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Deficiency Records for St Elizabeth Care Center
A list of the most recent deficiencies for 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 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? |
|---|---|---|---|---|
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-10-20 | 2023-12-02 | 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 | 2023-10-20 | 2023-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-20 | 2023-12-02 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-10-20 | 2023-12-01 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-10-20 | 2023-12-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-20 | 2023-12-01 | 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 | 2023-10-20 | 2023-12-01 | N |
| 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 | 2023-10-20 | 2023-12-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-20 | 2023-12-01 | 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 | 2023-10-20 | 2023-12-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-20 | 2023-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-20 | 2023-12-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-20 | 2023-12-01 | 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 | 2023-10-20 | 2023-12-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-20 | 2023-12-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-10-20 | 2023-12-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-20 | 2023-12-01 | 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 | 2023-10-20 | 2023-12-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-10-20 | 2023-12-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-10 | 2023-09-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-10 | 2023-09-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-10 | 2023-09-20 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-10-21 | 2022-12-01 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-10-21 | 2022-12-01 | 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 | 2022-10-21 | 2022-12-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-21 | 2022-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-21 | 2022-12-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-21 | 2022-12-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-21 | 2022-12-01 | N |
| Post nurse staffing information every day. | Health | 2022-10-21 | 2022-12-01 | 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 | 2022-10-21 | 2022-12-01 | 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 | 2022-10-21 | 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 | 2022-10-21 | 2022-12-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-10-21 | 2022-12-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-21 | 2022-12-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-21 | 2022-12-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-21 | 2022-12-01 | 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 | 2022-10-21 | 2022-12-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-10-21 | 2022-12-01 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-10-21 | 2022-11-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-02-18 | 2022-03-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-30 | 2021-12-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-02 | 2021-12-12 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-09-26 | 2019-11-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-26 | 2019-11-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-26 | 2019-11-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-26 | 2019-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-26 | 2019-11-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-26 | 2019-11-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-26 | 2019-11-08 | N |
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