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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-13 | 2023-03-05 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-31 | 2023-02-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-31 | 2023-02-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-31 | 2023-02-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-01-31 | 2023-02-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-01-12 | 2023-02-06 | N |
| Provide activities to meet all resident's needs. | Health | 2023-01-12 | 2023-02-06 | N |
| Provide 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. | Health | 2023-01-12 | 2023-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-12 | 2023-02-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-12 | 2023-02-06 | N |
| Post nurse staffing information every day. | Health | 2023-01-12 | 2023-02-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-12 | 2023-02-06 | 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 | 2023-01-12 | 2023-02-06 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-12 | 2023-02-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-12 | 2023-02-06 | Y |
| 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 | 2023-01-12 | 2023-02-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-12 | 2023-02-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-12 | 2023-02-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-12 | 2023-02-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-12 | 2023-02-06 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-01-31 | 2023-02-02 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-01-31 | 2023-02-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-01-31 | 2023-02-02 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-01-31 | 2023-02-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-01-31 | 2023-02-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-31 | 2023-02-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-31 | 2023-02-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-31 | 2023-02-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-31 | 2023-02-02 | N |
| Have an externally vented heating system. | Fire Safety | 2023-01-31 | 2023-02-02 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-01-31 | 2023-02-01 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-05-04 | 2021-05-14 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-17 | 2020-03-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-02-17 | 2020-03-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-17 | 2020-03-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-17 | 2020-03-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-17 | 2020-03-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-17 | 2020-03-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-17 | 2020-03-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-17 | 2020-03-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-17 | 2020-03-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-17 | 2020-03-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-17 | 2020-03-18 | 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 | 2019-12-06 | 2020-01-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-06 | 2020-01-05 | 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 | 2019-12-06 | 2020-01-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-01 | 2018-12-01 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-11-01 | 2018-12-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-01 | 2018-12-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-11-01 | 2018-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-01 | 2018-12-01 | 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 | 2018-11-01 | 2018-12-01 | 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 | 2018-11-01 | 2018-12-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-11-01 | 2018-12-01 | 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 | 2018-11-01 | 2018-12-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-10-30 | 2018-11-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-30 | 2018-11-27 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2018-10-30 | 2018-11-27 | N |
