Holy Family Home

In the surveyor’s words

From the most serious findings on record at Holy Family Home, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 12, 2026

  Based on a review of facility policies, clinical records, facility documentation, staff, resident and family interviews, it was determined the facility failed to ensure that Resident R1 was adequately secured in a transportation van. This failure resulted in actual harm for Resident R1 who fell while being transported in the van and sustained a fracture of the left distal femur and fracture of the right distal tibia, requiring transfer to the hospital and surgery for one of three residents reviewed. (Resident R1) Findings Include: Review of facility policy titled, Wheelchair Transport with revision date of June 2025 revealed, Policy- To move a resident who cannot move from one location to another without assistance. […]

• No harm, potential for more than minimal, isolatedF684Apr 2, 2026

  Based on review of facility's policy, staff interviews and the review of clinical records, it was determined that the facility failed to clarify a physician's order related to a resident's alcohol consumption for 1 out of 18 residents reviewed (Resident R7).Findings include: Review of the facility policy Alcohol Beverage Consumption, dated April 1, 2026, stated that upon admission, a licensed nurse will review the resident's medications and diagnosis, with the resident's physician, and that the physician will determine if the resident's medication of health status has any interaction of adverse effects with the consumption of alcoholic beverages per facility protocol. […]

• No harm, potential for more than minimal, isolatedF692Apr 2, 2026

  Based on a review of the clinical record, review of facility's policy and staff interviews, it was determined that the facility failed to ensure that re-weights were completed in a timely manner for one of 18 clinical records reviewed. (Resident R7). Findings include: Review of the facility policy, Weight, Loss or gain/re-weights, dated July 2, 2023, indicated that the physician, dietician, and MDS (Minimum Data Set- assessment of resident's care needs) Assessment Coordinator will be notified of the results of the monthly weights as indicated in the physician orders. Continued review of the order indicated that for significant weight loss, labs may be recommended to see if indicators of malnutrition are present. […]

• No harm, potential for more than minimal, isolatedF842Apr 9, 2025

  Based on clinical record review and interview with staff, it was determined that the facility did not maintain complete and accurate medical records related to fall investigation for one of eight records reviewed (Resident R6). Findings include: Review of facility reported incidents revealed that resident R6 sustained an unwitnessed fall on January 17, 2025. A request was made to employee E2, the Director of Nursing, at 1:30 p.m. on April 9, 2025, to provide the surveyors with the fall investigation report. On April 10, 2025, at 9:30 a.m. the facility provided the report. Employee E2 stated that they could not find the original report and that she had recapitulated it to a new form. Review of the form revealed that the document was dated as 4-9-25 for event 1-17-25. […]

• No harm, potential for more than minimal, isolatedF812Jul 28, 2023

  Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure foods were stored in accordance with professional standards for food service safety and that dishes were cleaned under sanitary conditions. Findings Include: Review of undated facility policy titled, Labeling and Dating, revealed the facility staff is to label and date all stored foods. Review of facility policy titled, Dishwashing Machine Operation- High Temperature, dated April 7, 2006, revealed staff is to check and record temperatures of wash and rinse water. Wash temperatures should reach 160 degrees Fahrenheit and rinse temperatures must reach at least 180 degrees Fahrenheit. […]