St Elizabeth Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Oct 17, 2024

  Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change in condition for 2 of 4 sampled residents (R7 and R8). R7 had a change in condition on 6/22/24. R7 has diabetes mellitus type 2. The facility has not completed daily diabetic foot checks, assessed, nor measured R7's diabetic wound, described the wound bed or continuously monitored R7's wound. In addition, R7's provider was not updated. R7 was sent to the hospital on 6/27/24 for osteomyelitis of the right second toe. Subsequently, R7's right second toe was amputated on 6/28/24. […]

• Immediate jeopardy, isolatedF689Nov 7, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 1 supplemental residents (R180) reviewed for elopement, 2 of 2 residents (R17 and R23) reviewed for motorized wheelchair charging, and 1 of 3 sampled residents (R24) and 1 of 1 supplemental residents (R180) reviewed for falls. R180 was a high risk for elopement. The facility failed to ensure R180 had adequate supervision to prevent elopement. In addition, the facility did not ensure R180 had an elopement device on his person when the resident returned from a hospitalization . R180 eloped and traveled over 1/2 mile from the facility. R180 was at risk for falls and had numerous falls with fractures while at the facility. […]

• Actual harm, isolatedF881Jan 8, 2025

  Based on interview and record review the facility did not ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This affected 1 of 4 sampled residents (R2). On 10/15/24, R2 was seen in the Emergency Department (ED) where he was diagnosed with a Urinary Tract Infection (UTI) that grew greater than 100,000 colonies of Enterobacter cloacae complex and greater than 100,000 colonies of Methicillin Resistant Staphylococcus aureus (MRSA), a multi-drug resistant organism. The facility failed to obtain R2's Urinalysis Culture and Sensitivity (UA C/S) from the hospital to ensure R2 was receiving the appropriate antibiotic. R2 was not receiving the correct antibiotic to effectively treat MRSA. […]

• Actual harm, isolatedF686Sep 9, 2021

  Based on observation, interview and record review the facility did not ensure residents receive care, consistent with professional standards of practice, to prevent pressure ulcers for 3 of 3 residents ( R5, R14 and R25) with pressure injuries reviewed of a total sample of 18. R5 developed a DTI (Deep Tissue Injury) that worsened into an unstageable wound to her left heel. The facility did not measure or assess the Pressure Injury (PI) weekly and did not implement aggressive offloading when R5 refused heel boots. R14 developed two stage 2 pressure injuries to her bilateral buttocks that the Facility is not measuring or assessing weekly. […]

• No harm, potential for more than minimal, widespreadF880Feb 13, 2025

  Based on interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 33 of 33 residents residing in the facility. The facility's Water Management Plan team members were not aware of their role nor were control measures being executed and documented. The facility had no infection control rates calculated for the past year. The facilities COVID-19 and Pneumococcal vaccine protocol does not contain the newest Centers for Disease Control and Prevention (CDC) guidance. […]