Sacred Heart Care Center
1200 12th Street Southwest, Austin, MN 55912 · Non profit - Corporation · 59 certified beds · (507) 433-1808 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.3% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.7% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.5% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 9.1% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 4.5% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 4.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.2% | 20.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 7.2% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 5.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 16.0% | 24.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.2% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.4% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 71.0% | 82.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 32.9% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 23.6% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.90 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.78 | 1.90 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
44.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.4%CMS range 31.9–58.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.4–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 59.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 45.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 27.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 93.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 10.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 3.5–13.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 59 beds and averages 48.6 residents a day — about 82% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.66 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.79 hrs/resident/day on weekends vs 5.98 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.19 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · F2025-07-25 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
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. NA-B identified only a few of the mechanical lifts in the facility had rubber sling stoppers in place and nursing staff was directed to use the mechanical lifts for resident transfers. NA-B acknowledge the rubber sling stopper was to prevent the slings from sliding out of the sling support bar during transfers and to prevent resident falls from the lift, if not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Finding includes:R6, R16, R19, R23, R27, R35, R38, R42, R4, R20 and R33, care plans included nursing staff to provide 2-person assistance for transfers and mobility either with a mechanical lift or a sit to stand lift.During an observation and interview on [DATE] at 1:42 p.m., nursing assistant (NA)-B identified 2 mechanical lifts labeled 31, 32 and a sit to stand lift numbered 30 missing rubber sling stoppers on the 4-point sling support hook. NA-B indicated a few of the mechanical lifts in the facility had rubber sling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-25 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.R3 was admitted on [DATE] with diagnoses of Personality Disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems), Suicidal Ideation ((SI) thinking about or planning to harm yourself), Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Generalized Anxiety Disorder (mental health condition characterized by persistent and excessive worry about a variety of events or activities), and Post-traumatic Stress Disorder (mental health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-25 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:R3's Minimum Data Set (MDS) assessment dated [DATE] indicated R3 had intact cognition, adequate hearing, clear speech, can understand others, adequate hearing, and able to make needs known.R3 was admitted on [DATE] with diagnoses of Personality Disorder ((PD) a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems), Suicidal Ideation ((SI) thinking about or planning to harm yourself), Major Depressive Disorder ((MDD) mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Generalized Anxiety Disorder ((GAD) mental health condition characterized by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: Review of Employee Illness logs from May through July 2025 identified the following areas of documentation: department, employee name, job title, symptom onset, illness reported, last shift worked, resolution date, return to work, specimen source, and treatment results. However, the facility did not accurately complete the logs to ensure all necessary information was monitored or identified how staff were cleared to return to work. Review of Centers for Disease Control (CDC) article, Norovirus, located at https://www.cdc.gov/norovirus/about/index.html, identified Norovirus is a contagious virus that spreads through direct contact with another person. Symptoms develop 12 to 48 hours after being exposed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-29 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: R1's face sheet dated 4/29/25, identified diagnoses of dementia (memory loss), bipolar disorder (disorder associated with episodes of mood swings), and chronic kidney disease (damage to the kidneys). R1's hospice orders dated 3/18/25, identified morphine sulfate (a medication used for pain) and lorazepam (medication used for anxiety). Licensed practical nurse (LPN)-E sent an email on 4/11/25 at 10:57 p.m.,to registered nurses (RN)-B, RN-C, RN-D, and interim director of nursing (IDON) identifying R1's liquid morphine bottle was way off. There were 16.5 milliliters (ml) in the bottle and at the end of her shift there was 12 ml left in the morphine bottle. LPN-E requested the nurse managers to look into the situation and identifed the narcotic page number. Follow up email dated 4/11/25 at 10:59 p.m., identified RN-B replied to LPN-E asking if…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-29 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings included: R1's face sheet dated 4/29/25, identified diagnoses of dementia (memory loss), bipolar disorder (disorder associated with episodes of mood swings), chronic kidney, and chronic kidney disease (damage to the kidneys). R1's hospice orders dated 3/18/25, identified morphine sulfate (a medication used for pain) and lorazepam (medication used for anxiety). During an interview on 4/29/25 at 12:31 p.m., registered nurse (RN)-B stated she received an email on 4/11/25 at around 11:00 p.m., from one of the nurses stating that one of R1's narcotic count was not correct in the narcotic record. RN-B stated she responded via email on 4/11/25, however, did not call the facility until the next day to begin determination of the missing narcotics. RN-B stated she did not report R1's missing medication to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-29 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: R1's face sheet dated 4/29/25, identified diagnoses of dementia (memory loss), bipolar disorder (disorder associated with episodes of mood swings), and chronic kidney disease (damage to the kidneys). R1's hospice orders dated 3/18/25, identified morphine sulfate (a medication used for pain) and Lorazepam (medication used for anxiety). Review of R1's Individual Narcotic Record for morphine sulfate concentrate (RX#233843) identified the following: -Page 69 of the narcotic record identified on 3/18/25 (RX# 2333843) 30 milliliters (ml) was received from pharmacy. On 4/1/25 remaining amount was 22.50 ml and was transferred to page 79. -Page 79 of the narcotic record identified on 4/1/25 (RX# 2333843) 22.50 ml moved from page 69. On 4/13/25 remaining…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-05-02 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
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. the administrator stated she had been unaware of the any days where the facility lacked eight consecutive hours with RN coverage. The administrator stated she had reviewed the schedules as outlined above, and verified both with the schedules and time card entries there was not eight consecutive hours of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-05-02 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
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. The document identified the QAPI program; assessed quality in all areas, aimed for safety and high quality with all clinical interventions, used the best available evidence to determine appropriate care, and defined measures and goals. The document indicated the QAPI program provided guidelines for supervisors and the nursing home board. The document also listed the resources available for QAPI,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · Fcited before2024-05-02 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Findings include: ENHANCED BARRIER PRECAUTIONS, (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities), PPE USE AND HAND HYGIENE Review of CDC guidance, dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) indicated examples of high-contact resident care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R32's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R32 had intact cognition and required assistance with all activities of daily living (ADL)'s. R32's diagnoses included Parkinson's disease with dyskinesia (uncontrollable and involuntary movements of the body), heart failure, hypertension (high blood pressure), renal failure (condition in which the kidneys can no longer adequately filter waste products from the blood), Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior) and depression. R32's care plan dated 3/20/24, indicated R32 did not want to self-administer or was not currently self-administering medications. During observation and interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: R44's initial Minimum Data Set (MDS) assessment, completed on 8/3/23, indicated her medical diagnoses included coronary artery disease, hypertension, and anxiety and was cognitively impaired. MDS also identified R44 was able to express herself and be understood, and was able to understand others. R44's responses regarding her preferences for customary and routine activities identified R44 consistently responded it was very important for her to be around animals and to go outside to get fresh air when the weather was good. R44's care plan, last reviewed on 3/20/24, identified the following diagnoses; impaired mobility due to lower back pain; anxiety; frailty; age related physical debility; and cognitive deficit due to dementia. The care plan identified a strength of R44 was her ability to walk independently with a four wheeled walker. Although it was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R21's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R21 had intact cognition and required assistance with all activities of daily living (ADL)'s. R21's diagnoses included schizoaffective disorder (mental disorder characterized by abnormal though processes and an unstable mood), heart failure, hypertension, peripheral vascular disease (vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain), renal failure, schizophrenia (mental disorder characterized by reoccurring episodes of psychosis that are correlated with a general misperception of reality), and chronic obstructive pulmonary disease (progressive lung disease). R21's progress notes indicated R21 was hospitalized on [DATE] and returned to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R15's quarterly minimum data set (MDS) assessment dated [DATE] indicated R15 was moderately cognitively impaired, had no history of rejection of care/behaviors, was dependent on staff for all activities of daily living (ADL's), and had limited range of motion on both upper extremities. R15's Careplan dated 3/14/2024 indicated staff were to put on white hand splints in the morning and remove them at 3 pm. R15's care plan further indicates resident was dependent for showering/bathing, upper and lower body cares. R15's skin integrity care plan indicated R15 had bilateral hand contractures (tightening of muscles and ligaments causing joint deformity). R15's provider orders, active as of 5/1/2024, indicated please place hand rolls (bilateral) from morning AM till 3 pm daily. Watch for redness. R15's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 had intact cognition and was independent with all activities of daily living (ADL)'s. R29's diagnoses included dyspnea (feeling that you can't get enough air into your lungs), anxiety disorder, depression, Post Traumatic Stress Disorder (PTSD) and slow transit constipation. R29's care plan dated 4/3/24, indicated R29 had potential for altered airway clearance related to sleep apnea and dyspnea. Interventions indicated SPO2 (pulse oximeter reading which indicates what percentage of your blood is saturated) as ordered and prn. The care plan lacked interventions related to oxygen tubing, bubbler, or humidified oxygen. R29's orders dated 2/8/24, indicated R29 received humidified oxygen two liters…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R27 had intact cognition and required supervision/assistance with all activities of daily living (ADL)'s. R27's diagnoses included type 1 diabetes mellitus, cancer, hypertension, renal failure, anxiety disorder, Waldenstrom macroglobulinemia (rare, slow-growing type of cancer that affects white blood cells called plasma cells and lymphoplasmacytoid cells), encephalitis (inflammation of the active tissues of the brain caused by an infection or an autoimmune response), auditory and visual hallucinations. The MDS also indicated that R29 received an antibiotic. R27's physician orders, printed 5/2/24, indicated R27 received Bactrim 400-80 mg tablet once daily at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-13 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. M-A indicated water was heated from boilers and passed to storage tanks, storage tank #1 to have a temperature maintained at 180 degrees F, tank #2 to have a temperature maintained at 115 degrees F. Record review of facility temperature checks to boilers and storage tanks, reviewed from 1/1/23-7/12/23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-13 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: During tour of the facilities only medication room on 7/12/23 at 9:30 a.m., licsensed practical nurse (LPN)-B entered the medication room without use of key. LPN-B indicated the ice machine is in this room so the room is not locked. LPN-B opened the refrigerator with one key. Inside the refrigerator were 7 square metal boxes with a key lock on the top. LPN-B removed each metal box from the refrigerator and opened each without using a key. LPN-B indicated they aren't locked even though a lock is present. LPN-B attempted using a key to try to lock them, but no key on her key ring worked. In 5 of the metal containers, a liquid bottle of lorazepam intensol (benzodiazepine used to treat seizures, decrease anxiety) 2 mg/ml (a schedule IV, controlled medication)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-13 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R11's quarterly Minimum Data Set (MDS) assessment, dated 5/10/23, indicated an admission date of 10/4/21, was [AGE] years of age, had moderately impaired cognition, updated pneumococcal vaccination status had not been assessed. The MDS further indicated R11's diagnoses included Alzheimer's disease (brain disorder causing memory loss/mental impairment), heart failure, and renal insufficiency (kidney impairment). R20's significant change in status MDS assessment, dated 5/26/23, indicated an admission date of 12/12/22, was [AGE] years of age, had moderately impaired cognition and medically complex health conditions, updated pneumococcal vaccination status had not been assessed. The MDS further indicated R20's diagnoses included congestive heart failure (CHF), renal insufficiency, Alzheimer's disease,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R3's quarterly Minimum Data Set (MDS) assessment, dated 6/10/23, indicated intact cognition and required extensive assistance by 1 staff for personal hygiene cares. R3's care plan indicated washes face and hands after given a prepared cloth, staff completes bathing including peri-area, partial bed bath on alternate days. R21's significant change in status MDS assessment, dated 7/5/23, indicated intact cognition and required extensive assistance by 1 staff for personal hygiene cares. R21's care plan indicated washes face and hands after given a prepared cloth, staff completes bathing including peri-area. During observation and interview on 7/10/23 at 2:24 p.m., R21 indicated did not have hot water to bathroom sink since admission to facility on 4/19/23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R51's face sheet, printed 7/13/23, identified R51 was admitted to the facility on [DATE], with diagnosis including pneumonia, pulmonary fibrosis (lung disease that causes scarring and thickening of the tissue around the air sacs) and rheumatoid arthritis. R51's progress note dated 4/14/23 at 10:10 a.m., identified R51 was discharged to home on 4/14/23 at 10:10 a.m. via private transportation with son. R51 left in a wheelchair from the wing, but left wheelchair at the front door. R51 took front wheeled walker and medications with her. R51 also took a portable oxygen tank and will return to facility once oxygen supplies delivered to home. A discharge note dated 4/12/23 at 11:07 a.m., identified R51 as alert and oriented with a brief interview for mental status (BIMS) score of 10 indicated moderate impairment. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R9's facesheet printed on 7/13/23 included diagnoses of cerebral infarction (stroke), generalized muscle weakness, arthritis of both shoulders, dementia, and Alzheimer's disease. R9's annual Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment. R9 who did not walk, required extensive assistance or was totally dependent upon one or two staff for all activities of daily living (ADLs). R9's physician orders and care plan did not include or identify restorative nursing services or ROM exercises. During an interview on 7/10/23 at 5:19 p.m., family member (FM)-C stated she did not know if R9 received ROM exercises or therapy, adding, I sure hope he is getting it.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: During an interview on 7/12/23 at 2:21 p.m., dietary manager (DM)-A stated the facility did not encourage food to be brought in from home for residents and did not have a designated refrigerator for this purpose. DM-A stated if food was brought in from home for residents, it might be stored in refrigerators located in the nurses stations. During observations on 7/13/23 at 10:25 a.m., observations were made of dormitory-sized refrigerators in each of the three nurses stations. --Wing 2 refrigerator had facility food and beverages in it, such as juice and applesauce. Also observed were two small plastic containers of food. One container had a hand-written note taped to the lid which indicated, R32, 117 for supper. Mac Salad. The container contained a bow-tie pasta salad. There was no date on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-05-02 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: On 4/29/24, the nurse staff posting was observed to be in place in main entrance area. On 4/30/24, at 12:04 p.m. the nurse staff posting was noted to remain in place for staffing of 4/29/24, and had not been updated to reflect staffing for 4/30/24. Upon follow up observation on 4/30/24, at 2:00 p.m. it was noted to have been updated and reflected information for 4/30/24. At this time, the nurse staff posting information was present for 4/29/24, 4/30/24, and 5/1/24. On 5/1/24, at 8:34 a.m. the nurse staffing information posted was dated as 4/29/24. Additional nurse staffing information was present for 5/1/24, however…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-05-02 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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). Findings include: A review of the PBJ Staffing Data Report from fiscal year (FY) Quarter 1 2024 (October 1-December 31, 2023) identified there were no registered nurse (RN) hours for the time period from 10/1/23 through 12/31/23. In addition, the facility was also triggered for a lack of licensed nursing coverage 24 hours/day for the time period from 10/1/23 through 12/31/23. On 4/29/24, at 1:44 p.m., a request was made for the staff schedules for the time frame of 10/1/23 through 12/31/23. A review of the licensed staffing schedules for these dates was completed. A comparison of the staff schedules in correlation to the nursing staff postings from 12/8/23-12/31/23 was also completed. A comparison was unable to be completed prior to 12/8/23 as the postings had not been retained by the facility. The following discrepancies were noted. RN coverage was noted to be in place for all of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-05-02 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. 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. The document identified the QAPI program; assessed quality in all areas, aimed for safety and high quality with all clinical interventions,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-05-02 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: Review of the 9/10/21, Quality Assurance and Performance Improvement (QAPI) Plan Sacred Heart Care Center, Inc. identified the QAPI committee members required to be present consisted of the administrator, the Director of Nursing (DON), the Consultant Pharmacist, the Medical Director, the Infection Preventionist (IP), Director of Social Services, Environmental Services Director, Dietary Manager, Activity Director, Financial Managers, Clinical managers, Quality Assurance Coordinator, and other staff when expertise is needed. Review of the quarterly QAPI meeting attendance roster was completed for the following dates: 6/28/23, 10/25/23, and 1/31/24. Upon review of the attendance roster, it was identified the MD was present only at the meeting on 10/25/23. The attendance lacked evidence of the presence of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2024-02-28 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: Review of the facility's Abuse Prevention and Vulnerable Adult Procedure Program Policy with a revision date of 11/21/2022 included: External Reporting: Each covered individual shall report to the State Agency (SA) and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from, the facility, and each covered individual shall report immediately, but not more than 2 hours after forming the suspicion, if the events that caused suspicion result in serious bodily injury or not later than 24 hours if the events that caused the suspicion do not result in serious bodily injury. All reports of suspected crime and/or alleged sexual abuse must be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SACRED HEART CARE CENTER, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/28/1997 |
| HALVERSON, REBECCA | Individual | W-2 MANAGING EMPLOYEE | — | since 05/10/2010 |
| KNOPIK, CHARLES | Individual | CORPORATE DIRECTOR | — | since 07/01/2011 |
| MALLORY, ANTHONY | Individual | CORPORATE DIRECTOR | — | since 07/01/2012 |
| BRUCKER, MARIANNE | Individual | CORPORATE OFFICER | — | since 07/01/2013 |
| GARRY, TIMOTHY | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| KNORR, PAUL | Individual | CORPORATE OFFICER | — | since 07/01/2013 |
| WIEBELHAUS, EILEEN | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245447. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.