Deficiency Records for Holy Spirit Retirement Home
Updated as of October 01, 2021
This is not the most recent data for Holy Spirit Retirement Home. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-06-04 | 2020-07-03 | Y |
| 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-17 | 2019-11-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-17 | 2019-11-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-17 | 2019-11-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-17 | 2019-11-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-17 | 2019-10-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-26 | 2019-03-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-12-05 | 2019-01-29 | 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 | 2018-12-10 | 2019-01-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-05 | 2019-01-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-05 | 2019-01-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-05 | 2019-01-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-05 | 2019-01-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-05 | 2019-01-05 | 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 | 2018-12-05 | 2019-01-05 | 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 | 2018-12-05 | 2019-01-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-05 | 2019-01-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-05 | 2019-01-05 | Y |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-10 | 2018-12-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-08-24 | 2017-10-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-08-24 | 2017-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-24 | 2017-10-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-08-24 | 2017-09-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-08-24 | 2017-09-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-24 | 2017-09-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-08-24 | 2017-09-24 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-08-17 | 2017-09-17 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-17 | 2017-09-17 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-17 | 2017-09-17 | 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 | 2017-08-24 | 2017-09-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-08-24 | 2017-09-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-08-24 | 2017-09-07 | N |
