A list of the most recent deficiencies for St Elizabeth Nursing Home. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-09 | 2023-12-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-15 | 2023-09-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-15 | 2023-09-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-15 | 2023-09-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-15 | 2023-09-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-07 | 2023-01-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-05 | 2023-01-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-05 | 2023-01-06 | Y |
| 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 | 2022-11-30 | 2022-12-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-30 | 2022-12-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-07 | 2022-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-07 | 2022-12-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-07 | 2022-12-01 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-11-07 | 2022-12-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-07 | 2022-12-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-07 | 2022-12-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-07 | 2022-12-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-07 | 2022-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-07 | 2022-12-01 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-27 | 2022-12-01 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-10-27 | 2022-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-27 | 2022-12-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-27 | 2022-12-01 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-10-27 | 2022-12-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-27 | 2022-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-27 | 2022-12-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-27 | 2022-12-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-27 | 2022-12-01 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-10-27 | 2022-12-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-02 | 2022-07-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-02 | 2022-07-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-07-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-02 | 2022-07-16 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-02 | 2022-07-16 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-06-02 | 2022-07-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-13 | 2022-02-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-13 | 2022-02-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-13 | 2022-02-13 | 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 | 2022-01-13 | 2022-02-13 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-08 | 2022-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-08 | 2022-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-08 | 2022-01-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-10 | 2021-12-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-09 | 2021-10-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-09 | 2021-10-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-09 | 2021-10-08 | 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 | 2021-09-09 | 2021-10-08 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2021-09-09 | 2021-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-09 | 2021-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-09 | 2021-10-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-09 | 2021-10-08 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-09-09 | 2021-10-08 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-09-08 | 2021-10-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-08 | 2021-10-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-08 | 2021-10-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-08 | 2021-10-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-08 | 2021-10-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-31 | 2021-05-01 | Y |
| Have an externally vented heating system. | Fire Safety | 2019-07-30 | 2019-09-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-30 | 2019-09-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-30 | 2019-09-12 | N |
| 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 | 2019-07-31 | 2019-08-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-31 | 2019-08-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-31 | 2019-08-31 | 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 | 2019-07-31 | 2019-08-31 | 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 | 2019-07-31 | 2019-08-31 | 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 | 2019-07-31 | 2019-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-31 | 2019-08-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-30 | 2019-08-06 | 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 | 2019-07-30 | 2019-08-01 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-01-30 | Not Fixed | Y |
| 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 | 2024-01-30 | Not Fixed | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-01-30 | Not Fixed | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-01-30 | Not Fixed | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-30 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-30 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-30 | Not Fixed | Y |
| 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 | 2024-01-30 | Not Fixed | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-30 | Not Fixed | 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 | 2024-01-30 | Not Fixed | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-30 | Not Fixed | Y |
| Implement a program that monitors antibiotic use. | Health | 2024-01-30 | Not Fixed | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-30 | Not Fixed | Y |
