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Deficiency Records for Providence St Elizabeth Care Center

A list of the most recent deficiencies for Providence St Elizabeth Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Providence St Elizabeth 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?
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 2024-08-26 2024-09-06 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 2024-08-26 2024-09-06 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-08-26 2024-09-06 Y
Provide and implement an infection prevention and control program. Health 2024-01-11 2024-01-24 Y
Provide properly protected cooking facilities. Fire Safety 2023-10-18 2023-11-10 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-10-18 2023-11-10 N
Have proper medical gas storage and administration areas. Fire Safety 2023-10-18 2023-11-10 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-10-15 2023-11-07 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2023-10-15 2023-11-07 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 2023-10-15 2023-11-07 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-10-15 2023-11-07 N
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 2023-10-15 2023-11-07 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2023-10-15 2023-11-07 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-10-15 2023-11-07 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 2023-10-15 2023-11-07 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2023-10-15 2023-11-07 N
Provide enough food/fluids to maintain a resident's health. Health 2023-10-15 2023-11-07 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-10-15 2023-11-07 N
Ensure that residents are free from significant medication errors. Health 2023-10-15 2023-11-07 N
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2023-10-15 2023-11-07 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-10-15 2023-11-07 N
Have a policy regarding use and storage of foods brought to residents by family and other visitors. Health 2023-10-15 2023-11-07 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-10-15 2023-11-07 N
Provide and implement an infection prevention and control program. Health 2023-10-15 2023-11-07 N
Implement a program that monitors antibiotic use. Health 2023-10-15 2023-11-07 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2023-10-15 2023-11-07 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-09-25 2023-10-19 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 2023-08-21 2023-09-15 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 and emergencies. Health 2023-08-21 2023-09-15 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 2023-07-18 2023-07-28 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-07-18 2023-07-28 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-06-08 2023-06-24 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-06-08 2023-06-24 Y
Post nurse staffing information every day. Health 2023-03-13 2023-04-07 Y
Provide and implement an infection prevention and control program. Health 2023-03-13 2023-04-07 Y
Provide and implement an infection prevention and control program. Health 2022-12-05 2022-12-15 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-11-28 2022-12-14 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-11-28 2022-12-14 Y
Post nurse staffing information every day. Health 2022-09-21 2022-10-20 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 2022-09-21 2022-10-20 Y
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Health 2022-08-04 2022-08-12 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-08-04 2022-08-12 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-08-04 2022-08-12 Y
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2021-12-17 2022-04-15 N
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Health 2022-02-04 2022-02-14 Y
Provide and implement an infection prevention and control program. Health 2022-01-15 2022-02-10 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-12-17 2022-01-14 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-12-17 2022-01-14 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-12-17 2022-01-14 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-12-17 2022-01-14 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 2021-12-17 2022-01-14 N
Ensure that residents are free from significant medication errors. Health 2021-12-17 2022-01-14 N
Implement a program that monitors antibiotic use. Health 2021-12-17 2022-01-14 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-12-20 2022-01-06 N
Address patient/client population and determine types of services needed. Fire Safety 2021-12-20 2022-01-06 N
Establish policies and procedures for volunteers. Fire Safety 2021-12-20 2022-01-06 N
Establish roles under a Waiver declared by secretary. Fire Safety 2021-12-20 2022-01-06 N
Install an approved automatic sprinkler system. Fire Safety 2021-12-20 2022-01-06 N
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 2021-11-19 2021-11-29 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-11-19 2021-11-29 Y
Ensure each resident receives an accurate assessment. Health 2019-05-29 2019-06-21 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 2019-05-29 2019-06-21 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 2019-05-29 2019-06-21 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 2019-05-29 2019-06-21 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2019-05-29 2019-06-21 N
Establish policies and procedures for volunteers. Fire Safety 2019-05-22 2019-06-15 N
Establish roles under a Waiver declared by secretary. Fire Safety 2019-05-22 2019-06-15 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2019-05-22 2019-06-15 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-05-22 2019-06-15 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-05-22 2019-06-15 N

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