Sacred Heart Nursing Home

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Maintain the main kitchen and kitchen extension on the second floor in a clean and sanitary condition; and2. Maintain four of four kitchenettes in a clean and sanitary condition.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#2), out of a total sample of 24 residents, received the necessary care and treatment to prevent and promote healing of pressure injuries. Specifically, the facility failed to ensure a Resident at risk for skin breakdown with a contracted left upper extremity (LUE) did not develop a Stage 4 Pressure Injury (full thickness skin and tissue loss, potentially exposing muscle, tendons, ligaments, cartilage, or bone, with a high risk of infection and slow healing) to the LUE.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for one Resident (#85), out of a sample of 24 residents. Specifically, the facility failed to ensure staff utilized the appropriate personal protective equipment (PPE) when entering the room of Resident #85 who had an active diagnosis of Clostridioides difficile (formerly known as Clostridium difficile and often called C. diff, which is a bacterium (germ) that causes diarrhea and colitis (inflammation of the colon) and was on contact plus precautions.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain safe and clean equipment and ensured that food was stored properly, in three out of four kitchenettes.

Inspectors wroteBased on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program.

Inspectors wroteBased on observation and interview, the facility failed to ensure a functional, safe, and clean environment on two (2PY and 3PY) of four units in the facility. Specifically, the facility failed to ensure sharps containers were replaced when two thirds to three-quarters full to decrease the risk of needlestick injuries and exposure to bloodborne pathogens.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a person-centered plan of care which included care for residents who had experienced trauma and the identification of potential triggers to be avoided to help prevent potential re-traumatization for two Residents (#120 and #30), out of a total sample of 24 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that met professional standards of practice for one Resident (#57), out of a total sample of 24 residents. Specifically, the facility failed to ensure the Resident's foam dressing to the left heel unstageable deep tissue injury (DTI- pressure injury where the depth of the ulcer is obscured by a layer of dead tissue, or slough and/or eschar, covering the wound bed) was changed in accordance with the physician's order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two Residents (#57 and #96), out of a total sample of 24 residents, received care and treatment to prevent and to promote the healing of pressure injuries consistent with professional standards of practice. Specifically, the facility failed: 1. For Resident #57, who had an existing left heel unstageable deep tissue injury (DTI- pressure injury where the depth of the ulcer is obscured by a layer of dead tissue, or slough and/or eschar, covering the wound bed), to consistently implement physician's orders to offload the Resident's heels and adjust the low air loss (LAL) mattress (distributes body weight over a broad surface area to help prevent skin breakdown) per physician's orders and care planned interventions; and 2. [...]

Inspectors wroteBased on record review and interviews, the facility failed to identify the potential triggers to be avoided in two Residents (#120 and #30), with a history of trauma, to help prevent potential re-traumatization out of a total sample of 24 residents.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert and oriented, frequently incontinent but able to made his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 03/18/24, Certified Nurse Aide (CNA) #1 spoke to Resident #1 in degrading and insulting manner

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 3/18/24, Resident #1 told Certified Nurse Aide (CNA) #2 and Nurse #1 that CNA #1 had made an inappropriate and insulting statement to him/her, and although Nurse #1 told her supervisor (Nurse #3), about Resident #1's allegation and provided Nurse #3 with a written statement about the allegation, Nurse #3 did not immediately notify the Administrator and/or Director if Nurses (DON), but instead placed Nurse #1's written statement in the DON's mailbox where it was not seen or brought to Administration's attention for around 36 hours.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents on 2 of 4 units had a comfortable and homelike dining experience. Specifically, residents were provided meals on overbed tables while still on the food tray and inside heating elements, residents seated in the same area were provided meals at different times, staff stood while assisting residents with eating and residents not in a common area were placed in the doorway of their room to eat.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two Residents (#73 and #116), in a sample of 24 residents, had been seen by a physician every 30 days for the first 90 days of admission and then every 60 days thereafter and that required visits alternated between the Physician and the Nurse Practitioner. Specifically, the facility failed to ensure for 1. Resident #73, required visits alternated between the Physician and the Nurse Practitioner; and 2. Resident #116, visits occurred every 30 days for the first 90 days of admission.

Inspectors wroteBased on observations and interviews, the facility failed to provide food that was palatable and at a safe and appetizing temperature.

Inspectors wroteBased on record review and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#15), out of 24 sampled residents. Specifically, the facility failed to develop a care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed for one Resident (#70) to provide an ongoing activity program to meet and support the individual preferences of the resident, out of a total sample of 24 residents. Specifically, the facility failed to provide support for the Resident to pursue their one to one (1:1) preferred activities of choice in the Resident's room.

Inspectors wroteBased on observation, record review, and interview, the facility failed to reassess and document a clinical rationale for continued antibiotic use for one Resident (#15), out of a total sample of 24 residents. Specifically, the facility failed to ensure the Physician re-evaluated the use of Mucinex (generic name guaifenesin; used to help clear mucus or phlegm from the chest when you have congestion) following a hospitalization for pneumonia.

Inspectors wroteBased on observation, record review, document review, and interview, the facility failed for one Resident (#4), out of a sample of 24 residents to administer Eliquis timely and consistently per administration guidelines.