A list of the most recent deficiencies for Sacred Heart Home Inc. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-05 | 2023-02-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-14 | 2023-02-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-14 | 2023-02-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-12-14 | 2023-02-17 | N |
| Post nurse staffing information every day. | Health | 2022-12-14 | 2023-02-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-14 | 2023-02-17 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-12-14 | 2023-02-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-14 | 2023-02-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-12-14 | 2023-02-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-14 | 2023-02-17 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-14 | 2023-02-17 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-12-14 | 2023-02-17 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-12-14 | 2023-02-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-14 | 2023-02-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-14 | 2023-02-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-14 | 2023-02-17 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-12-14 | 2023-02-17 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-03-11 | 2019-04-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-03-11 | 2019-04-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-03-11 | 2019-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-11 | 2019-04-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-11 | 2019-04-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-25 | 2019-03-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-01-25 | 2019-03-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-25 | 2019-03-26 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-01-25 | 2019-03-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-25 | 2019-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-25 | 2019-03-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-09-15 | 2017-10-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-09-15 | 2017-10-31 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-08-31 | 2017-10-20 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-31 | 2017-10-20 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-08-31 | 2017-10-20 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-08-31 | 2017-10-20 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-31 | 2017-10-20 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-31 | 2017-10-20 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-31 | 2017-10-20 | N |
