Elizabeth Care Center

In the surveyor’s words

From the most serious findings on record at Elizabeth Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF585Mar 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF730Mar 25, 2026

  Based 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. Findings included:a) Nurse Aide #56 Review of Nurse Aide #56's personnel file showed a performance review was conducted on 11/14/24. On at 03/25/2026 at 1:05 PM, the Office Coordinator confirmed Nurse Aide #56 continued to work in the facility as a per diem employee. The Office Coordinator also confirmed the nurse aide's last performance review was on 11/14/24. […]

• No harm, potential for more than minimal, patternF732Mar 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF812Mar 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF804Sep 25, 2024

  Based 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. Findings included: a) Facility On 09/24/24 at 2:00 PM, a resident council meeting was held. During the meeting, Resident #26 stated Breakfast delivered to our rooms are cold. It just doesn't taste right. At that time, Resident #9 stated, Yes, sometimes our breakfast is cold when they bring it. I don't say anything about it though. They bring me something else if I ask them too. On 09/25/24 at 7:20 AM, an observation was made of breakfast trays being delivered resident rooms. […]