Church Home of the Protestant Episcopal Church

In the surveyor’s words

From the most serious findings on record at Church Home of the Protestant Episcopal Church, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF607Jan 9, 2024

  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. […]

• No harm, potential for more than minimal, patternF812Jan 9, 2024

  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. […]

• No harm, potential for more than minimal, patternF812Mar 11, 2022

  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. […]

• No harm, potential for more than minimal, isolatedF677Jan 9, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF697Jan 9, 2024

  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. […]