A list of the most recent deficiencies for St Elizabeth Healthcare 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-31 | 2024-01-31 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-05 | 2023-06-21 | 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 | 2023-05-05 | 2023-06-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-05 | 2023-06-21 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-05 | 2023-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-05 | 2023-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-05 | 2023-06-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-05 | 2023-06-21 | 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 | 2023-05-05 | 2023-06-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-05 | 2023-06-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-05 | 2023-06-21 | 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 | 2023-05-05 | 2023-06-21 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-05-05 | 2023-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-05 | 2023-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-05 | 2023-06-21 | N |
| Keep all essential equipment working safely. | Health | 2023-05-05 | 2023-06-21 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-05-05 | 2023-06-21 | N |
| Meet other general requirements. | Fire Safety | 2023-05-08 | 2023-05-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-08 | 2023-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-08 | 2023-05-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-08 | 2023-05-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-08 | 2023-05-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-14 | 2023-03-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-15 | 2023-02-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-14 | 2022-07-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-17 | 2022-03-23 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-07-23 | 2020-08-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-07-23 | 2020-08-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-07-23 | 2020-08-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-07-23 | 2020-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-02 | 2020-03-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-02 | 2020-03-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-03-02 | 2020-03-30 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-03-02 | 2020-03-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-03-02 | 2020-03-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-03-02 | 2020-03-30 | 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 | 2020-03-02 | 2020-03-30 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-03-02 | 2020-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-02 | 2020-03-30 | N |
| Dispose of garbage and refuse properly. | Health | 2020-03-02 | 2020-03-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-28 | 2019-06-17 | N |
| Use approved construction type or materials. | Fire Safety | 2019-05-28 | 2019-06-17 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-05-28 | 2019-06-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-28 | 2019-06-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-28 | 2019-06-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-28 | 2019-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-28 | 2019-06-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-28 | 2019-06-17 | 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 | 2019-03-25 | 2019-04-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-25 | 2019-04-25 | 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 | 2019-03-25 | 2019-04-25 | 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 | 2019-03-25 | 2019-04-25 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-25 | 2019-04-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-25 | 2019-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-25 | 2019-04-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-03-25 | 2019-04-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-25 | 2019-04-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-03-25 | 2019-04-25 | 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 | 2019-03-25 | 2019-04-25 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2019-03-25 | 2019-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-25 | 2019-04-25 | N |
| Dispose of garbage and refuse properly. | Health | 2019-03-25 | 2019-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-25 | 2019-04-25 | N |
