Holy Spirit Retirement Home

In the surveyor’s words

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

• Actual harm, isolatedF684Nov 30, 2021

  Based on observations, staff and resident interviews and record review the facility failed to identify and report change of condition to the physician in a timely manner and to provide adequate assessment and intervention for 4 of 36 residents reviewed. Residents #55, #001, #113, and #002 experienced a change in condition and the facility failed to ensure that pertinent information was communicated to the physician and that they received a timely response. Facility census was 55 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] assessed Resident #55 with a Brief Interview for Mental Status (BIMS) score of 13 (no cognitive impairment). The MDS showed that the resident required extensive assistance of one staff for transfers and toileting and set up only for eating. […]

• Actual harm, isolatedF686Nov 30, 2021

  Based on observation, staff and resident interview and record review the facility failed to ensure residents received adequate monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents #17, #40, #109 and #34 had incomplete skin evaluations and/or missed wound treatments. The facility reported a census of 55 residents. Findings include: The MDS (Minimum Data Set) assessment identified the definition of pressure ulcers: Stage I : intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• Actual harm, isolatedF689Nov 30, 2021

  Based on record review, observation, staff and resident interview, the facility failed to provide adequate nursing supervision to prevent injuries for 8 of 36 residents reviewed (Residents #16, #33, #40, #48, #50, #110, #00 and #112). The facility reported a total census of 55 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] assessed Resident #16 with a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment). The MDS identified the resident with the following sign of delirium: disorganized thinking that fluctuated. The MDS identified the resident as independent with transfer, ambulation and toileting. A balance during transitions and walking identified the resident as steady at all times in all areas of testing. […]

• No harm, potential for more than minimal, widespreadF880May 22, 2024

  Based on observation, record review, document review, and staff interview the facility failed to provide appropriate infection prevention practices by not completing appropriate hand hygiene, failed to develop policies related to COVID-19 vaccinations, and not following guidelines for enhanced barrier precautions for 63 of 63 residents reviewed. The facility reported a census of 63 residents. Finding include: 1. The Minimum Data Set (MDS) for Resident #24, dated 3/18/2024 documented a Brief Interview for Mental Status of 13 indicating no cognitive impairment. The MDS documented a feeding tube present while a resident. On 5/21/24 at 7:52 AM an observation of Staff E Licensed Practical Nurse (LPN) revealed no hand hygiene prior to entering Resident #24 ' s room. […]

• No harm, potential for more than minimal, widespreadF886Nov 30, 2021

  Based on record review and staff interview, the facility failed to provide Covid-19 testing for staff, based on parameters set forth during a facility outbreak period with onset of 10/04/21 thru 11/03/21. The facility reported a census of 55 residents. 1. CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP): During the Coronavirus Disease (Covid-19) Pandemic, dated 09/10/2021, documented following a high risk exposure for HCP to conduct two [CONDITION(S)] tests for [CONDITION(S)]-CoV-2 infection. The CDC recommended testing to be documented and to occur immediately, and if negative, repeat again 5-7 days after the exposure. […]