Ascension Living Sacred Heart Village

In the surveyor’s words

From the most serious findings on record at Ascension Living Sacred Heart Village, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 23, 2022

  Based on observation, interview, and record review, the facility failed to prevent abuse for 1 of 4 residents reviewed for abuse (Resident B). Applying the reasonable person concept, emotional distress and possible fear could occur after physical abuse from staff member. Findings include: On 8/22/22 at 12:42 P.M., Resident B's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided on the secured memory care unit. MDS (Minimum Data Set) assessments, dated 11/2/21, 1/25/22, and 4/26/22, indicated the resident had severely impaired cognition and mood indicators of depression which were as follows: -Annual MDS 11/2/21-Mood indicators were feeling down (1 day), trouble sleeping, and little energy (2-6 days). […]

• No harm, potential for more than minimal, widespreadF812Jan 9, 2026

  Based on observation, interview, and record review the facility failed to ensure dishes and equipment were stored in sanitary conditions, unit refrigerators were maintained and were free of expired foods for 99 of 99 residents residing in the facility who consumed food prepared in the kitchen.Findings include:During an observation, on 1/5/26 at 9:16 AM, the following was observed:A nested stack of stainless steel, 6-inch containers had moisture between 3 of 6 pans observed. A dietary staff member was observed taking 6 wet, plate sized, lids out of the dishwashing area and stacking them for storage.During an observation, on 1/05/2026 at 2:00 PM, the Unit B pantry refrigerator had 2 chocolate Glucerna liquid supplements with expiration dates of 8/1/25. […]

• No harm, potential for more than minimal, widespreadF812Dec 19, 2024

  Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food storage and serving practices for 5 of 5 observations. Food prepared in the kitchen was consumed by 74 of 74 residents who lived in the facility. Findings include: During a continuous observation on [DATE] from 10:16 AM - 11:00 AM the following observations were made: A countertop had open slotted drains and a brown, murky liquid puddle under the countertop. The opened bag of french fries and bread were not dated in Freezer 1. Freezer 2 had whipped cream in a bag not labeled or dated. The whipped cream was unsealed and open to air. The opened bag of macaroni was not dated in the dry pantry. […]

• No harm, potential for more than minimal, patternF761Jan 9, 2026

  Based on observation, interview and record review, the facility failed to ensure safe storage of medications for 6 of 15 residents observed (Resident 6, Resident 38, Resident 51, Resident 73, Resident 10, and Resident 4).Findings include:1.During an observation on 01/07/2026 8:51 AM, Registered Nurse (RN) 2 opened the top drawer of a medicine cart positioned outside the main dining room. 3 cups of pills were in a divided compartment of the drawer, positioned together with the cups touching. A cup labeled with Resident 6's first name contained 7 pills. A cup with Resident 38's name contained 8 pills. A cup with Resident 51's name had 10 pills. A cup labeled with Resident 73's name was in the same cart section separated from the others by a box and contained 11 pills. […]

• No harm, potential for more than minimal, patternF921Jan 9, 2026

  Based on observation, interview, and record review the facility failed to ensure ceiling tiles were maintained in 5 of 5 resident rooms reviewed. Findings include:During an observation starting on 01/05/2026 at 9:52 AM, the following was observed: Room A-15 had 2 areas of discolored ceiling tiles. 2 round areas with an irregularly round, brown outline surrounding black centers approximately 1/8th of a ceiling tile.Room A-18 had 6.25 ceiling tiles with 15 round areas of discoloration. In a line parallel to the hallway, 5 areas had round black centers measuring approximately 1-4 inches in diameter. An irregularly round brown outline surrounded the black colored areas of discoloration. […]