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Deficiency Records for St Elizabeth Nursing Home
View the most recent health deficiencies and inspection results for St Elizabeth Nursing Home. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for St Elizabeth Nursing Home. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 | 2026-02-03 | 2026-02-24 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-02-13 | 2025-03-18 | N |
| Construct fire resistant interior walls. | Fire Safety | 2025-02-13 | 2025-03-14 | 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 | 2025-02-13 | 2025-03-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-02-13 | 2025-03-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-02-13 | 2025-03-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-02-13 | 2025-03-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-02-13 | 2025-03-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-02-13 | 2025-03-14 | 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 | 2025-02-13 | 2025-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-02-13 | 2025-03-14 | 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 | 2025-02-13 | 2025-03-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2025-02-13 | 2025-03-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-02-13 | 2025-03-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2025-02-13 | 2025-03-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-02-13 | 2025-03-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-02-13 | 2025-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-02-13 | 2025-02-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2025-02-13 | 2025-02-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2025-02-13 | 2025-02-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-02-13 | 2025-02-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2025-01-08 | 2025-01-22 | Y |
| 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 | 2025-01-08 | 2025-01-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-01-08 | 2025-01-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-01-08 | 2025-01-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-10-17 | 2024-11-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-10-17 | 2024-11-15 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2024-10-17 | 2024-11-15 | 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 | 2024-10-17 | 2024-11-15 | 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 | 2024-10-17 | 2024-11-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-10-17 | 2024-11-15 | Y |
| Provide appropriate foot care. | Health | 2024-10-17 | 2024-11-15 | 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 | 2024-10-17 | 2024-11-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-17 | 2024-08-16 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-07-17 | 2024-08-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-17 | 2024-08-16 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-07-17 | 2024-08-16 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-17 | 2024-08-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-17 | 2024-08-16 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-07-17 | 2024-08-16 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-06-21 | 2024-07-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-21 | 2024-07-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-21 | 2024-07-18 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-30 | 2024-05-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-30 | 2024-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-30 | 2024-04-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-01-30 | 2024-04-01 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-01-30 | 2024-03-08 | 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 | 2024-01-30 | 2024-03-03 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-01-30 | 2024-03-01 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-01-30 | 2024-03-01 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-30 | 2024-03-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-30 | 2024-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-30 | 2024-03-01 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-01-30 | 2024-03-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-30 | 2024-03-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-30 | 2024-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-30 | 2024-03-01 | 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 | 2024-03-01 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-30 | 2024-03-01 | 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 | 2024-03-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-30 | 2024-03-01 | Y |
| Implement a program that monitors antibiotic use. | Health | 2024-01-30 | 2024-03-01 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-30 | 2024-03-01 | 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 | 2024-03-01 | 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 | 2024-03-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-30 | 2024-02-23 | N |
| 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 | 2024-01-31 | Y |
| 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 | 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 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-07 | 2022-12-01 | N |
| Respond appropriately to all alleged violations. | Health | 2022-11-07 | 2022-12-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-07 | 2022-12-01 | N |
| 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 |
| Provide and implement an infection prevention and control program. | 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 |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-07 | 2022-12-01 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-11-07 | 2022-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-07 | 2022-12-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-07 | 2022-12-01 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-11-07 | 2022-12-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-07 | 2022-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-07 | 2022-12-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-07 | 2022-12-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-07 | 2022-12-01 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-11-07 | 2022-12-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2026-04-28 | Not Fixed | 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 | 2026-04-28 | Not Fixed | Y |