Elizabeth Seton

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF656Aug 31, 2023

  Based on observation, record review and interview the facility failed to implement a comprehensive care plan for 4 Residents (#1, #17, #18, and #21) from a total sample of 23 residents. Finding Included: Review of the facility policy titled, Care Plans-Comprehensive, undated, indicated the following: Policy Interpretation and Implementation *2. Residents will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. *10. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. 1. […]

• No harm, potential for more than minimal, patternF656Aug 17, 2022

  Based on observation, record review, policy review and interview the facility failed to implement the medical plan of care for 4 Residents (#69, #44, #13 and #11 ) out of total sample of 17 residents. Findings include: 1. For Resident #69, the facility failed to ensure the air mattress setting was implemented in accordance with the medical plan of care. Resident #69 was admitted to the facility in 11/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #69 scored a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating Resident #69 is cognitively intact. In addition, Resident #69 is totally dependent on staff for activities of daily living. […]

• No harm, potential for more than minimal, patternF812Aug 17, 2022

  Based on observation, record review and interview the facility 1) failed to properly store and label food in the facility kitchen, ensure food ready for resident consumption was stored properly and not expired on three out of five nourishment kitchens and the country kitchen on the first floor modules, 2) failed to maintain clean, sanitary food storage in the kitchen, and 3) failed to perform hand hygiene in accordance with professional standards of practice for food safety and sanitation to prevent potential foodborne illness to residents who are at high risk. […]

• No harm, potential for more than minimal, isolatedF656Sep 4, 2024

  Based on observations, interviews, and record review, the facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for two Residents (#63 and #34), out of a total sample of 18 residents. Specifically: 1.) For Resident #63, the facility failed to ensure nursing implemented a care plan intervention for bilateral floor mats for fall prevention. 2.) For Resident #34, the facility failed to ensure nursing developed and implemented a care plan intervention for bilateral floor mats for fall prevention. Findings include: Review of the facility policy titled 'Falls', undated, indicated, but was not limited to the following: - The licensed nurse, in conjunction with the interdisciplinary team will identify interventions to try to prevent subsequent falls. […]

• No harm, potential for more than minimal, isolatedF695Sep 4, 2024

  Based on observations, interviews, and record review, the facility failed to provide respiratory care services in accordance with professional standards of care and the plan of care for one Resident (#31) out of a total sample of 18 residents. Specifically, the facility failed to ensure nursing implemented a physician's order to change Resident #31's oxygen tubing. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2018, indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. […]