St. Elizabeth Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure alternative food choices were offered to residents who chose to receive meals in their room for 3 of 3 residents reviewed for resident rights. (Resident 4, 40 and 41)

Inspectors wroteBased on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when the resident had a new mental health diagnosis added for 1 of 5 residents reviewed for PASARR. (Resident 24)

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented for 1 of 2 residents reviewed for care plans. (Resident 24)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received a medication timely according to the scheduled administration time and to ensure a resident had a physician's order in place for a non-pressure skin impairment for 2 of 3 residents reviewed for quality of care. (Resident 24 and 56)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive assessment, person-centered care plan, and physician's orders were implemented for the use of an assistive device with transfers for 1 of 1 resident reviewed for range of motion and mobility. (Resident 44)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for the use of oxygen was implemented for 1 of 1 resident reviewed for respiratory care. (Resident 62)

Inspectors wroteBased on interview and record review, the facility failed to ensure the care strategies to meet the individual needs of a resident who had a history of post-traumatic stress disorder (PTSD) were documented and implemented for 1 of 1 resident reviewed for post-traumatic stress disorder. (Resident 24)

Inspectors wrote4. The clinical record for Resident 27 was reviewed on 5/6/25 at 11:03 a.m. The diagnoses included, but were not limited to, displaced intertrochanteric fracture of left femur, pneumonitis due to inhalation of food and vomit, diabetes type 2, hypertension, depression, anxiety, dysphagia, pain, heart attack, stroke, and myalgia. A progress note, dated 4/29/25 at 11:35 a.m., indicated Resident 27 was sent to the emergency room for symptoms of a stroke. The record did not contain documentation to indicate Resident 27 or the resident's representative were given information in writing regarding the reason for the resident's transfer to the hospital or the facility's bed hold policy, including the facility's charge to hold a bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff had documented training prior to administering 2 step Mantoux skin tests for tuberculosis (TB) and all parts of the procedure were documented to ensure accuracy for 1 of 5 employees and 3 of 7 residents reviewed for infection control. (CNA 16, Resident 2, 20, and 50)

Inspectors wroteBased on interview and record review, the facility failed to ensure resident council concerns and grievances were resolved for 3 of 5 residents reviewed for resident council concerns. (Resident 28, 37 and B)

Inspectors wroteBased on interview and record review, the facility failed to ensure staff obtained a follow-up weight to determine if a significant weight loss or gain had occurred and to document if a resident refused for 1 of 3 residents reviewed for nutrition. (Resident B)

Inspectors wrote3a. The clinical record for Resident 31 was reviewed on 4/18/24 at 12:22 p.m. The diagnoses included, but were not limited to, pneumonia, type 2 diabetes mellitus, chronic anemia, dementia, pleural effusion, atelectasis (partial collapse or closure of part of the lung), and diastolic congestive heart failure. A care plan for Resident 31, dated 3/27/24, indicated the resident was at risk for hypo/hyperglycemia related to diabetes mellitus. A long-term goal indicated the resident would be free of symptoms of hypo/hyperglycemia through the next review. A physician's order, dated 3/8/24, indicated insulin Aspart U-100 per sliding scale and to call MD if blood sugar was greater than 400 mg/dL. A progress note, dated 3/8/24 at 5:20 p.m., indicated Resident 31 had a blood glucose level of 591 prior to dinner. [...]

Inspectors wrote2. During an observation, on 4/15/24 at 12:45 p.m., Resident 31 was wearing oxygen tubing connected to an empty portable oxygen tank. During an interview, on 4/15/24 at 12:49 p.m., CNA 10 indicated the portable tank was empty and the resident relied on supplemental oxygen. CNA 10 indicated she would fill up the tank. During an observation, on 4/16/24 at 10:28 a.m., the portable oxygen tank for Resident 31 was empty and the flow rate dial was set on 2.5 liters while he was sitting in the activities room in his reclining wheelchair (Broda chair). The nurse was notified. LPN 9 took the portable oxygen tank off Resident 31's Broda chair and refilled tank. LPN 9 returned the refilled portable oxygen tank to Resident 31 and reconnected the oxygen tubing. The flow rate remained at 2.5 liters of oxygen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed infection control standards related to handwashing during food service, following enhanced barrier precautions during wound care, during incontinence care, for urinary catheters, for storing linens and clothes in rooms, and disposing of soiled linens for 6 of 6 staff and 3 of 3 residents randomly observed for infection control practices. (Assistant Food Director, Guest Relations 5, Director of Health Services, RN 6, QMA 2, Resident 40, Resident 5, Resident 149 and CNA7)

Inspectors wroteBased on interview and record review, the facility failed to ensure resident council concerns and grievances were addressed and the resolutions to the concerns/grievances were documented in the meeting minutes for 4 of 12 months reviewed for resident council meeting minutes. (July 2023, January 2024, February 2024, March 2024.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Medicare Non-Coverage was given 48 hours prior to the Medicare benefits ending date for 2 of 3 residents reviewed for beneficiary notices. (Resident 38 and 101)

Inspectors wroteBased on interview and record review, the facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) level I was completed after psychotropic medications were prescribed for 1 of 5 residents reviewed for PASARR. (Resident 40)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications were removed from the medication cart and medications were labeled for 1 of 3 medication carts reviewed for medication storage. (500 back hall medication cart)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rooms and hallways were in good repair and rooms were free of odors for 5 of 28 rooms observed for environment on the 500 hall. (room [ROOM NUMBER], 512, 517, 518 and 519).