Sacred Heart Care Center

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a process was in place to maintain 4 of 4 MedCare mechanical lifts and 2 of 4 MedCare sit to stands. This practice had the potential for unsafe transfers of 11 of 11 residents (R6, R16, R19, R23, R27, R35, R38, R42 R4, R20, R33) when it was identified the equipment used was missing safety parts used to help prevent accidents and hazards and equipment was not routinely maintained per manufacturer's recommendation.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed for 1 of 2 resident (R3) reviewed for PASARR R3's Minimum Data Set (MDS) assessment dated , 4/23/25, indicated R3 had intact cognition, adequate hearing, clear speech, can understand others, and able to make needs known. [...]

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess past trauma and implement individualized care plan interventions utilizing a trauma-informed approach for 1 of 2 residents (R3) reviewed who had post-traumatic stress disorder (PTSD) symptoms.

Inspectors wroteBased on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employees would be able to return to work after an illness, dependent upon their symptoms for 2 of 3 sampled staff (certified nursing assistant (NA)-Y and dietary aide (DA)-A). This had the potential to affect all 50 residents, staff and visitors.

Inspectors wroteBased on interview and document review the facility failed to implement their abuse prohibition policy when there was an allegation of misappropriation of resident property for 1 of 1 resident (R1) reviewed for drug diversion.

Inspectors wroteBased on interviews and document review the facility failed to report to state agency (SA) potential misappropriation of resident property (missing narcotics) no later than twenty-four after an allegation was made for 1 of 3 resident (R1) reviewed for narcotic diversion.

Inspectors wroteBased on observation, interview, and document review the facility failed to implement policies and procedures to ensure accurate reconciliation of controlled substances to ensure rapid detection of potential narcotic diversion for 2 of 3 residents (R1, R3) reviewed for medication pass who received narcotic medications.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 1 of 1 resident (R32) observed with medications at bedside.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide opportunities for participation in the activities of choice (walking outside) for 1 of 1 residents (R44), reviewed for choices.

Inspectors wroteBased on interview and document review, the facility failed to provide the resident or their representative a written bed hold policy at the time of hospital transfer for 1 of 3 residents (R21) who was reviewed for hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently follow orders for application of splints for 1 of 2 residents (R15) reviewed for limited range of motion.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure respiratory equipment was changed weekly according to professional standards to prevent infection for 1 of 1 resident (R29) reviewed for respiratory care.

Inspectors wroteBased on interview and document review, the facility failed to develop an antibiotic stewardship program which included the development of protocols and a system to monitor antibiotic use for 1 of 1 resident (R27) who was prescribed antibiotics prophylactically.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the required and complete nurse staffing information was posted and readily available for viewing by the residents and visitors. Additionally, the facility failed to maintain the staffing logs for 18 months, as required, in the event this information was needed for review. This had the potential to affect all 49 residents and visitors who wanted to review the information.

Inspectors wroteBased on interview and document review, the facility failed to submit complete and accurate direct care staffing information during 1 of 1 quarters (Quarter 1) reviewed for payroll based journal (PBJ).

Inspectors wroteBased on interview and document review the facility failed to ensure infection control data and performance improvement plans were incorporated into the facility-wide Quality Assurance and Performance Improvement (QAPI) Plan. In addition, the facility failed to provide documentation to reflect systems management, tracking and trending of infection control program, and performance improvement plan process and progress. This had the potential to effect all 49 residents currently residing in the facility.

Inspectors wroteBased on document review and interview, the facility failed to demonstrate routine attendance and participation in the QA/QAPI process for 1 of 1 medical director (MD) required to be in attendance quarterly at Quality Assurance Performance Improvement (QAPI) meetings.

Inspectors wroteBased on interview and document review the facility failed to have a policy consistent with federal requirements for reporting allegations of abuse to the State Agency immediately but no later than two (2) hours. This had the potential to affect all residents that reside at this facility.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interview, the facility failed to ensure doses of controlled substances were stored in a manner to reduce the risk of theft and/or diversion in 1 of 1 refrigerators and emergency kit (E-kit) observed for medication storage. This had the potential to affect all residents in the facility.

Inspectors wroteBased on interview and document review the facility failed to provide evidence pneumococcal vaccinations were up to date for 4 of 5 residents (R11, R20, R22, R28, R202) reviewed for vaccinations.

Inspectors wroteBased on observation, interview, and document review, facility failed to ensure a comfortable environment, having hot water available for 2 of 2 residents (R3, R21), who were reviewed for concerns with cold water to resident bathroom sinks.

Inspectors wroteBased on interview and document review the facility failed to ensure an appropriate discharge summary had been completed for 1 of 1 resident (R51) who was discharged to home.

Inspectors wroteBased on observation, interview, and document review, the facility failed to reassess residents for restorative services and provide restorative services to maintain and/or prevent loss of range of motion (ROM) with and without contractures for 3 of 3 residents (R9, R35 and R16 ) reviewed for limited ROM.

Inspectors wroteBased on observation and interview, the facility failed to ensure food brought in from home was dated and stored separately from facility food for 2 of 2 residents (R32, R202) reviewed for food storage.