Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sacred Heart Nursing Home during CMS and state inspections, most recent first.
Unsanitary kitchen and kitchenette conditions: The facility failed to keep the main kitchen, second-floor kitchen extension, and four unit kitchenettes clean and sanitary. Surveyors observed soiled refrigerator handles, dirty cabinets and drawers, buildup of black substance and food particles on floors and around equipment, stained shelves and containers, rusted drawer damage, and open or undated food items such as peanut butter and coffee stored in cabinets. Staff and leadership stated there was no clear assigned process for cleaning the kitchenette cabinets and drawers.
Failure to provide contracture-related skin care led to a stage 4 pressure injury. A resident with CVA-related hemiplegia, severe LUE contracture, and dependence for care had OT for PROM and orthotic management, but the facility could not produce the caregiver education referenced in the OT discharge summary. The care plan, CNA tasks, and MAR/TAR did not include a specific PROM or skin-monitoring plan for the contracted elbow area, and nursing notes did not document contracture-site skin assessments or PROM refusals. A new wound later developed at the left AC/elbow area and progressed to exposed tendon and a stage 4 pressure ulcer; staff stated no preventative skin care had been done before the wound appeared.
Failure to use PPE for a resident on contact plus precautions. A resident with active C. diff had orders and a care plan for contact precautions, and signage outside the room directed staff to wear a gown and gloves and perform hand hygiene. An activity staff member entered the room without PPE while handling the resident's TV remote and said PPE was not needed because no personal care was being provided; the DON stated staff should wear PPE when entering the room for any reason.
The facility failed to maintain food safety and sanitation standards in three out of four kitchenettes, with issues such as rusted microwaves and improper storage of food items under sinks. Dietary staff were responsible for cleaning and stocking but did not adequately perform these tasks, leading to potential foodborne illness risks.
The facility failed to implement an effective antibiotic stewardship program by not performing or documenting required antibiotic time outs (ATOs) for two residents who were prescribed antibiotics despite not meeting infection criteria. The Infection Preventionist and Director of Nurses acknowledged the oversight, indicating a lapse in following the facility's policy.
The facility failed to ensure a safe environment by not replacing sharps containers when full, as required by policy. Observations showed containers overfilled on two units, increasing the risk of needlestick injuries. Staff interviews revealed confusion about the replacement process, and maintenance did not perform weekly checks due to staffing issues.
The facility failed to develop and implement person-centered care plans for two residents with trauma histories, leading to a deficiency in addressing their mental health needs. One resident, with a history of robbery and sexual assault, had no trauma-related care plan, leaving staff unaware of potential triggers. Another resident, diagnosed with PTSD, also lacked a care plan addressing their trauma, despite receiving psychotherapy. The facility's oversight in creating trauma-informed care plans was acknowledged by the Director of Social Services and the DON.
A resident with an unstageable DTI on the left heel did not receive wound care according to the physician's orders. The nurse failed to cleanse the wound with normal saline and pat dry before applying a new foam dressing, as observed by a surveyor. The resident was at risk for pressure ulcers and dependent on staff for mobility. The DON and ADON confirmed the need for adherence to the physician's orders for dressing changes.
Two residents with existing pressure injuries did not receive care consistent with physician's orders at a facility. One resident's heels were not offloaded, and the LAL mattress was incorrectly set to static mode. Another resident's LAL mattress settings were not adjusted to their weight, and the static mode was left on. Staff interviews revealed a lack of understanding of proper mattress settings and interventions, leading to inadequate care.
The facility failed to identify and document potential triggers for two residents with a history of trauma, risking re-traumatization. One resident, with Parkinson's disease, reported past trauma and specific triggers, but these were not documented in their care plan. Another resident, with schizoaffective disorder and PTSD, also lacked a care plan reflecting their trauma history and triggers. Staff interviews revealed a lack of awareness and documentation, and the facility lacked a policy on trauma-informed care.
A resident, who was alert and frequently incontinent, requested to be put on a bedpan. A CNA told the resident to defecate in their pants and that they would be cleaned later. The resident was found soiled and distressed, and the CNA admitted to making the degrading statement. The facility failed to uphold its policy on resident rights.
A resident reported an inappropriate statement made by a CNA, but the facility failed to follow its Abuse Policy by not immediately notifying the Administrator or DON. The written statement was left in the DON's mailbox for 36 hours, causing a delay in addressing the abuse allegation.
Unsanitary kitchen and kitchenette conditions
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation in the main kitchen, the second-floor kitchen extension, and four kitchenettes. The report states the facility did not maintain these areas in a clean and sanitary condition, and it also notes concerns with food storage and date marking practices for food items kept in resident-accessible areas. In the main kitchen on the first floor, the surveyor observed visibly soiled refrigerator and freezer door handles and front panels, sticky and dirty cabinet drawers and panels, dirty hood filters, a dirty transparent ice cream freezer door, and frozen food items encased in ice on the top shelf of the reach-in freezer. The surveyor also observed magnetic clips holding dietary instruction sleeves that were visibly soiled inside and out. In the second-floor kitchen extension, the surveyor observed visible buildup of black substance and food particles along the floor edges in the dish room, steam table serving area, door jambs, prep area, and in front of three refrigerators, along with dirt, debris, and food particles under the silver reach-in refrigerator and dish machine. Cabinet doors and drawers by the dishwasher and coffee station were dirty, shelves and containers at the coffee station were stained with coffee spills, and two white refrigerators had dirty shelves, produce drawers, and food remnants. The floor in front of one refrigerator was soft and split, leaving a hole with visible buildup of dirt and food particles. In the Saint Joseph's, 2PY, 3PY, and Saint [NAME] unit kitchenettes, the surveyor observed spilled granular substances, brown tacky residue, stained shelf liners, dirty drawers and cabinets, rusted holes and loose rust flakes in a drawer, and open or undated food items including peanut butter. Additional observations included an open cup of coffee stored in a cabinet, food and snack items stored on soiled shelves, and drawers containing debris, crumbs, keys, and dirt. Staff interviews showed uncertainty about who was responsible for cleaning inside drawers and cabinets, and the Food Service Manager stated dietary did not clean those areas and that undated items should be discarded if not labeled when opened on the unit. The Administrator stated the kitchenettes were expected to be kept clean and sanitary, but there was no assigned process for cleaning the cabinets and drawers.
Failure to Provide Contracture-Related Skin Care Led to Stage 4 Pressure Injury
Penalty
Summary
The facility failed to ensure a resident at risk for skin breakdown with a contracted left upper extremity received necessary care and treatment to prevent and promote healing of a pressure injury. The resident had a history of CVA with left hemiplegia/hemiparesis, spastic hemiplegia, restlessness, agitation, and dependence for care. The resident was documented as having impaired mobility on one side, being at risk for pressure ulcers, and later having a stage 4 pressure ulcer and a surgical wound. OT records before the wound developed documented increased tone, decreased ROM, and a left upper extremity flexion pattern contracture, with treatment focused on PROM and hand roll orthotic use for contracture management. The record showed that the resident had discomfort with PROM and had refused PROM and wearing the left-hand orthotic during earlier OT treatment, and later OT again documented PROM to the bilateral upper extremities and caregiver education for contracture management. However, the facility could not provide the caregiver education referenced in the OT discharge summary. The care plan did not include the left upper extremity contracture, a PROM treatment plan for that contracture, or preventative skin integrity monitoring for the contracted left elbow/acromioclavicular area. CNA task records and the MAR/TAR also did not show a contracture-specific PROM plan or skin monitoring for that area. Nursing progress notes documented the resident as at risk for pressure ulcers and noted refusals of left hand checks, but did not document skin assessment of the contracture site or refusals of PROM or inspection of that area. A new wound was later documented to the left AC area with odor, granulation tissue, drainage, macerated edges, and surrounding darkened non-blanchable tissue. Weekly skin checks did not identify new pressure areas, and the weekly wound management detail report was not completed weekly. Subsequent notes described the wound as a stage 4 pressure ulcer with slough, exposed tendon, and deep wound bed. Specialist and physician notes described severe contractures and a degenerating ulcerative wound caused by the severe flexion contracture. Staff interviews stated that no preventative skin care or specific elbow contracture monitoring had been done before the wound developed, that only routine weekly skin checks were performed, and that there were no orders, care plan interventions, or CNA flow sheet tasks for PROM or skin inspection of the left elbow contracture site.
Failure to Use PPE for Resident on Contact Plus Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for one resident with an active diagnosis of C. diff who was on contact plus precautions. The facility policy for Contact Precautions stated that gloves and a gown shall be donned upon entering the resident's room, and the posted Contact Plus Precaution signage outside the room directed staff to clean hands before entering, wear a gown and gloves, and wash hands with soap and water before exiting the room. Resident #85 had physician's orders to maintain contact precautions for C. diff and a care plan noting the resident had a communicable gastrointestinal infection and that staff should use contact precautions when entering the room and caring for the resident. During observation, Activity Staff #2 was in the resident's room without any PPE while holding the resident's television remote control and assisting with changing the channel. The staff member stated she did not need PPE because she was not providing personal care and was only assisting with the television. The DON stated that for a resident on contact plus precautions, staff should don the appropriate PPE before entering the room and doff it before exiting, and that for a resident with C. diff, staff should be wearing PPE when they enter the room for any reason.
Food Safety and Sanitation Deficiencies in Kitchenettes
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to the spread of foodborne illnesses among residents. The surveyor observed several deficiencies in three out of four kitchenettes, including rusted and peeling microwaves with food particle spatter and stains, and improper storage of food items under sinks next to plumbing piping. These observations were made on different units, including the Third Floor Unit, Saint Michael's Unit, and Saint Joseph's Unit. Interviews with the Unit Manager and Food Service Director revealed that dietary staff were responsible for cleaning and stocking the kitchenettes, but they failed to notice or report the rusted microwaves and improper storage practices. The Unit Manager and Food Service Director acknowledged the issues upon observation and noted that the microwaves needed replacement and that no items should be stored under the sink due to contamination risks. The dietary staff were expected to clean and sanitize the microwaves daily and ensure proper storage, but these tasks were not adequately performed.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as required by their policy. The policy mandates an antibiotic review process, known as an antibiotic time out (ATO), to reassess the need for antibiotics when the clinical picture becomes clearer. However, the facility did not perform or document ATOs for residents who were prescribed antibiotics despite not meeting the infection criteria as per the McGeer guidelines. Specifically, Resident #73 was prescribed antibiotics for a skin concern that did not meet infection criteria, and Resident #106 was prescribed antibiotics for a urinary issue that also did not meet infection criteria. In both cases, there was no documentation of an ATO being performed, which is a requirement of the facility's policy. Interviews with the Infection Preventionist (IP) and the Director of Nurses revealed that the facility was aware of the requirement to perform and document ATOs for residents on antibiotics who do not meet infection criteria. Despite this awareness, the facility failed to adhere to its policy, as evidenced by the lack of ATO documentation in the medical records of Residents #73 and #106. The Director of Nurses acknowledged that residents on antibiotic therapy are discussed daily in morning meetings, but the policy was not being followed as required at the time of the survey.
Failure to Properly Manage Sharps Containers
Penalty
Summary
The facility failed to maintain a functional, safe, and clean environment on two of its four units, specifically regarding the management of sharps containers. The facility's policy required that sharps containers be replaced when they are two-thirds to three-quarters full to prevent needlestick injuries and exposure to bloodborne pathogens. However, during a survey, it was observed that sharps containers in several rooms on the 2PY and 3PY units were filled above the three-fourths full line, posing a potential hazard. The facility's policy also mandated weekly checks of these containers by the maintenance department, but there was no evidence of such checks being conducted since May 2024. Interviews with staff revealed a lack of clarity and consistency in the process for replacing full sharps containers. Nurses and CNAs were unsure of the procedure, with some indicating that they verbally informed maintenance or filled out repair slips when containers needed replacing. The Maintenance Director confirmed that the maintenance department did not routinely check the containers weekly due to staffing constraints, relying instead on nursing staff to notify them when replacements were needed. This lack of adherence to the facility's policy and the absence of a systematic approach to managing sharps containers contributed to the deficiency identified by the surveyors.
Failure to Implement Trauma-Informed Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents who had experienced trauma, leading to a deficiency in addressing their mental health needs. Resident #120, who was admitted with Parkinson's disease, had a history of being robbed and sexually assaulted, which was not reflected in their care plan. Despite being cognitively intact and having shared this trauma with the facility, staff members, including CNAs and nurses, were unaware of the resident's trauma history or any potential triggers that could lead to re-traumatization. The care plan for Resident #120 did not include any mention of the trauma or strategies to avoid potential triggers, which was acknowledged as an oversight by the Director of Social Services. Similarly, Resident #30, who had diagnoses including schizoaffective disorder and PTSD, also had a history of trauma that was not adequately addressed in their care plan. The resident had reported a history of trauma during a recent hospitalization and was receiving psychotherapy for PTSD. However, the care plan failed to document the trauma history or identify triggers to prevent re-traumatization. Staff members, including nurses, were not informed of the resident's trauma or potential triggers, despite the resident's ongoing psychiatric treatment and history of paranoia and suspicious demeanor. The Director of Social Services and the Director of Nurses both acknowledged the lack of appropriate care plans for residents with known trauma histories. The facility did not have care plans in place to alert staff to the residents' trauma histories or to guide them in avoiding potential triggers, which could lead to negative reactions or behaviors. This deficiency highlights a significant gap in the facility's approach to person-centered care for residents with trauma histories.
Failure to Follow Wound Care Protocol for Resident with DTI
Penalty
Summary
The facility failed to provide services that met professional standards of practice for a resident with an unstageable deep tissue injury (DTI) on the left heel. The resident, who was admitted with diagnoses including peripheral vascular disease and bilateral paralytic syndrome following cerebral infarction, was at risk for developing pressure ulcers and was dependent on staff for mobility. The resident's care plan included applying an Allevyn foam dressing to the left heel as ordered by the physician. However, during a surveyor's observation, it was noted that Nurse #5 did not follow the physician's order to cleanse the wound with normal saline and pat dry before applying the new foam dressing. The surveyor observed that the nurse removed the old dressing and applied a new foam dressing without cleansing the wound, as required by the physician's order. The nurse acknowledged the oversight during an interview and stated that she should have followed the order. The Director of Nursing and the Assistant Director of Nursing, who is also the facility's wound care nurse, confirmed that the resident was at risk for pressure injuries and that dressing changes should be performed according to the physician's orders. This failure to adhere to the prescribed wound care protocol resulted in a deficiency in meeting professional standards of quality care.
Inadequate Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent and promote the healing of pressure injuries for two residents, Resident #57 and Resident #96. Resident #57, who was admitted with a left heel unstageable deep tissue injury (DTI), did not consistently receive care as per physician's orders. The orders included offloading the heels and adjusting the low air loss (LAL) mattress settings. Observations revealed that the resident's left heel was in contact with the mattress, and the LAL mattress was set to static mode, contrary to the physician's instructions. Interviews with staff indicated a lack of awareness and understanding of the correct mattress settings and the importance of offloading the heels. Resident #96, who had an unstageable DTI on the coccyx, also did not receive care in accordance with physician's orders. The LAL mattress settings were not adjusted to the resident's weight, and the static mode button was left on, which was against the prescribed care plan. Observations showed discrepancies in the mattress weight settings, and staff interviews revealed a lack of knowledge about the correct settings and interventions required to prevent further pressure injuries. The facility's policies on wound and skin care and the use of LAL mattresses were not effectively implemented, leading to inconsistencies in care. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the deficiencies in care and the failure to adhere to physician's orders. The lack of proper training and communication among staff contributed to the inadequate care provided to the residents, putting them at risk for further complications related to pressure injuries.
Failure to Identify and Document Trauma Triggers for Residents
Penalty
Summary
The facility failed to identify and document potential triggers for two residents with a history of trauma, which could help prevent potential re-traumatization. Resident #120, who was admitted in March 2024 with Parkinson's disease, reported a past trauma involving robbery and sexual assault. Despite being cognitively intact and expressing concerns about specific triggers, such as being approached from behind, the facility did not document these triggers in the resident's care plan. Interviews with staff, including CNAs and nurses, revealed a lack of awareness regarding the resident's trauma history and potential triggers, indicating a gap in communication and documentation. Similarly, Resident #30, admitted in November 2019 with schizoaffective disorder, bipolar disorder, and generalized anxiety, also had a history of trauma. Despite receiving psychotherapy and having a diagnosis of PTSD, the resident's care plan did not reflect their trauma history or potential triggers. Interviews with nursing staff and the Director of Social Services highlighted a lack of updated social history assessments and care plans that should have included the resident's trauma and triggers. The facility's failure to reassess and update care plans contributed to the oversight. The Director of Social Services acknowledged the errors in documentation and the absence of a care plan addressing the residents' trauma and triggers. The facility's Director of Nursing confirmed the lack of a policy on trauma-informed care and recognized the need for reassessment to identify any new or existing triggers. The absence of a structured approach to trauma-informed care and the failure to document and communicate residents' trauma histories and triggers were central to the deficiency identified by the surveyors.
Resident Dignity and Respect Violation
Penalty
Summary
The Facility failed to ensure that a resident was treated in a dignified and respectful manner. The resident, who was alert, oriented, and frequently incontinent but able to make their needs known, requested to be put on a bedpan. In response, a Certified Nurse Aide (CNA) told the resident to defecate in their pants and that the CNA would clean them later. This incident was corroborated by another CNA who found the resident's bed soiled with urine and feces, with dried feces on the resident's skin, causing redness and irritation. The resident was distressed and cried when recounting the incident, expressing that they did not want to get the CNA in trouble and felt they were paying a lot of money for such treatment. The CNA involved admitted to making the degrading statement to the resident. The incident was reported to the nursing staff, and an internal investigation was initiated. The resident's condition and the inappropriate response from the CNA were documented by multiple staff members, including another CNA and a nurse. The facility's policy on resident rights was not upheld, as the resident was not treated with the respect and dignity they deserved, and their request for assistance was met with an inappropriate and disrespectful response from the CNA.
Failure to Follow Abuse Reporting Procedures
Penalty
Summary
The Facility failed to ensure staff implemented and followed their Abuse Policy when a resident, who was cognitively intact, reported an inappropriate and insulting statement made by a CNA. The resident informed a CNA and a nurse about the incident, and although the nurse reported it to her supervisor and provided a written statement, the supervisor did not immediately notify the Administrator or the Director of Nurses. Instead, the written statement was placed in the DON's mailbox, where it remained unnoticed for approximately 36 hours. This delay in reporting violated the Facility's Abuse Prohibition Policy, which mandates immediate reporting of abuse allegations to the Administrator and DON. The resident, who had diagnoses including hemiplegia and hemiparesis following a non-traumatic intracranial hemorrhage, reported that the CNA told him/her to defecate in his/her pants and that the CNA would clean him/her later. This incident caused the resident significant distress, as evidenced by the resident crying and complaining about the treatment. The failure to promptly report and address the allegation of abuse highlights a significant lapse in following established procedures designed to protect residents from abuse and neglect.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 312 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brandon Woods Of New Bedford | 1.2 mi | ★★★★★ | 1 | 0 |
| Royal Of Fairhaven Nursing Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Vantage Health & Rehab Of New Bedford | 1.4 mi | ★★★★★ | 25 | 0 |
| Hathaway Manor Extended Care | 1.7 mi | ★★★★★ | 1 | 0 |
| Our Ladys Haven Of Fairhaven Inc | 1.9 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sacred Heart Nursing Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.