Holy Family Manor

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Aug 18, 2022

  Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and failed to maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Sanitation and Infection Control, Receiving and Storage, dated [DATE], revealed that food items were to be dated and rotated using the First in-First out system. Upon opening a food item, it was to be dated with the opened date. Observations made during the initial tour of the kitchen on [DATE], at 10:15 a.m., revealed in the walk-in cooler there were mandarin oranges with a use by date of [DATE], navy beans in liquid with a use by date of [DATE], and an uncovered container of romaine lettuce not dated. […]

• No harm, potential for more than minimal, isolatedF552Jun 3, 2026

  Based on a review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to inform a resident and/or responsible party, in advance, of a treatment and treatment options prior to receiving psychotropic medication for one of 19 sampled residents. (Resident 67)Findings include: Review of facility documentation entitled, Informed Consent for Psychotropic Medication Use, revealed that before receiving any psychotropic medication, an informed consent must be obtained. The resident or responsible party was to receive information and education regarding the benefits and potential side effects of the psychotropic medication. […]

• No harm, potential for more than minimal, isolatedF554Jun 3, 2026

  Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 19 sampled residents. (Resident 60)Findings include: Review of facility policy entitled, Self-Administration of Medications/Bedside Medication Storage, last reviewed April 28, 2026, revealed that a resident may exercise the right to self-administer medications when determined that this practice is safe. […]

• No harm, potential for more than minimal, isolatedF580Jun 3, 2026

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the responsible party was notified of a change in condition for one of 19 sampled residents. (Resident 67)Findings include: Review of the facility policy entitled, Change in Condition- Notification of Change, dated April 28, 2026, revealed the resident and the resident's legal representative/family, would be notified of any change in condition which included a change in behavior, medications, activities of daily living, a new onset of pain, and a change in treatment. Clinical record review revealed that Resident 67 had diagnoses that included metabolic encephalopathy (brain dysfunction), dementia, and muscle weakness. […]

• No harm, potential for more than minimal, isolatedF605Jun 3, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to offer non-pharmacological interventions prior to the administration of as needed anti-anxiety medications for one of 19 sampled residents. (Resident 67)Findings include: Review of the facility policy entitled, Change in Condition- Notification of Change, dated April 28, 2026, revealed the resident and the resident's legal representative/family, would be notified of any change in condition which included a change in behavior, medications, activities of daily living, a new onset of pain, and a change in treatment. Clinical record review revealed that Resident 67 had diagnoses that included metabolic encephalopathy (brain dysfunction), dementia, and muscle weakness. […]