Deficiency Records for Gundersen St Elizabeth's Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Gundersen St Elizabeth's 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 a written emergency evacuation plan. | Fire Safety | 2023-01-11 | 2023-02-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-11 | 2023-02-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-12 | 2023-02-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-11 | 2023-02-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-11 | 2023-02-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-14 | 2021-10-15 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-10 | 2019-10-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-09-10 | 2019-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-10 | 2019-10-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-10 | 2019-10-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-10 | 2019-10-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-10 | 2019-10-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-10 | 2019-10-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-09-12 | 2019-10-10 | 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 | 2019-09-12 | 2019-10-10 | 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 | 2019-09-12 | 2019-10-10 | 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 | 2019-09-12 | 2019-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-12 | 2019-10-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-08-23 | 2018-09-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-08-23 | 2018-09-28 | 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 | 2018-08-23 | 2018-09-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-23 | 2018-09-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-23 | 2018-09-28 | 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 | 2018-09-17 | 2018-09-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-17 | 2018-09-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-17 | 2018-09-28 | N |
