Holy Cross Rehabilitation and Wellness

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure wound treatment orders were obtained timely and wound treatments were completed and signed out as ordered for 2 of 2 residents reviewed for non-pressure related skin conditions. (Residents B and C)Findings Include:1. Resident B's record was reviewed on 3/12/26 at 10:00 a.m. The diagnoses included, but were not limited to, diabetes, atrial fibrillation, high blood pressure, and GERD.The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact for daily decision making. The resident had a surgical wound prior to admission. A Care Plan, dated 2/5/26, indicated the resident had alteration in skin integrity related to an incision of the scrotal and perineal area. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were implemented regarding glove change and hand hygiene during a dressing change. In addition, the facility failed to ensure nursing staff understood the required protective equipment needed to care for a resident requiring Enhanced Barrier Precautions for 1 of 2 resident's reviewed for non-pressure skin conditions. (Resident C)

Inspectors wroteBased 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).

Inspectors wroteBased on interview and record review, the facility failed to effectively act and resolve Resident Council's concerns related to long call light response times. This failure affected 2 of 7 residents attending the Resident/Surveyor group meeting. Findings Include: During a Resident/surveyor meeting on 4/22/25 at 12:59 P.M., seven of seven residents indicated the Resident Council had complained about long wait times for their call lights to be answered. Two of seven residents reported they were experiencing continued delays, and Resident B stated he had waited as long as an hour within the past couple of weeks. A review of Resident Council meeting minutes revealed repeated concerns over the past year about delayed call light responses on the following months: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the Discharge Minimum Data Set (MDS) assessment was completed and submitted in a timely manner for 1 of 4 residents who were reviewed for discharge assessments. (Resident 29)

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for 2 of 17 residents reviewed for care planning ( Resident 22-bowel issues) and (Resident 27-skin issues).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the skin of a resident with a Gastronomy tube (G-tube) did not develop blisters caused by the friction from the G-tube for of 1 of 6 residents who were reviewed for skin problems. (Resident 27)

Inspectors wroteBased on record review and interviews, the facility failed to ensure there was adequate monitoring of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 25)

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen equipment was in working order for 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 66 of 66 residents who received meals from the kitchen.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure enhanced barrier precautions were followed for 2 of 5 residents reviewed for isolation needs. (Resident 27 and 35)

Inspectors wroteBased on observation and interview the facility failed to ensure water faucets were functional in 4 of 30 rooms in the long term care unit. (Rooms W7, W12, W15 and W24)

Inspectors wroteBased on record review and interviews the facility failed to ensure a resident received the required transfer assistance for 1 of 2 residents reviewed for accident hazards. (Resident E)

Inspectors wroteBased 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.

Inspectors wroteBased 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

Inspectors wroteBased on interview and record review, the facility failed to provide the resident or representative, a notice of transfer/discharge or a copy of the bed hold policy for 1 of 1 resident reviewed for hospitalizations. (Resident 65)

Inspectors wroteBased on record review and interview, the facility failed to develop a person-centered care plan addressing depression for 1 of 21 residents whose care plans were reviewed. (Resident 53)

Inspectors wroteBased on record review, and interview, the facility failed to ensure care plans were revised and care conferences were held quarterly for 2 of 3 residents reviewed for care planning. (Resident 37 & 58)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to bed baths, shaving, and turning and positioning per standards of care for 2 of 3 residents reviewed for ADL care. (Resident 37 & 46)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a limited range of motion received appropriate treatments and services to prevent further decrease in range of motion for 1 of 3 residents for range of motion. (Resident 46)

Inspectors wroteBased on observation and interview, the facility failed to ensure medications stored in the med cart were labeled according to accepted professional standards for 1 of 3 medication carts observed. (St. John's Way medication cart)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice for infection control to help prevent the development and transmission of communicable diseased and infections for 1 of 3 residents who received pressure ulcer care requiring enhanced barrier precautions (EBP) and 1 of 4 residents observed during medication administration. (Residents 181 and 16)

Inspectors wroteBased on observation, record review and interview, the facility failed to assess and monitor a wound for 1 of 1 residents reviewed for skin conditions. (Resident 45)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the physician's order was followed regarding pressure ulcer treatment for 1 of 3 residents reviewed for pressure ulcer care. (Resident 42)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure narcotics were stored appropriately and failed to ensure liquid medications were dated when opened for 1 of 1 narcotic storage areas and 1 of 12 residents whose medications were observed. (Rehab Narcotic Drawer and Resident 202)