St. Elizabeth Care Center

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide meals which were palatable, attractive and served at a safe and appetizing temperature. Facility staff also failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit (F) or higher when served to residents. The facility census was 59.1. Review of the facility's Dietary Food Preparation policy, revised 07/05/23, showed: -The cook or Dietary Manager (DM) will taste food before serving;-Food will be served at the proper temperature to ensure food safety;-Acceptable serving temperature for hot foods including hot pureed foods is 135 degrees Fahrenheit (F) but preferably 160-175;-Each food item, served separately in the regular diet, is pureed and served separately for the pureed diet according to the pureed recipes. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to clean and maintain equipment in a manner to prevent potential contamination. Facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to maintain and serve food items at temperatures adequate to prevent food borne illness. Facility staff failed to maintain an ice machine air gap. These failures have the potential to affect all residents. The facility census was 59.1. Review of the facility's policy titled Dietary - Equipment Operations, Infection Control and Sanitation, revised 02/02/24, showed staff were directed to: -Place food waste in covered garbage and trash cans;-Wash and sanitize the meat slicer blade and all parts after each use;-Thoroughly wash walls and ceilings at least twice a year. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease, a serious type of pneumonia caused by Legionella bacteria. Facility staffs' failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 59 with a capacity of 63. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment instrument) when staff did not accurately code Section F for activities of interest, for eight residents (Residents #1, #4, #9, #18, #34, #41, #43, and #44) of 41 sampled residents. The facility census was 59. 1. Review of the facility's MDS 3.0 Care Assessment Summary and Individualized Care Plans policy, dated 11/06/23, showed the MDS 3.0 Section F is to be completed by the Activity Director which allows the resident to determine his or her own preferences for daily activities. 2. Review of Resident #1's Annual MDS, dated [DATE], showed staff documented the resident as cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop measurable goals and interventions for comprehensive care plans and update existing care plans to reflect care needs for seven residents (Residents #1, #2, #5, #8, #18, #43, and #44) out of 21 sampled residents. The facility census was 59.1. Review of the facility's policy titled Comprehensive Care Plans, dated 10/31/24, showed: -The facility is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs; -The Comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an ongoing activity program designed to meet the residents' interest, mental, and psychosocial well-being on the weekends for eleven residents (Resident #59, #44, #41, #4, #1, #3, #34, #29, #43, #18, and #9) out of 21 sampled residents. The facility census was 59.1. Review of the facility's policy titled Activity, dated 07/19/23, showed the purpose is to ensure all residents in the facility are provided an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, their interests and their physical, mental and psychosocial well-being. 2. Review of the facility's Activity Calendar, dated January 2026, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve and prepare food in accordance with the nutritionally calculated recipes and menus to all residents. The facility census was 59.1. Review ow the facility's Dietary Food Preparation policy, revised 07/05/23, showed:-Standardized recipes will be used for all products prepared. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure residents received their mail on Saturdays. The facility census was 52. Review of the facility's policy titled, Resident Rights, revised July 2023, showed residents have the right to privacy in written communications including the right to send and promptly receive mail that is unopened. During the resident group meeting on 02/05/25 at 10:07 A.M., the residents said staff does not deliver their mail on Saturdays. During an interview on 02/06/25 at 1:54 P.M., Licensed Practical Nurse (LPN) E said the activities department is in charge of and distributes the mail. The LPN said he/she did not know who delivered the mail on Saturdays. During an interview on 02/06/25 2:59 P.M., the activity director said the administrator gets the mail and hands it out. The activity director typically just takes care of packages. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for seven residents (Resident #4, #31, #34, #40, #42, #48 and #55) out of seven sampled residents. The facility census was 52. 1. Review of the facility's policy titled Care Plan Policy, revised 5/18/24 showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain professional standards of care when staff failed to transcribe accurate and complete physician's orders for five residents (Resident #10, #20, #34, #42 & #55) out of five sampled residents. The facility census was 52. 1. Review of the facility's policy titled Medications Order, dated 05/18/24, showed: -The order should be recorded in the physician orders in the electronic health records, which will add the order to the Medication Administration Record (MAR); -Clarify the order; -If using electronic medication records, input the medication order according to the electronic health record (EHR) instructions and facility policy; -Call or fax the medication order to the provider pharmacy if EHR states to; -Ensure the order is in the electronic MAR (eMAR); [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain consent for the use of bed rails for two residents (Resident #31 and #48) of two sampled residents. The facility census was 52. 1. Review of the facility's policy titled Proper Use of Bed Rails, dated February 2025, showed informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. The information that the facility should provide to the resident, or resident representative includes, but is not limited to: the resident's risk from the use of bed rails and likelihood of the benefits, and the risks from the use of bed rails an how these risk will be mitigated. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow infection control practices when staff did not properly sanitize the blood glucose monitor for four residents (Resident #53, #7, #6 and #20) out of four sampled residents. The facility census was 52. 1. Review of the facility's policy titled Glucometer Disinfection, dated February 2025 showed the facility will ensure glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometers will be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA), an independent agency of the United States government tasked with environmental protection matters, registered healthcare disinfectant that is effective against Human Immunodeficiency Virus (HIV), Hepatitis C and Hepatitis B virus. -Procedural steps include: [...]

Inspectors wroteBased on interview and record review, facility staff failed to educate and offer the Coronavirus disease (COVID-19) vaccination for five residents (#14, #31, #34, 40 and #51) out of five sampled residents. The facility census was 52. 1. The Center's for Disease Control COVID-19 Vaccination Long Term Care guidelines, dated August 2024, recommends everyone ages 5-64 years, including people who live and work in long-term care (LTC) settings, get one dose of a 2024-2025 COVID-19 vaccine; and everyone ages 65 years and older, including people who live and work in LTC settings, get two doses of a 2024-2025 COVID-19 vaccine 6 months apart. 2. Review of Resident #14's medical record showed: -The resident is under age [AGE]; -admitted on [DATE]; -The record did not contain a COVID-19 vaccination consent or declination form; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #2) remained free from verbal and emotional abuse, when Certified Nurse Aid (CNA) E threatened to take the resident to the floor, blocked and refused to leave the resident's room after repeated requests made by the resident. The facility census was 58. 1. Review of the facility's policy titled Abuse and Neglect , dated 06/12/24, showed abuse is the willful infliction, injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Verbal abuse includes speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to report an allegation of employee to resident emotional abuse to the Department of Health and Senior Services (DHSS) within the two hour timeframe for one resident (Resident ##2) who reported an allegation of abuse. The facility census was 58. 1. Review of the facility's policy titled Abuse and Neglect , dated 06/12/24, showed the licensed nurse will protect the resident from further incident and remove the accused employee from resident care areas. The nurse will then notify the administrator or designee. Should the incident be a reportable event, the administrator should notify appropriate agencies immediately, as soon as possible, but no later that 24 hours after the discovery of the incident. In case of serious bodily injury, no later than two hours after discovery or forming the suspicion. 2. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility census was 49. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. [...]

Inspectors wroteBased on record review and interview, the facility staff failed to maintain an accurate accounting system that assured the resident fund bank statement matched the reconciliation for the same month from 09/01/22 through 03/31/23. This had the potential to affect all residents that had funds entrusted to the facility on the residents' behalf. The facility census was 49. 1. Review of the Facility's Resident Trust policy, dated 9/17/21, showed: -The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed; -A reconciliation of the bank statements, checkbook and trust funds must be completed monthly. 2. Review of the facility's Bank Statement dated 09/30/22 showed: -A beginning balance of $6,699.59; -An ending balance of $5,138.51. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide refunds of personal funds to residents from the facility operating account in a timely manner for four residents (Resident #1, #2, #3, #4, and #8) discharged from the facility. The facility census was 49. 1. Review of the Facility's Resident Trust policy, dated [DATE], showed: -Upon the discharge of a resident, the facility shall provide an up-to-date accounting of the resident trust account balance; -The resident shall be issued a check for all remaining personal funds in his/her account within five (5) days of discharge along with a complete accounting record of the funds; -Checks received after a resident is discharged should be either forwarded to the resident or returned to the sender; [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure complete privacy for residents by failing to close an exterior curtain for one resident whose abdomen was exposed during an insulin injection (Resident #27), close an exterior curtain for one resident who was being assisted to bed (Resident #30), and to close a privacy curtain between two residents who shared a room during assistance to bed (Resident #30 and #34) and failed to ensure resident's personal information was protected when they left the Medication Administration Records (MARs) open and unattended in public hallways. The facility census was 49. 1. Review of the facility's Resident Rights Policy, dated 7/5/23, showed: -The resident has the right to personal privacy and confidentiality of his or her personal and clinical records; -Personal privacy includes personal care and accommodations. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed to clean and maintain resident rooms. The facility census was 49. 1. Review of the facility's policy Environmental Rounds, dated 6/09/23, showed staff were directed as follows: -Environmental rounds are to be done daily by department heads using the environmental rounds form; -The department head should be inspecting the rooms for potentially hazardous items and any areas that may not be in compliance of state and federal regulations. Review of the facility's policy Work Order Policy, dated 12/21/22, showed staff were directed as follows: -The facility maintenance department's function is to provide material and labor to maintain the buildings, equipment and grounds; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written notice to the resident or the resident's representatives regarding resident transfers to the hospital for two of two sampled residents (Resident #26 and #42). The facility census was 49. 1. Review of the facility's policy titled, Resident Transfer / Discharge, Immediate Discharge, and Therapeutic Leave Policy, revised 06/30/23, showed before any resident is transferred or discharged , staff are directed to notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand. 2. Review of Resident #26's medical record showed the following: -Transferred to the hospital on [DATE] and returned on 09/27/23; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for two sampled residents (Resident #26 and #42). The facility census was 49. 1. Review of the facility's policy titled, Resident Transfer / Discharge, Immediate Discharge, and Therapeutic Leave Policy, revised 06/30/23, showed: Notice of Bed Hold Policy; -When a resident is transferred to the hospital or other location or when the resident goes on therapeutic leave, the facility must provide to the resident or their legal representative, a written copy of the bed hold policy; -This notice must be given at the time of transfer or therapeutic leave. For emergency transfers, the notice must be given within 24 hours of transfer; [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment instrument) by not accurately coding use of a blood thinner and gastrostomy tube (g-tube, tube inserted into the stomach used for nutrition and medication administration) for one resident (Resident #34), failed to record signs and symptoms of possible swallow disorders for two resident's (Resident #19 and #38). The facility census was 49. 1. Review of the facility's MDS Care Assessment Summary and Individualized Care Plans policy, dated 02/26/21 showed: -Section K to be completed by Dietary Manager. This section addresses nutritional and swallowing status; -Section N is to be completed by Nursing Staff. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and/or revise the comprehensive person-centered care plan for four residents (Resident #19, #38, #42, and #46) to meet their medical and nursing needs. The facility census was 49. 1. Review of the facility's policy titled, Comprehensive Care plans and Baseline Care Plans, revised 01/19/22, showed staff were directed to do the following: -The facility must develop a comprehensive care plan for each resident that includes measureable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment; -A Licensed Nurse, that has been designated by the facility administration, will coordinate each assessment with the appropriate participation of health professionals known as the Interdisciplinary Team (IDT); [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to maintain professional standards of documentation for falls and neurological checks of one resident (Resident #19), failed to appropriately sign out administration of Schedule narcotics (drugs based on medical value and potential for abuse as classified by the Drug Enforcement Agency (DEA)) for three residents (Resident #5, #22, and #27), failed to obtain a hold order for an antipsychotic for one resident (Resident #22), failed to clarify medication orders for one resident (Resident #34) who was to receive nothing by mouth, and failed to update the advanced directives listed in a folder on a crash cart (cart used in emergency situations) in the main dining area per facility policy. The facility census was 49. 1. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure three Nurse Aides (NA) (NA O, NA P, and NA Q) of a sample of seven completed the nurse aid training program within four months of their employment in the facility. The facility census was 49. 1. Review of the facility's policy titled, Facility Assessment Policy and Tool, revised 06/29/23, showed staff were directed to: -Facility must have sufficient nursing staff with appropriate competencies and skills to provide nursing and related services to assure resident safety; -Facility must develop, implement, and maintain an effective training program for all new and existing staff. Review of the facility staff list showed seven NAs employed in the facility. Three were found to be employed beyond 120 days without becoming certified. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of one medication storage room, and one of two medication carts sampled. The facility census was 49. 1. Review of the facility's policy Medication Storage and Destruction, dated 01/05/23, showed the policy did not contain direction on expired medications. Observation on 10/19/23 at 10:35 A.M., showed the medication storage room contained: -1 Assure dose bottle with an expiration date of 05/19/23; -6 boxes of Evencare G2 glucose control solution with an expiration date of 07/08/23; -1 bottle of Fiber laxative 90 capsules with an expiration date of 02/23; -1 bottle of Flamontidine 30 tablets with an expiration date of 06/23. -Bottles of Gatorade and a bottle of vodka stored with disinfectant cleaners and a spray bottle of odor eliminator. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to document the administration or refusal of the pneumococcal (lung inflammation caused by bacterial or viral infection) vaccine for four (Resident #22, #32, #33, and #40) of six sampled residents. The facility census was 49 residents. 1. Review of the facility's Pneumococcal Vaccine Policy, dated 6/30/23 showed: -As part of the admission process, the resident or the resident's legal representative will be provided education on both the benefits and potential side effects of the pneumococcal immunization; -All Centers for Disease Control (CDC) recommendations for the pneumococcal immunization will be followed; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure staff received the required trainings upon hire and/or annually. The facility census was 49. Review of the facility's policies showed staff did not provide a policy for staff training. Review of the facility assessment, dated 09/20/23, showed staff were to have the following training: -All New hires receive Preventing, Recognizing, and Report Abuse; -All New Nursing, Social Service, and Activities hires receive additional training of Care of the Cognitively Impaired, and Communicating with Older Adults with Dementia; -All New Administrators, Director of Nursing (DON), Register Nurse (RN), and Licensed Practical Nurse (LPN) hires receive additional training of Documentation that Prevents Fraud and Abuse; -All employed staff receive annual training of Preventing, Recognizing, and Reporting Abuse. [...]

Inspectors wroteBased on interview and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for two residents (Resident #19 and #45). The facility census was 49. 1. Review of the facility's policy titled, Antipsychotic and Psychotropic Medications, revised 06/29/23, showed staff were directed to do the following: -Residents who use psychotropic drugs will receive GDR and behavior intervention, unless clinically contraindicated, in effort to discontinue these drugs; i. If GDR is not desired by the physician, they must document reasoning in resident's clinical record; ii. Documentation should include any previous attempts failed, and/or resident is at baseline with current dose, and/or current dose is needed for resident to sustain a quality of life. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to have a system to provide residents with a written response to grievances. The facility census was 49. 1. Review of the facility's policy titled Grievance Policy Residents, dated 9/25/23, showed staff were directed as follows: - If requested by the resident or legal representative or family/friend, the response to grievance shall be put in writing. Any written response shall include the date the grievance was received, a summary statement of the resident's grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not, any corrective action taken or to be taken by the facility, and the date the written decision was issued. [...]