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Deficiency Records for Holy Spirit Retirement Home
View the most recent health deficiencies and inspection results for Holy Spirit Retirement Home. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Holy Spirit Retirement Home. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-10-07 | 2025-10-08 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2025-05-15 | 2025-06-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2025-05-15 | 2025-06-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2025-05-15 | 2025-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-05-15 | 2025-06-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2025-05-15 | 2025-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-05-15 | 2025-06-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-05-15 | 2025-06-13 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2025-05-15 | 2025-06-13 | N |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2025-05-15 | 2025-06-13 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2025-05-15 | 2025-06-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-05-15 | 2025-06-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-05-15 | 2025-06-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2025-05-15 | 2025-06-13 | 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 | 2025-05-15 | 2025-06-13 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-05-22 | 2024-06-27 | 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 |
| Provide and implement an infection prevention and control program. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-22 | 2024-06-22 | 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 |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-22 | 2024-06-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-22 | 2024-06-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-22 | 2024-06-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-05-22 | 2024-06-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-22 | 2024-06-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-22 | 2024-06-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-22 | 2024-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-08 | 2024-03-11 | Y |
| 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 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 |
| 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 | 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 |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-16 | 2023-04-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-16 | 2023-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-16 | 2023-03-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-16 | 2023-03-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-04-30 | Not Fixed | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2026-04-30 | Not Fixed | Y |