Curtis Home St Elizabeth Center, The

In the surveyor’s words

From the most serious findings on record at Curtis Home St Elizabeth Center, The, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 11, 2025

  Based on observations, review of clinical records, facility documentation, facility policies, and interviews for 1 of 4 residents (Resident #47) reviewed for accidents, the facility failed to provide adequate supervision to prevent a fall with injury and failed to follow the fall care plan interventions for injury prevention; and for the only sampled resident (Resident #36) reviewed for smoking, the facility failed to ensure a container being used for smoking materials was safe from potential fire hazard. The findings include: 1. Resident #47 was admitted to the facility in March 2024. Resident #47's diagnoses included dementia with behavioral disturbances, mood disturbance, anxiety, and large right cerebellar infarcts (stroke). […]

• No harm, potential for more than minimal, widespreadF851Mar 11, 2025

  Based on facility documentation and staff interview regarding Payroll Based Journal (PBJ) submission, the facility failed to submit accurate PBJ staffing data for the 3rd quarter of 2024 (April 1, 2024, through June 30, 2024). The findings include: The PBJ 3rd quarter submission report for April 1, 2024, through June 30, 2024, triggered as having no Registered Nurse (RN) coverage for 8 consecutive hours a day, low weekend staffing, and no licensed nurses 24 hours a day. Interview with the Business Office Manager on 3/11/25 at 12:42 PM identified that she inadvertently submitted the incorrect data. She indicated that she reviewed the staff payroll list for the skilled nursing center and the Residential Care Home (RCH). […]

• No harm, potential for more than minimal, patternF561Mar 11, 2025

  Based on interviews, observations, clinical record review, and facility policies for 1 of 5 sampled residents (Resident #8) reviewed for abuse, and for 2 of 2 residents (Resident #11 and Resident #45) reviewed for choices, the facility failed to ensure the resident right to choose was honored. The findings include: 1.Resident #8's diagnoses included anxiety, hypothyroidism, and asthma. The quarterly Minimum Set (MDS) assessment dated [DATE] identified Resident #8 as cognitively intact, independent with transfers, dressing, and personal hygiene. The Resident Care Plan dated 12/10/24 identified behavior/refusal of care issues. […]

• No harm, potential for more than minimal, patternF684Mar 11, 2025

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 sampled residents (Resident #28 and Resident #58) reviewed for edema and with diagnoses of Congestive Heart Failure (CHF), the facility failed to consistently obtain and document daily weights per the physician's order, for Resident #58, the Registered Nurse (RN) staff and Advanced Practice Registered Nurse (APRN) failed to ensure documentation of an assessment when a significant weight gain occurred, and for 1 of 3 sampled residents (Resident #45), reviewed for nutrition the facility failed to obtain weekly weights on admission per the facility policy and monthly weights per the physician orders. The findings include: 1. […]

• No harm, potential for more than minimal, patternF812Mar 11, 2025

  Based on the tour of the Dietary Department/Nourishment Rooms, staff interviews, and review of the facility policies, the facility failed to ensure food items were sealed, labeled and dated when opened and the only nourishment refrigerator/freezer temperatures were documented. The findings included: 1. Tour of the Dietary Department on 3/3/25 at 10:40 AM during the initial walk through with the Dietary Director identified the following: a. 3 bags (16 ounce) each Penne pasta bag #1 was 3/4/ full, bag #2 was 1/2 full, bag #3 1/4 full were opened and failed to include the date opened. b. An opened 5 pound bag of heart shaped pasta that was 1/4 full failed to include the date opened. c. An opened 5 pound bag of elbow pasta that was 1/2 full failed to include the date opened. d. […]