Holy Trinity Eastern Orthodox N & R Center

In the surveyor’s words

From the most serious findings on record at Holy Trinity Eastern Orthodox N & R Center, in the surveyor’s own words.

• Actual harm, isolatedF656Jan 3, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required extensive physical assistance of two staff members with bed mobility and toilet use, the Facility failed to ensure that staff implemented and followed interventions identified in his/her plan of care related to the need for two staff members to assist during care. On 12/05/22, Certified Nurse Aide (CNA) #1, who was assigned to care for Resident #1, provided incontinence care and repositioned him/her in bed without another staff member present to provide assistance, and when she repositioned Resident #1 onto his/her side, he/she rolled out of bed and landed face down on the floor. […]

• Actual harm, isolatedF689Jan 3, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required extensive physical assistance of two staff members with bed mobility and toilet use, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety to prevent incidents and/or accidents resulting in an injury. On 12/05/22, Certified Nurse Aide (CNA) #1 who was assigned to care for Resident #1, provided incontinence care and repositioned him/her in bed without another staff member present to provide assistance, when CNA #1 rolled Resident #1 onto his/her side, Resident #1 rolled out of bed and landed face down on the floor. […]

• No harm, potential for more than minimal, patternF804Jun 8, 2023

  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. […]

• No harm, potential for more than minimal, patternF880Jun 8, 2023

  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. […]

• No harm, potential for more than minimal, patternF880Jan 5, 2021

  Based on document review, policy review, interview and observation, the facility failed to ensure staff maintained an infection prevention and control program, relative to Personal Protective Equipment (PPE) and hand hygiene, to help prevent the development and transmission of communicable diseases, infections and/or the COVID-19 virus. Findings include: Review of the Centers for Disease Prevention and Control (CDC) website, Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 11/4/20, indicated the following; -Implement universal use of PPE for HCP working in facilities located in areas with moderate to substantial community COVID-19 transmission. […]