Holy Cross Rehabilitation and Wellness

In the surveyor’s words

From the most serious findings on record at Holy Cross Rehabilitation and Wellness, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF565Sep 17, 2025

  Based on interview and record review, the facility failed to adequately address resident grievances regarding call light wait times for 18 of 18 residents reviewed for call-light wait times, (Residents B, C, D, E, F, G, H, K, L, M, N, P, Q, R, S, T, and U).Findings include:During an interview, on 9/17/25 at 9:10 A.M., the Director of Nursing indicated the facility call light system was in working order and had not been out of working order at any time that she was aware of. The Director of Nursing indicated that each resident had a staff member, called a Guardian Angel, who checked on their assigned residents addressing concerns including concerns regarding call ight wait times. […]

• No harm, potential for more than minimal, patternF804May 21, 2024

  Based on interview, observation and record review, the facility failed to maintain appropriate food temperatures of the meal trays on St. Paul's Unit. This had the potential to affect the 21 Residents who eat on St. Paul's Unit. Finding includes: During an interview, on 4/15/2024 at 11:15 A.M., Resident 117 indicated he ate his meals in the dinning area on the unit and most of his meals were cold. Resident 117 was able to request to have his meals heated to a warmer temperature, but stopped asking because every meal was cold. An observation of food temperatures for the meal trays on St. Paul's Unit was completed, on 5/20/2024 at 12:13 P.M. The Dietary Project Manager pulled the first tray off the food cart and used her thermometer to take the temperature of the food. […]

• No harm, potential for more than minimal, patternF812May 21, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served in a sanitary manner in 1 of 1 kitchens observed. The facility also failed to ensure food brought in by outside sources and placed in resident nourishment refrigerators was stored in accordance with professional standards for food safety and used for food and beverages only for 4 of 4 panty rooms observed. This deficient practice had the potential to affect 76 of 77 residents who resided in the facility and consumed from from the kitchen or pantries Findings include: 1. Upon entering the kitchen on [DATE] at 9:05 A.M., on top of the ice machine was 2 scoops lying uncovered, and the storage container was open but empty. […]

• No harm, potential for more than minimal, isolatedF684May 15, 2026

  Based on interview and record review, the facility failed to assess a resident who had fallen for 1 of 3 residents who were reviewed. (Resident G)Finding includes:During an interview on 5/15/2026 at 10:00 A.M., Resident G indicated she had fallen about a month prior when a staff member had moved her with the Hoyer lift by themselves. Resident G indicated she had not been injured during the fall. Resident G denied have been assessed by a staff member before she was lifted off the floor and back into her bed. She also denied having been assessed by staff after she was put back into her bed. Resident G's record review was complete on 5/15/2026 at 11:00 A.M. Diagnoses included, but were not limited to: type two diabetes mellitus, chronic kidney disease, obesity and major depressive disorder. […]

• No harm, potential for more than minimal, isolatedF689May 15, 2026

  Based on interview and record review, the facility failed to transfer a resident appropriately resulting in the resident falling for 1 of 3 residents reviewed for falls. (Resident G)Finding includes:During an interview on 5/15/2026 at 9:30 A.M., the Director of Nursing (DON) indicated there had been an incident when Resident G had been in the process of being transferred with a lift by CNA 2 on 4/13/2026. The resident had been assisted to the floor during the transfer because the resident had been falling out of the mechanical lift transfer sling. CNA 2 had been sent home on 4/13/2026. An investigation into the incident had been started. […]