Holy Spirit Retirement Home

Inspectors wroteBased on observation, resident interview, staff interview and policy review the facility failed to provide food at an appetizing temperature when mashed potatoes had a temperature of 125 degrees on the steam table before the lunch meal and had a temperature of 121 degrees for a room tray with 2 of 8 residents reviewed (Resident #24 and #40) that had complained about food temperatures. The facility reported a census of 56 residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards. The facility did not label and date open food items, follow best-by dates, discard expired food items, perform hand hygiene prior to or during food services, complete hand hygiene when assisting residents with meals, or wear appropriate hair nets during food preparation. The facility reported a census of 56 residents. Findings Include:On 4/27/26 at 11:00 AM, a continuous observation in the kitchen revealed several improperly dated items. The first stand-up refrigerator contained apple juice with an open date of 4/23/26, grape juice with an open date of 4/23/26, and prune juice with an open date of 2/26/26. [...]

Inspectors wroteBased on observations, staff interviews, Electronic Health Record (EHR) review, resident interviews, family interviews, and policy review the facility failed to utilize Enhanced Barrier Precautions (EBP) during wound care for 2 of 4 residents (Residents #50, and #4). The facility further failed to use universal infection control measures (hand hygiene) during catheter care for 2 of 4 residents (Resident #1, and #2). The facility reported a census of 56 residents. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief interview for Mental Status (BIMS) of 15 that indicated cognitive mental status. Review of Resident #1's EHR page titled, Order Summary Report revealed an order for a Foley catheter size 16 French with a 10 milliliter balloon to be changed monthly and flush catheter with 60-120 cc of normal saline as needed for urine retention. [...]

Inspectors wroteBased on observation, Electronic Health Records (EHR) review, resident interview, staff interviews and policy review the facility failed to provide dignity and respect to a resident who wanted a brief change and staff refused to change the brief for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 56 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #3) reviewed for PASRR requirements. The facility reported a census of 56 residents.

Inspectors wroteBased on observations, staff interviews, Electronic Health Records (EHR) review, and policy review, the facility failed to maintain a professional standard of quality when staff did not apply the prescribed Thrombo-Embolic Deterrent (TED) hose for Resident #7. The facility reported a census of 56 residents.

Inspectors wroteBased on observations, record review and interviews the facility failed to properly use both mechanical stand brakes in a manner that prevented accidents and hazards for 1 of 2 residents reviewed (Resident #21). The facility reported a census of 56 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to provide complete and accurately documented electronic health records for 4 of 5 residents (Residents #2, #5,#6, and #7) reviewed. The facility reported a census of 61 residents.

Inspectors wroteBased on direct observation, resident interviews, staff interviews, and document review the facility failed to provide and document restorative cares for 4 of 4 residents reviewed (Residents #4, #37, #41 and #42). The facility reported a census of 61 residents.

Inspectors wroteBased on review of the planned menu, observations, staff interviews and facility policy review the facility staff failed to follow the planned menu for residents. The facility identified a census of 61 residents.

Inspectors wroteBased on record review, interview, and facility policy the facility failed to have the Medical Director at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 61.

Inspectors wroteBased on observation, interview and record review the facility failed to update the Care Plan for 1 of 17 residents reviewed. Resident #36 was admitted to Hospice on 4/16/25 and staff failed to include a focus area for the special service. The facility reported a census of 61 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate assistance with Activities of Daily Living (ADL) for 2 of 3 residents reviewed (Resident #3 and #19.) Resident #3 required regular toileting and repositioning, she was found to be sitting in a urine saturated brief, and in her wheel chair with her legs dangling without support. Resident #19's urinary catheter was hanging on the bedrail above the bladder. The facility reported a census of 61 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to adequately supervise vulnerable residents to prevent injury for 1 of 3 residents reviewed (Resident #3). Resident #3 was observed to have a bruise on her right cheek that spread up under her eye. Staff hypothesized about the cause, but were unable to fully explain the injury. The facility reported a census of 61 residents.

Inspectors wroteBased on observations, record review, staff and resident interviews, and policy reviews, the facility failed to provide staff with current continuous positive airway pressure (CPAP) machine settings, and failed to monitor and maintain CPAP mask and tubing needs for 2 of 2 residents reviewed (Resident #8 and #42). The facility reported a census of 61.

Inspectors wroteBased on observation, clinical record review, staff and resident interviews, the facility failed to train staff to maintain properly maintain CPAP settings for resident usage for 1 of 2 residents reviewed (Resident #42). The facility reported a census of 61 residents.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that staff used appropriate hand hygiene during resident cares for 1 of 3 residents reviewed, (Resident #3). The facility reported a census of 61 residents.

Inspectors wroteBased 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.

Inspectors wroteBased on personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal Background check and dependent adult/child abuse registry check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff N). The facility reported a census of 63 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, observation, policy review and staff interviews the facility failed to prepare food in a form designed to meet individual needs by sending incorrect consistency for modified diet ordered for 4 of 6 residents reviewed (Resident #33, #35, #39, and #44). The facility reported a census of 63 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to store food and follow proper sanitation to prevent spread of illness in accordance with professional standards for 61 of 63 residents. The facility reported a census of 63 residents.

Inspectors wroteBased on electronic health records (EHR) review, observations, staff interview, policy review and resident family interview the facility failed to provide dignity by leaving food on a residents clothing protector as well as face to 1 of 1 resident reviewed (Resident #44). The facility reported a census of 63 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer one resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #48) reviewed for PASRR requirements. The facility reported a census of 63 residents.

Inspectors wroteBased on clinical record review, observations and staff interview the facility failed to follow a care plan to provide supervision while the resident sat in a wheelchair located in his room for 1 of 21 sampled residents reviewed for comprehensive care plans (Resident #33). The facility reported a census of 63 residents.

Inspectors wroteBased on electronic health records review (EHR), staff interview, and observation the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not accurately measuring supplemental formula according to physician ' s order and pushing medications with a piston syringe into feeding tube for 1 of 1 residents (Resident #24). The facility reported a census of 63 residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility to properly store medications in a locked storage area for 1 or 1 resident observed (Resident #63). The facility reported a census of 63 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, observations, staff interview, and policy review the facility failed to provide complete and accurately documented electronic health records for 1 of 5 resident reviewed (Resident #5). The facility reported a census of 63 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance twice weekly and/or per resident preference for 4 of 4 residents reviewed for bathing (Resident #5, #11, #12, #13).

Inspectors wroteBased on observation, interview and record review the facility failed to keep all residents safe from abuse for 1 of 3 reviewed (Resident #2). Resident #2 had a diagnosis of dementia with behavioral disturbances. Around 8:00 PM, while caring for Resident #2, one of three Certified Nurse Aides (CNA)'s, Staff G, saw another CNA, Staff H, with a closed fist and then heard the hand connect with Resident #2's back. Staff G said Staff H and Resident #2 exchanged cuss words between the two. According to the CNA in training, Staff E, she didn't see Staff H hit Resident #2 but did hear him ask why she hit him. Staff G reported that she didn't intervene and was in shock after the situation. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate assessments and interventions for 2 of 2 residents reviewed (Residents #2 and #6). The facility failed to provide treatment for Resident #2's chronic sores on his legs as ordered and failed to notify the doctor when his wounds changed. The facility failed to offer to apply Resident #6's edema wear to treat his edema (swelling) of his left leg as ordered and charted the treatment as refused.