Gundersen St Elizabeth's Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 14, 2021

  Based on observation, interview, and document review, the facility failed to follow the care plan which resulted in a fall for 1 of 3 residents (R1) reviewed for falls. This caused actual harm to R1 when she fell out of her recliner, fractured her pelvis in three places and eventually died . Findings include: R1's diagnosis list dated [DATE], indicated R1 had diagnoses of [CONDITION(S)], chronic obstructive pulmonary disease (difficulty breathing) and depression. R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate impairment of vision, moderately impaired cognition and required limited one person assistance with bed mobility, transfers, locomotion on/off unit, dressing and toileting. […]

• No harm, potential for more than minimal, patternF605May 21, 2025

  Based on observation, interview, and document review, the facility failed to develop and implement a system to ensure ongoing, adequate monitoring for side effects with consumed psychotropic medications to promote continuity of care for 3 of 5 residents (R39, R56, R9); and failed to ensure the use of as-needed (i.e., PRN) psychotropic medication was limited to 14-days or extended to a certain date with supporting rationale provided by the medical provider for 1 of 5 residents (R31) reviewed for unnecessary medication use. Findings include: SIDE EFFECT MONITORING: R39 R39's annual Minimum Data Set (MDS) assessment dated [DATE], identified R39 had intact cognition and demonstrated no delusional thinking during the review period. […]

• No harm, potential for more than minimal, patternF700May 21, 2025

  Based on observation, interview, and document review, the facility failed to ensure alternatives (i.e., small grab bar, positioning devices) were offered, attempted and recorded in the medical record prior to the use of bilateral one-half (1/2) side rails for 4 of 4 residents (R122, R45, R56, R222) observed to have side rails attached to their bed. Findings include: R122 R122's admission Minimum Data Set (MDS) assessment dated [DATE], identified R122 had intact cognition and demonstrated no delusional thinking during the review period. […]

• No harm, potential for more than minimal, isolatedF880Jun 10, 2026

  Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 resident (R54) reviewed for transmission-based precautions.Findings Include: R54's comprehensive Minimum Data Set (MDS) dated [DATE] indicated R54 had moderate cognitive impairment, used a walker for mobility, required substantial/maximal assistance for toileting, partial/moderate assistance for transferring from bed to chair. R54's diagnosis included kidney disease requiring a urinary catheter (flexible, hollow tube inserted into the bladder to drain urine when a person cannot urinate naturally). […]

• No harm, potential for more than minimal, isolatedF699May 21, 2025

  Based on interview, observation, and record review the facility failed to identify and document the trauma-related history, post-traumatic stress disorder (PTSD), known triggers and lacked a system or process for completing trauma assessments for 1 of 1 residents (R59) with a known history of PTSD. Findings include: R59's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition with no behaviors. Diagnosis included post traumatic stress disorder and anxiety. R59 required partial to moderate assist for transfers, ambulation, toileting and personal hygiene. R59 was taking an antidepressant medication. R59's care plan dated 9/12/24, included a problem of self-care deficit related to activity intolerance, due to medical diagnoses. […]