Elizabeth Care Center

Inspectors wroteBased on documentation review, resident interview, and staff interview, the facility failed to allow residents the right to file a grievance anonymously without having to ask for assistance from staff. This was true for five (5) of five (5) residents interviewed for for grievances. Resident identifiers: #15, #20, #24, #6, and #27. Facility Census: 35 Findings Included: Review of the facility policy titled, Grievances/Complaints, revealed that grievances and/or complaints may be submitted orally, or in writing, and may be filed anonymously. a) Resident Council Meeting During a Resident Council meeting, held on 03/24/26 at 2:30 PM, residents reported they did not know how to file their own grievance. If they had a complaint they would talk to staff, who would file the complaint and generally resolve the issue. They were not aware of any way to file a complaint anonymously. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete a performance review of nurse aides at least once every 12 months. This was true for one (1) of five (5) nurse aides reviewed for the care area of sufficent and competent nurse staffing. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 35.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents, staff and visitors. This failed practice had the ability to affect more than a limited amount of residents and/or visitors to the facility. Facility Census 35. Findings Included: a) Daily Staff Posting On 03/24/2026 at 10:35 AM, the daily staffing post at the nurse's desk was observed to be dated for 03/23/26. b) Interview with Administrator On 03/24/26 at 10:45 AM, interview with Administrator who reported the Director of Nursing had the staffing sheet in her hand this morning and she was unsure what might have occurred. She returned around 10:55 AM and reported the staff posting had been placed behind yesterday's posting and has now been corrected. [...]

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to store and prepare food in accordance with professional standards for food safety. There were foods not labeled and dated in the freezer and pantry refrigerator, there were missing temperatures for the kitchen equipment, outdated food in the refrigerator, dented cans, and kitchen utensils that needed cleaned. This deficient practice had the potential to affect all residents receiving nutrition from the kitchen. Census: 35. Findings Included: A policy titled, Food Preparation and Service, states the temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services. [...]

Inspectors wroteBased on resident interview, observation, and staff interview, the facility failed to ensure resident dignity during dining. The facility failed to ensure tablemates in the dining room received their meal trays at the same time. This was a random opportunity for discovery. Resident Identifiers: #3, #16 and #5. Facility Census: 35.

Inspectors wroteBased on documentation review, resident interview, observation, and staff interview, the facility failed to ensure one (1) of two (2) residents received the assistance needed with activities of daily living. Resident #6 did not receive the assistance needed to maintain personal grooming according to her preferences. Resident identifier: #6. Facility census: 35.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents had appropriate assistive devices for eating and drinking. Resident #12 did not have a Kennedy cup (a lightweight open handle cup used to prevent spills) at bedside. Resident #14 had a suction divided plate that was set inside of the plate cover and therefore unable to suction to the table. This was true for one (1) of one (1) residents sampled for nutrition and one (1) of twelve (12) residents sampled for dining during the Long-Term Care Survey Process. Resident Identifiers: #12, #14 Census: 35.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records for Resident #13 and Resident #4. This was true for one (1) of three (3) residents sampled for beneficiary notification and one (1) of five (5) residents sampled for unnecessary medications during the Long-Term Care survey process. Resident identifiers: #13, #4. Facility Census: 35.a) Resident #13 During a record review, it was noted the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form was missing a check in the boxes under the options category. These options explain how the resident or Power of Attorney (POA) want the facility to bill Medicare for their continued stay after Medicare A stops paying. It was confirmed by Business Office Manager, at approximately 12:00 PM on 03/24/26, the boxes were not checked and should have been. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain adequate, appetizing temperatures for breakfast foods served in resident rooms. This was a random opportunity for discovery in the Long Term Care Survey process. Resident identifiers: Resident #09, Resident #26. Facility census: 32.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure all required members of the Quality Assurance and Performance Improvement Committee (QAPI) attend a quarterly meeting as required. Facility Census: 62. Findings Included: a) On 09/25/14 at 11:57 AM record review indicates the facility Quality Assurance Committee meets every second (2nd) Tuesday of each month. The following individuals are listed as individuals that attend: Medical Director Consultant Pharmacists Director of Nursing (DON) Administrator Social Service Director Therapy Director Activities Director Dietary Manager Minimum Data Set (MDS) Nurse Nursing House Supervisor (Infection Preventionist) IP Nursing Unit Manager Business Office Manager Human Resources Director Review of the QAPI meeting sign in sheets for four (4) quarters starting in September 2023, the following information was obtained: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure advanced directives were implemented for Resident #133. This was true for one (1) of three (3) residents reviewed during the survey. This will be cited as past non-compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the plan of correction were completed prior to this survey beginning. This did occur, and was substantiated by the facility as occurring. Resident #133 had completed a Physician Order for Scope of Treatment (POST) form, indicating her wishes to be a full code therefore this will be cited as past non-compliance. Facility census: 32. Resident identifiers: Resident #133.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a safe and effective transition of care for one (1) of two (2) residents reviewed for the care area of hospitalization during the long term care survey process. There was no documentation the following information was sent with Resident #24 when transferred to the hospital: the reason for the transfer, contact information of the practioner responsible for care, resident representative contact information, advance directive information, diagnosis, medications (including when last received) comprehensive care plan goals, any treatment or devices, most recent labs, other diagnostic tests, and recent immunizations, recent vital signs, etc. Resident identifier: #25. Facility census: 32.

Inspectors wroteBased on record review and staff interview, the facility failed to provide a copy of the bed-hold policy to two (2) of two (2) residents and or the responsible party when the residents were admitted to the hospital. This was true for two (2) of two (2) residents reviewed for the care area of hospitalization during the long term care survey process. Resident identifiers: #25 and #35. Facility census: 32.

Inspectors wroteBased on observation, medical record review, resident interview and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessments for two (2) of thirteen (13) residents reviewed during the Long-Term Care Survey (LTCSP). The MDS's for Resident #20 did not accurately reflect the use of hearing aides and Resident #34 MDS did not accurately reflect the prognosis of end of life of less than six (6) months. Resident identifier: #20 and #34. Facility Census: 32 Findings Included: a) Resident #20 During an interview on 12/05/22 at 2:40 PM Resident # 20 stated I have a hearing aid in one ear and the other hearing aid is broken. During an observation on 12/05/22 at 2:40 PM Resident # 20 had a hearing aid in the right ear only. Review of the quarterly MDS's on 12/06/22 with Assessment Reference Dates (ARD) of 09/02/22 discovered the following: [...]

Inspectors wroteBased on observation, medical record review, resident interview and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with communication devices such as hearing aid. This is true for one (1) of thirteen (13) resident care plans reviewed during the Long-Term Care Survey (LTCSP). Resident # 20. Facility Census: 32 Findings Included: a) Resident #20 During an interview on 12/05/22 at 2:40 PM Resident # 20 stated I have a hearing aid in one ear and the other hearing aid is broken. During an observation on 12/05/22 at 2:40 PM Resident # 20 had a hearing aid in the right ear only. Further review of the medical record revealed Resident # 20 care plan with an initiation date of 08/11/22. The care plan contained the following: Focus: Communication deficit related to difficulty being understood Goal: Basic needs will be met through review date. [...]

Inspectors wroteBased on medical record review, resident interview and staff interview the facility failed to ensure the residents had the right to participate and must be given the opportunity to participate in development, review and revision of his/her care plan. This was true for one (1) of thirteen (13) reviewed for care plans during the Long-Term Care Survey Process. Resident Identifiers: Resident #30. Facility Census: 32. Findings Included: a) Resident #30 During an interview on 12/05/22 at 12:03 PM, Resident # 30 stated I am not invited and have never attended a care planning meeting. During a review on 12/06/22, Resident # 30 medical record revealed a Care plan note dated 10/26/2022 Typed as written Resident #30's name was discussed in care plan meeting today. R/P (responsible party) was invited but did not attend. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the oxygen concentrator was set on the physician ordered flow rate. Resident #5. Facility census: 32.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the physician addressed each recommendation made by the pharmacist for a gradual dose reduction (GDR) for medications for two (2) of five (5) residents reviewed for unnecessary medications during the long - term care survey. Resident identifiers: #8 and #19. Facility census: 32. Findings Included: a) Resident #8 On 12/06/22 at 09:54 AM, based on documentation, a Gradual Dose Reduction (GDR) recommendation was completed by Pharmacist on 08/08/22 for multiple antipsychotic medications. The GDR listed two medications, olanzapine 2.5mg qhs and quetiapine 12.5mg qhs. The Physician signed the GDR form on 08/29/22 agreeing with the recommendation, discontinuing only the olanzapine. The physician failed to provide any clinical contraindications for the quetiapine to be continued at current level. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure two (2) of five (5) residents receiving psychotropic medications received a gradual dose reduction (GDR) or had documentation by the physician a GDR was clinically contraindicated. Resident identifiers, #8, #19. Facility census 32.

Inspectors wroteb) Resident #27 During a medical record review on 12/05/22 at 3:04 PM, Resident # 27's Physician Orders for Scope of Treatment (POST) form was reviewed. On the POST form section E, Signature: Patient or Patient Representative signature date was her date of birth not the date of signature. During a interview on 12/06/22 10:26 AM the Social Worker acknowledged on Resident # 27's POST form, Resident signature date was her date of birth not the date it was signed. Based on observation and staff interview, the facility failed to ensure the resident's medical record was accurate and complete. Resident #25's dental assessments were incorrect. Resident #27's post form did not have the correct date. Resident identifiers: #25 and #27. Facility census: 32.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the arbitration agreement was explicitly explained informing residents and or family members the arbitration agreement does not need to be completed as a condition of admission or as a requirement to continue to receive care at the facility. This has the potential to affect all residents at the facility. Facility census: 32.