A list of the most recent deficiencies for Providence St Elizabeth Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-01-24 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-18 | 2023-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-18 | 2023-11-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-18 | 2023-11-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-15 | 2023-11-07 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-15 | 2023-11-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-15 | 2023-11-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-15 | 2023-11-07 | N |
| Honor 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. | Health | 2023-10-15 | 2023-11-07 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-15 | 2023-11-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-15 | 2023-11-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-15 | 2023-11-07 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-15 | 2023-11-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-15 | 2023-11-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-15 | 2023-11-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-15 | 2023-11-07 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-10-15 | 2023-11-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-15 | 2023-11-07 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-10-15 | 2023-11-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-15 | 2023-11-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-15 | 2023-11-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-10-15 | 2023-11-07 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-10-15 | 2023-11-07 | N |
| Have 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. | Health | 2023-08-21 | 2023-09-15 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-08-21 | 2023-09-15 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-07-18 | 2023-07-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-18 | 2023-07-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-08 | 2023-06-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-06-24 | Y |
| Post nurse staffing information every day. | Health | 2023-03-13 | 2023-04-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-13 | 2023-04-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-05 | 2022-12-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-28 | 2022-12-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-28 | 2022-12-14 | Y |
| Post nurse staffing information every day. | Health | 2022-09-21 | 2022-10-20 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-21 | 2022-10-20 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-08-04 | 2022-08-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-04 | 2022-08-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-04 | 2022-08-12 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-12-17 | 2022-04-15 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-02-04 | 2022-02-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-15 | 2022-02-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-17 | 2022-01-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-17 | 2022-01-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-17 | 2022-01-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-17 | 2022-01-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-12-17 | 2022-01-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-17 | 2022-01-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-17 | 2022-01-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-20 | 2022-01-06 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-12-20 | 2022-01-06 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-12-20 | 2022-01-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-12-20 | 2022-01-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-20 | 2022-01-06 | N |
| Have 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. | Health | 2021-11-19 | 2021-11-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-19 | 2021-11-29 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-10-26 | 2021-11-05 | Y |
| Post nurse staffing information every day. | Health | 2021-09-28 | 2021-10-08 | Y |
| Notify 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. | Health | 2021-09-04 | 2021-09-13 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-03-24 | 2021-04-06 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-03-24 | 2021-04-06 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-29 | 2019-06-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-29 | 2019-06-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-29 | 2019-06-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-05-29 | 2019-06-21 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-29 | 2019-06-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-05-22 | 2019-06-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-22 | 2019-06-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-22 | 2019-06-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-22 | 2019-06-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-22 | 2019-06-15 | N |
