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Deficiency Records for Holy Spirit Retirement Home
A list of the most recent deficiencies for Holy Spirit Retirement Home. 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 Spirit Retirement Home. 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 testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-05-28 | 2024-06-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-22 | 2024-06-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-22 | 2024-06-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-05-22 | 2024-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-22 | 2024-06-22 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-05-22 | 2024-06-22 | 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 | 2024-05-22 | 2024-06-22 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-05-22 | 2024-06-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-22 | 2024-06-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-22 | 2024-06-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-22 | 2024-06-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-28 | 2024-06-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-28 | 2024-06-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-28 | 2024-06-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-05-28 | 2024-06-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-28 | 2024-06-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-28 | 2024-06-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-28 | 2024-06-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-08 | 2024-03-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-08 | 2024-03-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-08 | 2024-03-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-16 | 2023-04-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-16 | 2023-04-16 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-03-16 | 2023-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-16 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-23 | 2023-04-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-23 | 2023-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-23 | 2023-03-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-23 | 2023-03-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-27 | 2022-06-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-30 | 2022-03-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-30 | 2022-03-03 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-30 | 2022-03-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-30 | 2022-03-03 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-30 | 2021-12-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-30 | 2021-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-30 | 2021-12-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-30 | 2021-12-30 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-11-30 | 2021-12-30 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-11-30 | 2021-12-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-30 | 2021-12-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-30 | 2021-12-30 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-11-30 | 2021-12-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-30 | 2021-12-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-30 | 2021-12-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-30 | 2021-12-30 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-11-30 | 2021-12-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-30 | 2021-12-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-11-30 | 2021-12-30 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-11-30 | 2021-12-30 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-11-30 | 2021-12-22 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-11-30 | 2021-12-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-30 | 2021-12-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-30 | 2021-12-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-30 | 2021-12-16 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-11-30 | 2021-12-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-30 | 2021-12-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-30 | 2021-12-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-30 | 2021-12-16 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-02 | 2021-11-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-02 | 2021-11-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-02 | 2021-11-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-02 | 2021-11-10 | N |
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