CMS Inspection Results for SACRED HEART HOSPITAL TCF

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 10/08/2008 Fire Safety Survey for SACRED HEART HOSPITAL TCF

Building Contruction
Deficiency	Scope	Level of Harm
approved construction type or materials.	Widespread	Potential for minimal harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
properly constructed piped-in oxygen systems.	Isolated	Minimal harm or potential for actual harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
Vertical Openings
Deficiency	Scope	Level of Harm
proper stairway enclosures and vertical shafts.	Isolated	Minimal harm or potential for actual harm

 

• 10/02/2008 Health Survey for SACRED HEART HOSPITAL TCF

Administration
Deficiency	Scope	Level of Harm
Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Try to resolve each resident's complaints quickly.	Pattern	Potential for minimal harm

 

• 11/08/2007 Fire Safety Survey for SACRED HEART HOSPITAL TCF

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
Building Contruction
Deficiency	Scope	Level of Harm
a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
Exits and Egress
Deficiency	Scope	Level of Harm
exit stairways and towers that are smoke proof.	Widespread	Potential for minimal harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
properly located and lighted Exit signs.	Pattern	Potential for minimal harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
properly constructed piped-in oxygen systems.	Isolated	Minimal harm or potential for actual harm
proper medical gas storage and administration areas.	Pattern	Potential for minimal harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
Vertical Openings
Deficiency	Scope	Level of Harm
proper stairway enclosures and vertical shafts.	Widespread	Potential for minimal harm

 

• 10/31/2007 Health Survey for SACRED HEART HOSPITAL TCF

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm

 

• 12/28/2006 Health Survey for SACRED HEART HOSPITAL TCF

Administration
Deficiency	Scope	Level of Harm
Train all employees on what to do in an emergency.	Widespread	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm

 

• 12/13/2006 Fire Safety Survey for SACRED HEART HOSPITAL TCF

Building Contruction
Deficiency	Scope	Level of Harm
a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Widespread	Potential for minimal harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
properly located and lighted Exit signs.	Widespread	Potential for minimal harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
properly constructed piped-in oxygen systems.	Pattern	Potential for minimal harm
Vertical Openings
Deficiency	Scope	Level of Harm
proper stairway enclosures and vertical shafts.	Widespread	Minimal harm or potential for actual harm
protected exits that allow the resident to escape the building.	Pattern	Minimal harm or potential for actual harm