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Deficiency Records for Sacred Heart Care Center
A list of the most recent deficiencies for Sacred Heart Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Sacred Heart Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-05-02 | 2024-05-30 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-05-02 | 2024-05-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-05-02 | 2024-05-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-02 | 2024-05-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-02 | 2024-05-30 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-05-02 | 2024-05-30 | N |
| Post nurse staffing information every day. | Health | 2024-05-02 | 2024-05-30 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-05-02 | 2024-05-30 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-05-02 | 2024-05-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-02 | 2024-05-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-05-02 | 2024-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-02 | 2024-05-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-05-02 | 2024-05-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-04-30 | 2024-05-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-28 | 2024-03-06 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-13 | 2023-09-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-13 | 2023-09-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-13 | 2023-09-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-07-13 | 2023-09-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-07-13 | 2023-09-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-07-13 | 2023-09-06 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-07-13 | 2023-09-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-13 | 2023-09-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-07-13 | 2023-09-06 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-11 | 2023-09-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-11 | 2023-08-25 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-01 | 2022-04-22 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-20 | 2021-09-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-20 | 2021-09-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-20 | 2021-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-20 | 2021-08-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-20 | 2021-08-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-20 | 2021-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-20 | 2021-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-20 | 2021-08-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-22 | 2021-08-22 | N |
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