Deficiency Records for Ascension Living Sacred Heart Village
Updated as of March 01, 2024
A list of the most recent deficiencies for Ascension Living Sacred Heart Village. 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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2024-01-29 | 2024-02-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-29 | 2024-02-20 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2024-01-29 | 2024-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-29 | 2024-02-20 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2024-01-29 | 2024-02-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-01-08 | 2024-01-26 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-08 | 2024-01-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-08 | 2024-01-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-08 | 2024-01-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-08 | 2024-01-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-08 | 2024-01-26 | 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 | 2024-01-08 | 2024-01-26 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-08-28 | 2023-10-02 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-19 | 2023-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-19 | 2023-03-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-19 | 2023-03-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-19 | 2023-03-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-09 | 2023-01-30 | 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 | 2023-01-09 | 2023-01-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-23 | 2022-09-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-23 | 2022-09-09 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-24 | 2022-04-11 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-14 | 2022-01-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-03 | 2021-12-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-03 | 2021-12-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-12-03 | 2021-12-27 | N |
