had moderate cognitive impairment of cognitive function and required supervision or touching assistance for eating. Resident #8's current Comprehensive Care Plan included providing adaptive equipment per Occupational Therapy…

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 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. The policy also included that food items should be dated as it is placed on shelves and date marking should be done to indicate the date or day by which ready-to-eat, potentially hazardous foods should be consumed, sold, or discarded and will be visible on all high-risk foods. All foods…

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, 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. The findings are: Resident # 2 had diagnoses including dementia, diabetes, and adult failure to thrive. The Minimum Data Set (MDS) Assessment, dated 11/24/21, documented that Resident #2 was severely impaired cognitively, that their ability to understand others was sometimes understands, and their ability to make themself understood was sometimes understood. The MDS Assessment documented that the resident's preferred language was other than English and that the resident required an interpreter to communicate with health care staff.…

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, 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. The resident also required total dependence on staff for bathing, extensive assist of staff with personal hygiene and dressing and was independent with eating after set up. The Resident Care Card (care plan used by the Certified Nursing Assistants (CNAs) for daily care), dated 3/11/22, documented that Resident #120 was non-ambulatory and used a Broda chair.…

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 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. The Minimum Data Set (MDS) Assessment, dated 1/13/22, revealed the resident was moderately impaired of cognitive function and required extensive assistance of staff with bed mobility and total dependence with personal hygiene. The current Resident Care Card included that Resident #60 was at risk for falls due to blindness and required the assistance of two staff for transfers using a mechanical lift. The Care Card…

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 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. The RN will interview the resident and staff. If the resident is unable to explain what happened, determine if there is documentation in the chart to…

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 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. The Assessment Reference Date must be within 14 days from the effective date of the hospice election. A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is…

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 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. The Minimum Data Set Assessment, dated 8/20/19, revealed the resident had severely impaired cognition and received 51 percent or more of their calories through the tube feeding. The facility…

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.