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.

• Actual harm, isolatedF760Jan 12, 2023

  Based on record review and interview, the facility failed to ensure pain patches were monitored for placement and to change an order received from a hospital discharge for 1 of 5 residents reviewed for medication errors. (Resident E). Resident E was admitted to the hospital due to a change in mental condition. Finding includes: 1. A Facility Incident Report, dated 11/3/22 at 6:20 p.m., indicated the resident displayed a change in condition. When the nurse assessed Resident E, two fentanyl 37.5 mcg (microgram) patches (a pain patch apply to the skin) were discovered on the resident's chest. On the right side the patch was dated 10/30/22, and on the left side the patch was dated 11/2/22. The record for Resident E was reviewed on 1/9/23 at 4:21 p.m. […]

• No harm, potential for more than minimal, widespreadF725Jan 12, 2023

  Based on observation, interview and record review, the facility failed to ensure enough staff were available to check on call light response times, to staff CNAs according to the Facility Assessment plan, to complete resident baths and showers, to check and change incontinent residents every 2 hours, and to observe medication administration. This deficient practice had the potential to affect 56 of 56 residents residing in the facility. Findings include: 1. During an interview, on 1/4/23 at 3:21 p.m., Resident T indicated it took one hour to get staff to answer her call light. During an interview, on 1/4/23 at 3:34 p.m., Resident K indicated the facility had staffing issues due to illnesses with covid and the flu. […]

• No harm, potential for more than minimal, patternF628May 7, 2025

  Based on interview and record review, the facility failed to ensure the written reason for discharge and the bed hold policy with cost information was provided to the resident and resident's representative for 4 of 4 residents reviewed for hospitalization . (Resident 2, F, 23 and 27) Findings include: 1. The clinical record for Resident 2 was reviewed on 5/1/25 at 11:49 a.m. The diagnoses included, but were not limited to, cervical spina bifida, pressure ulcer, type 2 diabetes mellitus, paraplegia, hydrocephalus, cerebral palsy, major depressive disorder, anxiety disorder, neuromuscular dysfunction of the bladder, and mood affective disorder. A notice of transfer discharge, dated 4/30/25, indicated the reason for the discharge and the bed hold policy was included. […]

• No harm, potential for more than minimal, patternF880May 7, 2025

  Based on interview and record review, the facility failed to ensure staff had documented training prior to administering 2 step Mantoux skin tests for tuberculosis (TB) and all parts of the procedure were documented to ensure accuracy for 1 of 5 employees and 3 of 7 residents reviewed for infection control. (CNA 16, Resident 2, 20, and 50) Findings include: 1. A facility tuberculin testing for employees' form indicated CNA 16 was given a second step Mantoux test on 4/10/24 and read on 4/12/24. There was no documentation to indicate the time the second step test was given or read to ensure there was a 48-hour lapse before reading the test. 2. The clinical record for Resident 2 was reviewed on 5/1/25 at 11:49 a.m. […]

• No harm, potential for more than minimal, patternF684Apr 19, 2024

  Based on observation, interview and record review, the facility failed to assess and document the progress of a non-pressure skin wound, to assess and document the skin condition of a resident with a splint in place, to notify the physician when blood sugar readings were elevated, failed to follow the physician's orders for medications and to notify the physician per the physician's order for 5 of 5 residents reviewed for quality of care. (Resident 23, 37, 31, 29 and 16) Findings include: 1. During an observation, on 4/16/24 at 11:13 a.m., Resident 23 had a bandage on her right and left elbows and another bandage on her left forearm. She indicated the bandages on the elbows were used as a preventative. She had an area of open skin on the left forearm. […]