CMS Inspection Results for ST ELIZABETH HEALTH SERVICES

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 10/09/2008 Fire Safety Survey for ST ELIZABETH HEALTH SERVICES

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
Building Contruction
Deficiency	Scope	Level of Harm
approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
corridors or aisles that are unobstructed and are at least 8 feet in width.	Pattern	Minimal harm or potential for actual harm

 

• 10/08/2008 Health Survey for ST ELIZABETH HEALTH SERVICES

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm

 

• 12/12/2007 Health Survey for ST ELIZABETH HEALTH SERVICES

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Potential for minimal harm
Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Use a registered nurse at least 8 hours a day, 7 days a week.	Isolated	Minimal harm or potential for actual harm

 

• 12/12/2007 Fire Safety Survey for ST ELIZABETH HEALTH SERVICES

Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm

 

• 10/19/2006 Health Survey for ST ELIZABETH HEALTH SERVICES

Administration
Deficiency	Scope	Level of Harm
Choose a doctor to be the medical director.	Widespread	Potential for minimal harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Actual harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm

 

• 10/19/2006 Fire Safety Survey for ST ELIZABETH HEALTH SERVICES

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm