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Deficiency Records for St. Elizabeth Rehabilitation and Nursing Center
A list of the most recent deficiencies for St. Elizabeth Rehabilitation and Nursing 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 St. Elizabeth Rehabilitation and Nursing 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? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-15 | 2024-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-15 | 2024-12-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-10-15 | 2024-11-21 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-10-16 | 2024-11-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-10-16 | 2024-11-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-10-16 | 2024-11-13 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-10-16 | 2024-11-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-10-16 | 2024-11-13 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-10-16 | 2024-11-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-10-16 | 2024-11-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-10-16 | 2024-11-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-10-16 | 2024-11-13 | N |
| Post nurse staffing information every day. | Health | 2024-10-16 | 2024-11-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-10-16 | 2024-11-13 | 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 | 2024-10-16 | 2024-11-13 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2024-10-16 | 2024-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-16 | 2024-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-16 | 2024-11-13 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-10-16 | 2024-11-13 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-10-16 | 2024-11-13 | 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 | 2024-10-16 | 2024-11-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-10-16 | 2024-11-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-16 | 2024-10-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-31 | 2019-12-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-31 | 2019-12-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-28 | 2019-11-11 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-10-28 | 2019-11-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-28 | 2019-11-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-10-28 | 2019-11-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-28 | 2019-11-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-06-08 | 2018-07-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-06-08 | 2018-07-12 | N |
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