Deficiency Records for Holy Spirit Retirement Home

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Updated as of March 01, 2024

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?
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
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
Perform COVID19 testing on residents and staff. 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
Conduct testing and exercise requirements. Fire Safety 2020-02-03 2020-03-03 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2020-02-03 2020-03-03 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2020-02-03 2020-03-03 N
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 2020-01-30 2020-03-01 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2020-01-30 2020-03-01 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 2020-01-30 2020-03-01 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-01-30 2020-03-01 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2020-01-30 2020-03-01 N
Establish roles under a Waiver declared by secretary. Fire Safety 2020-02-03 2020-02-13 N
Use approved construction type or materials. Fire Safety 2020-02-03 2020-02-13 N
Have corridors or aisles that are unobstructed and are at least 8 feet in width. Fire Safety 2020-02-03 2020-02-13 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2020-02-03 2020-02-13 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2020-02-03 2020-02-10 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2020-02-03 2020-02-10 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2020-02-03 2020-02-10 N
Install corridor and hallway doors that block smoke. Fire Safety 2020-02-03 2020-02-04 N
Have simulated fire drills held at unexpected times. Fire Safety 2020-02-03 2020-02-04 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2020-02-03 2020-02-04 N
Ensure proper usage of power strips and extension cords. Fire Safety 2020-02-03 2020-02-04 N