Holy Cross Health Center

In the surveyor’s words

From the most serious findings on record at Holy Cross Health Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 25, 2026

  Based on observation, record review and interviews, the facility failed to ensure appropriate sanitization of dishware for 1 of 1 kitchen observed. Findings include:Observation on 2/23/26 at 9:00 a.m. in the dishwashing room revealed the dish machine had a final rinse temperature of 176 F (degrees Fahrenheit). During the next run, the final rinse temperature was 172 F. Interview on 2/23/26 at 9:05 a.m. with Staff A (Dietary Aide) confirmed the above findings. Staff A stated that the dish machine is a high temperature unit.Review on 2/23/26 of the February 2026 dish machine temperature logs revealed the following dates that the final rinse temperature was below 180 F with no documented corrective action: 2/1/26 (172 F),2/4/26 (170 F), 2/11/26 (175 F), 2/12/26 (175 F, 178 F), 2/13/26 (175… […]

• No harm, potential for more than minimal, patternF727Jan 26, 2023

  Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 6 of 92 days reviewed for Quarter 4 - 2022 (July 1 - September 30, 2022). Findings include: Review on 1/25/23 of the facility's Payroll Based Journal Staffing Data Report for Quarter 4 - 2022 revealed that there were no RN hours for the following days; 7/4/22, 7/9/22, 7/10/22 and 8/20/22. Review on 1/26/23 of the facility's daily staffing for 7/1/22 through 9/30/22 revealed the following; - On 7/4/22, 7/9/22, 7/10/22, 8/20/22, 9/4/22 and 9/5/22 revealed that a RN was not scheduled or documented as worked. - These 6 days fell either on a weekend or a holiday. Interview on 1/26/23 at 1:12 p.m. […]

• No harm, potential for more than minimal, patternF727Feb 3, 2022

  Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse was on duty for 8 consecutive hours a day 7 days a week for 9 out of 10 weekend days reviewed (1/1/22 to 2/3/22). Findings include: Review on 2/3/22 of the facility's daily staffing from 1/1/22 to 2/3/22 revealed that a Registered Nurse was not scheduled or documented as worked on Saturday or Sunday for the following days; 1/2/22, 1/8/22, 1/9/22, 1/15/22, 1/16/22, 1/22/22, 1/23/22, 1/29/22 and 1/30/22 (total of 9 days). Interview on 2/3/22 at 8:45 a.m. with Staff B (Director of Nursing) and Staff C (Administrator) revealed that the facility typically did not have a Registered Nurse working on the weekends. […]

• No harm, potential for more than minimal, patternF812Jan 21, 2021

  Based on observation, interview, and record review, it was determined that the facility failed to ensure that perishable food and liquids in two of two resident refrigerators on the nursing units observed were not expired or past perish dates. Findings include: Observation on [DATE] at approximately 10:10 a.m. revealed a staff member removing liquids to give to a resident from the first floor resident refrigerator. Observation on [DATE] at 10:10 a.m. of the first floor resident refrigerator revealed the following: -One chocolate supplement shake with a hand written date of ,[DATE]; -Two [MEDICATION NAME] milks with manufacturer stamped date of [DATE]; -One fat free milk with manufacturer stamped date of ,[DATE]; -One fat free milk with manufacturer stamped date of ,[DATE]; -One ensure… […]

• No harm, potential for more than minimal, isolatedF868Jan 3, 2025

  Based on interview and record review, it was determined that the facility failed to ensure that the required committee members attended Quality Assurance Performance Improvement (QAPI) meetings at least quarterly for 3 of the 4 quarterly meetings reviewed for 2024. Findings include: Review on 1/3/25 of the first quarter QAPI meeting attendance sheet, dated 1/26/24, revealed that the Medical Director or designee (required member) was not in attendance. Review on 1/3/25 of the second quarter QAPI meeting attendance sheet, dated 4/26/24, revealed that the Infection Preventionist (required member) was not in attendance. Review on 1/3/25 of the fourth quarter QAPI meeting attendance sheet, dated 10/25/24, revealed that the Infection Preventionist (required member) was not in attendance. […]