St Elizabeth Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF689Jun 30, 2026

  Based on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to ensure three of three sampled residents (Residents 1, 2 and 3) were provided with the necessary care and services. * The facility failed to ensure Resident 1, who was at risk for falls, was supervised while using the restroom resulting in an unwitnessed fall. * The facility failed to ensure the post-fall neurological assessments for Resident 2 were complete. In addition, the facility failed to complete a fall-risk assessment on admission for Resident 2. * The facility failed to ensure the post-fall neurological assessments for Resident 3 were complete. […]

• No harm, potential for more than minimal, patternF812Mar 19, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed. * The RD's facial hair was not covered while inside the kitchen. * The kitchen utensils and equipment were not stored or kept in sanitary conditions. * The meat thawing process was not followed. These failures posed the risk for food borne illnesses in a highly susceptible residents population of 84 facility residents who received food prepared in the kitchen.Findings: Review of the facility matrix showed 84 of 88 residents who resided in the facility consumed food prepared in the kitchen. 1. Review of the facility's P&P titled Dress Code dated 2023 showed beards and mustaches (any facial hair) must wear a beard restraint. […]

• No harm, potential for more than minimal, patternF880Mar 19, 2026

  Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. * The facility failed to ensure the transmission based precautions (additional infect control measures used in healthcare settings for the residents with known or suspected infections which can spread beyond standard precautions (minimum infection prevention practices that apply to all resident care, regardless of a resident's suspected or confirmed infection status)) were followed for Resident 63 when CNA 1 failed to sanitize the face shield after she removed the face shield, and before she hung on the hook placed outside the resident's room door… […]

• No harm, potential for more than minimal, patternF761May 5, 2023

  Based on observation, interview, facility P&P review, and facility pharmacy P&P, the facility failed to ensure the medications and supplies were properly stored. * LVN 1 left MiraLAX (medication for constipation) unattended on the medication cart. * Multiple expired medications and supplies were observed in the central supply room. * Oral and suppository medications were stored next to each other on the same shelf in the central supply room. * Expired wound care supplies were observed in the treatment cart. * Expired IV supplies were observed in the IV cart. * Medication labeled for a resident was opened, used, and stored in the central supply room. * The facility failed to store a bottle of acetaminophen (pain medication) securely and inaccessible by the staff, residents, and visitors. […]

• No harm, potential for more than minimal, patternF812May 5, 2023

  Based on observation, interview, facility documents review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the food items in the refrigerator and resident refrigerator were properly labeled. * The facility failed to ensure the resident refrigerator and the bin containing the scoops were clean. * The facility failed to ensure the kitchen utensils were in good repair. * The facility failed to ensure the cutting boards were in sanitary condition. These failures had the potential to expose the residents who consumed food prepared in the kitchen to foodborne illnesses. […]