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Deficiency Records for St Elizabeth Nursing Home
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.
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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-07-17 | 2024-08-16 | Y |
| Respond appropriately to all alleged violations. | 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 |
| Plan the resident's discharge to meet the resident's goals and needs. | 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 |
| 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 and implement an infection prevention and control program. | Health | 2024-07-17 | 2024-08-16 | 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 |
| 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 |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-06-21 | 2024-07-18 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-26 | 2024-05-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-26 | 2024-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-26 | 2024-04-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-01-26 | 2024-04-01 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-01-26 | 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 | 2024-01-26 | 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 |
| 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 |
| 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 |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-26 | 2024-03-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-26 | 2024-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-26 | 2024-03-01 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-01-26 | 2024-03-01 | N |
| 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 | 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 |
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