Sacred Heart Care Center

In the surveyor’s words

From the most serious findings on record at Sacred Heart Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF726Jul 25, 2025

  Based on observation, interview and document review, the facility failed to ensure staff were appropriately trained and educated on how to identify and report mechanical lift maintenance concerns to prevent accidents and hazards. This practice had the potential to affect 11 of 11 residents who were assessed to use the mechanical lifts and stands.Findings include:Review of July 2025 mandatory training skills fair attendance sheet identified 27 of 88 nursing staff had completed the competency checklist.During an observation and interview on 7/21/25 at 1:42 p.m., nursing assistant (NA)-B identified 2 mechanical lifts labeled 31, 32 and 30 a sit to stand lift was missing rubber sling stoppers on the 4-point sling support hook. […]

• No harm, potential for more than minimal, widespreadF727May 2, 2024

  Based on interview and record review the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day on 10/7/23 and 10/21/23. Findings include: A review of the facility schedule was completed for the dates of 10/1/23 through 12/31/23. Upon this review, it was identified there was a lack of RN coverage for eight consecutive hours on 10/7/23 and 10/21/23. During interview on 5/2/23, at 3:20 p.m. the director of nursing (DON) stated she had been unaware of any days where there was not an RN on the schedule for a minimum of eight consecutive hours. DON stated she had reviewed the schedules for those dates identified, and verified there was not RN coverage for eight consecutive hours on the dates listed. During interview on 5/2/23, at 4:00 p.m. […]

• No harm, potential for more than minimal, widespreadF865May 2, 2024

  Based on interview and document review the facility failed to provide policies and procedures for their quality assurance and quality improvement committee (QAPI). This had the potential to effect all 49 residents currently residing in the facility. Findings include: During entrance conference on 4/29/24, at 1:44 p.m. a copy of the facilities QAPI plan was requested from the director of nursing (DON). The facility provided a Quality Assurance and Performance Improvement (QAPI) Plan Sacred Heart Care Center, Inc. document, reviewed and updated on 9/10/21. This document included the following: Vision Statement, Mission Statement, QAPI statement, QAPI Guiding Principles, and the Scope of QAPI. […]

• No harm, potential for more than minimal, widespreadF880May 2, 2024

  Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene and donning/doffing of personal protective equipment (PPE) were put into place for 4 of 4 residents (R10, R16, R22, and R45) In addition, the facility failed to complete contact source tracing during two outbreaks (norovirus and COVID-19). This deficient practice had the potential to affect all 49 residents who resided in the facility. Further, the facility failed to perform hand hygiene and PPE audits to ensure proper technique. […]

• No harm, potential for more than minimal, widespreadF880Jul 13, 2023

  Based on observation, interview, and document review, the facility failed to adequately follow water management program to consistently monitor water temperatures and implement corrective action when water temperatures were out of range for Legionella (a bacteria causing pneumonia and flu-like symptoms) prevention, which had the potential to affect all 52 residents residing within facility. Findings include: On 7/12/23 at 10:44 a.m., during observation and interview of boilers/storage tanks completed with maintenance (M)-A; temperature to boiler #1- 175 degrees Fahrenheit (F), temperature to boiler #2- 205 degrees F, temperature to storage tank #1- 144 degrees F, temperature to storage tank #2- 114 degrees F. […]