Elizabeth Church Manor Nursing

Total Number of Beds: 121	Percent of Occupied Beds: 90%
Total Number of Residents: 109	Located Within a Hospital: No
Type of Ownership: Non profit - Church related	Multiple Nursing Homes by Same Owner: No
Councils the Nursing Home Participates in: Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 09/12/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.74

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.57

Number of CNA Hours per Nursing Home Resident per Day: 2.02

Number of Staff Hours per Nursing Home Resident per Day: 3.33

Nursing Home Resident Information**:

Percent of Low-Risk Residents Who Have Pressure Sores: 6%
Percent of Short-Stay Residents With Pressure Sores: 21%
Percent of High-Risk Residents Who Have Pressure Sores: 13%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 21%
Percent of Residents Who Have Moderate to Severe Pain: 3%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 19%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 5%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 21%
Percent of Residents Who are More Depressed or Anxious: 25%
Percent of Short-Stay Residents With Delirium: 0%
Percent of Residents Who Were Physically Restrained: 7%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 71%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 6%
Percent of Residents With a Urinary Tract Infection: 5%
** Details Last Reported on: 9/12/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-07-15	2001-08-16	Resident Rights Deficiencies	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
2001-07-15	2001-08-16	Environmental Deficiencies	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
2001-07-15	2001-08-16	Resident Assessment Deficiencies	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
2001-07-15	2001-08-16	Quality Care Deficiencies	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	Pattern	Minimal harm or potential for actual harm
2001-07-15	2001-08-16	Pharmacy Service Deficiencies	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.	Pattern	Minimal harm or potential for actual harm
2001-07-15	2001-08-16	Nutrition and Dietary Deficiencies	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Potential for minimal harm
2001-07-15	2001-08-16	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
2001-07-15	2001-08-16	Resident Assessment Deficiencies	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Pattern	Minimal harm or potential for actual harm
2002-09-05	2002-10-31	Resident Rights Deficiencies	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Isolated	Minimal harm or potential for actual harm
2002-09-05	2002-10-31	Mistreatment Deficiencies	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.	Pattern	Minimal harm or potential for actual harm
2002-09-05	2002-10-31	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
2002-09-05	2002-10-31	Resident Rights Deficiencies	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Widespread	Potential for minimal harm
2002-09-05	2002-10-31	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
2002-09-05	2002-10-31	Resident Assessment Deficiencies	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.	Widespread	Potential for minimal harm
2002-09-05	2002-10-31	Quality Care Deficiencies	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
2002-09-05	2002-10-31	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Minimal harm or potential for actual harm
2002-09-05	2002-10-31	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Potential for minimal harm
2002-09-05	2002-10-31	Resident Assessment Deficiencies	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
2003-09-12	2003-11-01	Resident Rights Deficiencies	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Isolated	Minimal harm or potential for actual harm
2003-09-12	2003-11-01	Resident Assessment Deficiencies	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
2003-09-12	2003-11-01	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
2003-09-12	2003-11-01	Quality Care Deficiencies	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
2003-09-12	2003-11-01	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
2003-09-12	2003-11-01	Quality Care Deficiencies	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
2003-09-12	2003-11-01	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
2003-09-12	2003-11-01	Administration Deficiencies	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.