St. Elizabeth's Place

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 2, 2026

  Based on record review, video surveillance review, facility document review, interview, and facility policy review, it was determined that the facility failed to ensure the facility provided an environment that was free from avoidable accidents and hazards for one (Resident #1) of six residents reviewed. Specifically, the facility staff failed to address a sounding alarm on an exit door that directly opened to an unsecured area and allowed Resident #1, who had an altered mental status, to leave the facility premises and travel to an establishment located 0.1 miles behind the facility without the facility's knowledge.It was determined the facility's past non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or… […]

• Actual harm, isolatedF689Jul 21, 2023

  Based on record review, witness statements, and interviews the facility failed to provide adequate assistance with transfers for 1 (Resident #3) resident who required a two person assist for transfers and had a documented history of falls. The failed practice resulted in past non-compliance. The findings are: 1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/27/23 documented resident required 2-person assistance with transfer. a. […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2024

  Based on observation, interview, and record review, the facility to ensure food preparation equipment was free of debris to prevent potential for cross contamination; spices stored in the cabinet or on a shelf in the storage room were dated for first-in-first out spice rotation; 1 of 2 ice machines and 1 of 2 ice scoop holders were maintained in clean and sanitary condition; and dietary staff washed their hands before handling clean equipment to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect 89 residents who received meals from the kitchen (total census 89). The findings are. 1. On 03/04/24 at 10:51 AM, the deep fryer had an accumulation of crumbs floating on the top of the oil. […]

• No harm, potential for more than minimal, patternF558Mar 7, 2024

  Based on observation, interview, and record review, the facility to ensure a call light was within reach for 2 (Resident #6 and R#387) of 17 sample mix residents who could use a call light. The findings are: 1. Resident #6 had diagnoses of Dementia, Muscle wasting and atrophy, Epilepsy, Difficulty in walking, and Abnormalities of gait and mobility. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/25/24 showed a Brief Interview for Mental Status (BIMS) of 13 (13 to 15 indicates cognitive intactness). 1a. The care plan showed .staff are to encourage the resident to .utilize the call light for assistance, if needed . 1b. On 03/04/24 at 01:25 PM, the Surveyor observed Resident # 6 call light lying on the floor. 1c. […]

• No harm, potential for more than minimal, patternF584Mar 7, 2024

  Based on observation and interview the facility failed to ensure residents meals were removed from the serving trays in the dining room to de-emphasize the institutional character of the setting to promote dignity and respect. This failed practice had the potential to affect 3 (Residents #20, #30, and #73) sampled residents who eat in the dining room. The findings are: On 03/04/24 at 12:54 PM, the Surveyor observed the Director of Nursing (DON) delivering meals to 3 separate residents, leaving the plate of food and drinks on the serving tray. On 03/04/24 at 01:02 PM, the DON confirmed leaving the meals on a serving tray was not homelike. […]