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Deficiency Records for Holy Cross Rehabilitation and Wellness
A list of the most recent deficiencies for Holy Cross Rehabilitation and Wellness. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Holy Cross Rehabilitation and Wellness. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-25 | 2024-07-22 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-19 | 2024-07-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-19 | 2024-07-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-19 | 2024-07-22 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-05-21 | 2024-07-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-21 | 2024-07-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-05-21 | 2024-07-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-21 | 2024-07-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-05-21 | 2024-07-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-05-21 | 2024-07-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-21 | 2024-07-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-21 | 2024-07-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-21 | 2024-07-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-13 | 2023-07-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-13 | 2023-07-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-13 | 2023-07-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-13 | 2023-07-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-13 | 2023-07-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-23 | 2023-06-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-23 | 2023-06-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-23 | 2023-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-26 | 2022-11-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-09 | 2020-02-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-11 | 2019-11-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-10-11 | 2019-11-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-11 | 2019-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-11 | 2019-11-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-11 | 2019-11-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-11 | 2019-11-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-10-11 | 2019-11-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-10-11 | 2019-11-08 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-11 | 2019-11-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-11 | 2019-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-11 | 2019-11-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-11 | 2019-11-08 | N |
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