St Elizabeth Care Center

In the surveyor’s words

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

• Actual harm, isolatedF600Aug 10, 2023

  Based on interview and record review, Registered Nurse (RN) F failed to assess and monitor one resident (Resident #2) in accordance with the resident plan of care, with a change in condition consistent with a previous seizure activity. RN F instructed staff to turn lights off and close the resident's door and did not notify the resident' physician with the change in condition. RN F failed to assess the resident from approxiamely 5:40 P.M., to 6:00 P.M. when shift change occurred. RN G immediately assessed the resident during rounds with RN F, notified the resident's physician who ordered they send the resident to the hospital for evaulation and treatment of the change in condition. The facility census was 46. 1. […]

• No harm, potential for more than minimal, widespreadF804Feb 27, 2026

  Based on observation, interview and record review, the facility staff failed to provide meals which were palatable, attractive and served at a safe and appetizing temperature. Facility staff also failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit (F) or higher when served to residents. The facility census was 59.1. Review of the facility's Dietary Food Preparation policy, revised 07/05/23, showed: -The cook or Dietary Manager (DM) will taste food before serving;-Food will be served at the proper temperature to ensure food safety;-Acceptable serving temperature for hot foods including hot pureed foods is 135 degrees Fahrenheit (F) but preferably 160-175;-Each food item, served separately in the regular diet, is pureed and served separately for the… […]

• No harm, potential for more than minimal, widespreadF812Feb 27, 2026

  Based on observation, interview and record review, facility staff failed to clean and maintain equipment in a manner to prevent potential contamination. Facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to maintain and serve food items at temperatures adequate to prevent food borne illness. Facility staff failed to maintain an ice machine air gap. These failures have the potential to affect all residents. The facility census was 59.1. […]

• No harm, potential for more than minimal, widespreadF880Feb 27, 2026

  Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease, a serious type of pneumonia caused by Legionella bacteria. Facility staffs' failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 59 with a capacity of 63. 1. […]

• No harm, potential for more than minimal, widespreadF880Oct 20, 2023

  43327 Based on interview and record review, the facility staff failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility census was 49. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. […]