A list of the most recent deficiencies for Elizabeth Seton. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-31 | 2023-09-28 | 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 | 2023-08-31 | 2023-09-28 | 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 | 2023-08-31 | 2023-09-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-31 | 2023-09-28 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-26 | 2022-09-30 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-08-17 | 2022-09-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-17 | 2022-09-19 | 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 | 2022-08-17 | 2022-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-17 | 2022-09-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-17 | 2022-09-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-26 | 2022-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-04 | 2019-11-16 | N |
