Elizabeth Nursing and Rehab Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Sep 19, 2024

  Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 9/15/24 at 9:35 AM, the surveyor in the presence of the Chef observed the following during the kitchen tour: 1. The inside of the ice machine was observed in two areas with a black colored substance. The Chef stated the maintenance department oversees cleaning the ice machine and they were not aware of the black colored substance in the ice machine. […]

• No harm, potential for more than minimal, patternF756Apr 29, 2021

  Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a recommendation made by the Consultant Pharmacist was acted upon in a timely manner. This deficient practice was identified for 1 of 6 residents reviewed for medication management (Resident #6). The evidence was as follows: On 4/26/21 at approximately 10:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #6 goes to the [CONDITION(S)] center three days a week due to end stage [CONDITION(S)]. On 4/27/21 at 9:42 AM, the surveyor observed Resident #6 sitting on the edge of the bed talking on the phone. The resident was unable to be interviewed at that time. […]

• No harm, potential for more than minimal, isolatedF558Sep 19, 2024

  Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide a safe medical equipment (wheelchair with no armrest pad) which would provide additional support and comfort to protect the arm of a resident. This deficient practice was observed for one (1) of eighteen (18) residents (Resident #23) reviewed for assistant medical device. This deficient practice was evidenced by the following: On 9/15/24 at 11:38 AM, during initial tour, the surveyor observed Resident #23 who was seated in a high back wheelchair in the dayroom. The surveyor further observed the left-side armrest of the resident's high back wheelchair had no cushion. On 9/16/24 at 9:35 AM, the surveyor observed Resident #23 in the day room. […]

• No harm, potential for more than minimal, isolatedF761Sep 19, 2024

  Based on observation, interview, and record review, it was determined that the facility failed (a). remove and dispose a discontinued medication (Namenda 5 mg) from the active inventory, this was identified for one (1) of four (4) residents, (Resident #85) observed during medication administration and (b). properly label, store, and dispose medications in two (2) of four (4) medication carts inspected. This deficient practice was evidenced by the following: a). On [DATE] at 9:05 AM, during morning medication pass observation, the surveyor observed a Licensed Practical Nurse (LPN# 1) preparing medications for Resident #85. […]

• No harm, potential for more than minimal, isolatedF636May 15, 2023

  Based on observation, interview, record review and review of facility provided documentation, it was determined that the facility failed to provide a comprehensive nutritional assessment to identify the nutritional needs of newly admitted and readmitted residents to the facility within a 14 day period as required by Centers of Medicare & Medicaid Services (CMS). This deficient practice was identified for 4 of 9 newly admitted / readmitted residents reviewed for nutritional assessments between 3/28/23 to 4/17/23, (Resident #231, 232, 233, and 234), and was evidenced by the following: The surveyor reviewed the Resident Admission List supplied by the Admission's Director for residents admitted or readmitted to the facility from 3/28/23 to 4/17/23 with the following findings: 1. […]