Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Elizabeth Healthcare Center during CMS and state inspections, most recent first.
The facility did not provide required written discharge notices and bed hold policy information, including cost details, to residents and their representatives during hospital transfers. Documentation and staff interviews confirmed that, despite facility policy, there was no evidence that this information was given to multiple residents with complex medical conditions at the time of their transfer.
Staff administered and read Mantoux TB skin tests without documented training and failed to record required times for test administration and reading, resulting in tests being read too early or without proper documentation. Residents with complex medical conditions were affected, and facility policy requiring trained staff and complete documentation was not followed.
Staff did not obtain a follow-up weight or document refusals for a resident who experienced significant weight loss and gain, and failed to notify the physician, dietitian, or family representative as required by facility policy. Interviews indicated inconsistent practices and lack of documentation regarding weight refusals and follow-up.
The facility did not resolve ongoing grievances from residents about delayed call light response times, as documented in multiple resident council meetings and confirmed by resident interviews. Despite repeated complaints and facility policies requiring follow-up, there was no evidence that specific concerns were addressed or resolved, and documentation of actions taken was lacking.
The facility failed to document the progress of a non-pressure skin wound, monitor and document edema for a resident with a splint, and notify physicians of elevated blood sugar readings. Additionally, the facility did not follow physician's orders for medications for multiple residents, as confirmed through observations, record reviews, and staff interviews.
The facility failed to ensure proper respiratory care for three residents, leading to deficiencies in oxygen administration. Observations revealed inconsistencies in oxygen flow rates and undated oxygen tubing, contrary to physician's orders. Interviews with staff indicated a lack of adherence to prescribed oxygen levels.
The facility failed to ensure staff followed infection control standards, including handwashing during food service, using enhanced barrier precautions during wound care, and proper handling of soiled linens. Staff members acknowledged these lapses during interviews.
The facility failed to address and document resident council concerns about call light response times over several months. Residents reported long wait times for call light responses, sometimes up to an hour, and had to provide their own care due to staff inaction. The facility's policies on grievance resolution were not followed, leading to unresolved and undocumented concerns.
The facility failed to provide the required 48-hour Notice of Medicare Non-Coverage (NOMNC) for two residents, giving only a 24-hour notice instead. The Executive Director could not explain the reason for the insufficient notice period, as the responsible staff member was on leave. The facility's policy mandates a 2-day notice prior to Medicare discharge.
The facility failed to complete a revised PASARR level I for a resident after prescribing duloxetine for depression. The oversight was confirmed by the Executive Director and Clinical Support Nurse, who noted the facility did not have a specific PASARR policy.
The facility failed to remove expired medications and ensure proper labeling in the 500 back hall medication cart. Expired bottles of Robitussin DM and Geri tussin Liquid were found, along with unlabeled Tums, Diclofenac gel, and Children's Tylenol. A QMA was unaware of which residents were receiving the unlabeled medications and acknowledged the expired medications should have been removed.
The facility failed to maintain resident rooms and hallways in good repair and free of odors. Observations showed missing carpet and loud, old beds. Several rooms had strong urine odors, and staff were unaware of actions being taken to address the issue. The facility did not provide an environmental policy at the time of the exit conference.
Failure to Provide Written Discharge and Bed Hold Policy Information During Hospital Transfers
Penalty
Summary
The facility failed to provide required written documentation regarding the reason for discharge and the bed hold policy, including cost information, to residents and their representatives during hospital transfers. For four residents with complex medical histories, including conditions such as spina bifida, diabetes, congestive heart failure, dementia, and stroke, there was no evidence in the clinical records that written notices or bed hold policy details were given at the time of transfer. In several cases, nursing notes documented the transfer to the hospital but did not indicate that the residents or their representatives received the necessary information. One resident specifically reported not recalling receipt of discharge or bed hold policy documents. Interviews with facility staff, including the DON and Clinical Support Nurse, confirmed that while discharge paperwork was typically sent with the resident to the hospital, there was no documentation in the electronic health record to show that the required information was provided to the residents or their representatives. Facility policies required advance communication of bed hold options and charges, but the records reviewed did not demonstrate compliance with these requirements for the residents transferred to the hospital.
Failure to Document Training and Proper Administration of TB Skin Tests
Penalty
Summary
The facility failed to ensure that staff administering and reading Mantoux skin tests for tuberculosis (TB) had documented training, and did not consistently document all required elements of the TB testing procedure. Specifically, there was no documentation of the time the second step Mantoux test was administered or read for one employee, making it impossible to confirm the required 48-hour interval before reading the test. Additionally, for three residents, clinical records showed that TB skin tests were administered and read by nurses without documentation of required training, and in some cases, the tests were read before the 48-hour minimum had elapsed. The facility's own policies required that Mantoux tests be administered and read by staff with documented training and that the date and time of administration and reading be recorded. Residents involved had complex medical histories, including conditions such as spina bifida with hydrocephalus, type 2 diabetes mellitus, paraplegia, cerebral palsy, chronic respiratory failure, dementia, and other significant diagnoses. The records for these residents showed missing documentation of the time of TB test administration and reading, and in some cases, the tests were read too early. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that the required training documentation was missing for several nurses, and that the facility could not verify training for some staff members.
Failure to Re-Weigh and Notify on Significant Resident Weight Changes
Penalty
Summary
Staff failed to obtain a follow-up weight for a resident who experienced significant fluctuations in weight, including a 23.65% loss in one month followed by a 27.49% gain the next month. There was no documentation of any re-weighing to confirm these significant changes, nor was there evidence that the physician, dietitian, or family representative were notified of the weight variances. The facility's own policy required re-weighing for weights outside the normal range and notification of significant weight changes, but these steps were not documented as completed. Interviews with staff revealed inconsistent practices regarding resident refusals to be weighed, with some staff stating they would attempt multiple times and inform management if a resident refused. However, there was no documentation of refusals or follow-up attempts for this resident, and some staff indicated the resident did not typically refuse to be weighed. The facility lacked a clear documentation policy for these situations, despite having written guidelines for weight tracking and management.
Failure to Resolve Resident Council Grievances Regarding Call Light Response
Penalty
Summary
The facility failed to resolve ongoing resident council concerns and grievances related to call light response times for three of five residents reviewed. Resident council meeting minutes over several months documented repeated complaints about long call light wait times, with no evidence of resolution. Residents reported waiting from 30 minutes to over an hour for assistance, including instances where a resident remained in soiled conditions for extended periods. Interviews with residents confirmed that the issue persisted over time, and the facility's documentation did not show specific actions taken to address or resolve these concerns. Facility staff, including the Clinical Support Nurse and Activity Director, indicated that grievances were recorded and reviewed by management, but could not provide evidence of specific concerns or their resolution. The only available call light audits covered a limited period, and facility policies required that grievances and recommendations be brought to the attention of leadership and reported back to the resident council, which was not demonstrated in practice. The deficiency was identified through interviews, record reviews, and examination of facility policies and procedures.
Failure to Document Wound Care and Notify Physicians of Abnormal Conditions
Penalty
Summary
The facility failed to assess and document the progress of a non-pressure skin wound for Resident 23. Despite having a physician's order to clean and dress the wound every five days, there was no documentation in the electronic health record (EHR) after the initial measurement on 2/25/24. The Director of Nursing Services (DNS) confirmed that the wound should have been assessed and measured weekly but was not. This lapse in documentation and follow-up care was evident during observations and interviews conducted on 4/16/24 and 4/17/24. Resident 37 had a left hand/wrist splint device in place, and her left wrist, hand, and fingers were swollen. Despite a physician's order to monitor for blanching, color, and odor three times a day, there was no documentation of the edema in the EHR. The DNS confirmed that there was no care plan in place for the resident's fracture and that the swelling and open skin area should have been documented. This deficiency was observed and confirmed during interviews on 4/18/24 and 4/19/24. The facility also failed to notify physicians of elevated blood sugar readings and to follow physician's orders for medications for multiple residents. For example, Resident 31 had blood glucose levels significantly above the normal range, but there was no documentation of physician notification. Similarly, Resident 29 received insulin despite blood sugar levels being below the threshold specified in the physician's order. Resident 16 was given digoxin despite having a pulse rate below the threshold, and there was no documentation of physician notification. These deficiencies were confirmed through record reviews and interviews with staff on 4/18/24 and 4/19/24.
Deficiencies in Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents, leading to deficiencies in oxygen administration. For Resident 23, observations revealed that the oxygen tubing was not dated, and the oxygen flow rate was inconsistently set at 1.5 liters, 2 liters, and 3 liters per minute, contrary to the physician's orders. The resident's care plan indicated a need for supplemental oxygen to manage chronic conditions such as congestive heart failure and chronic obstructive pulmonary disease, but the prescribed oxygen levels were not maintained consistently. Resident 31 was observed using an empty portable oxygen tank on multiple occasions, and the oxygen flow rate was set incorrectly at various times. The oxygen tubing was also not dated. Despite the physician's order for 2 liters of continuous oxygen, the flow rate was observed to be set at 2.5 liters and just under 3 liters. Interviews with staff indicated a lack of adherence to the prescribed oxygen flow rate, with only nurses authorized to adjust the flow rate. Resident 20's oxygen flow rate was observed to be set at 4 to 5 liters, contrary to the physician's order of 3 liters. The oxygen tubing was not dated, and the resident reported frequently asking staff to increase the oxygen flow when experiencing difficulty breathing. The resident's care plan and physician's orders were not followed, leading to inconsistent oxygen administration. Interviews with staff revealed a lack of awareness of the updated oxygen order, resulting in the incorrect flow rate being administered.
Infection Control Lapses
Penalty
Summary
The facility failed to ensure staff followed infection control standards in several instances. The Assistant Food Director was observed serving food to residents without washing his hands between serving plates on multiple occasions. Additionally, Guest Relations staff was seen touching her face and arm and then serving food without washing her hands. Both staff members acknowledged their lapses in hand hygiene during interviews. The Director of Health Services (DHS) and an RN did not follow enhanced barrier precautions while providing wound care and handling a urinary catheter for a resident with stage 3 and unstageable pressure ulcers, paraplegia, and osteomyelitis. Despite a physician's order requiring the use of gloves and gowns during high-contact care activities, both staff members only wore gloves. The DHS admitted they should have worn gowns during the procedure. Other infection control lapses included a Qualified Medication Aide (QMA) not changing gloves after performing incontinence care and then touching the resident's blankets and call light. A resident's catheter bag was found on the floor, and another resident had personal items and linens improperly stored on the floor and chair. Additionally, a soiled brief was left on a resident's bed, and a CNA was observed carrying soiled linens down the hall without placing them in a trash bag first. Staff members acknowledged these lapses during interviews, and the facility's policies on infection control were not followed in these instances.
Failure to Address and Document Resident Council Concerns
Penalty
Summary
The facility failed to ensure resident council concerns and grievances were addressed and documented in the meeting minutes for four of the twelve months reviewed. Specifically, concerns about call light response times were repeatedly raised by residents during council meetings in July 2023, January 2024, February 2024, and March 2024, but these concerns were not documented as reviewed or resolved in subsequent meeting minutes. Residents reported that call lights often went unanswered for extended periods, sometimes up to an hour or more, and in some cases, residents had to provide their own care due to the lack of timely response from staff. The Activity Director, who assisted residents in filling out grievances, was unaware of why the call light concerns had not been addressed, and the Director of Nursing Services confirmed that there was no documentation of call light audits being completed. The facility's policies on resident council meetings, resident rights, and the resident concern process were not followed. These policies require that grievances and recommendations be brought to the attention of the Executive Director, who should forward them to the appropriate department leader for attention and response. The resolutions should be documented and reported back to the Resident Council at the next meeting. However, this process was not adhered to, as evidenced by the lack of follow-up and resolution documentation in the meeting minutes. This failure to address and document resident concerns about call light response times indicates a significant lapse in the facility's grievance resolution process.
Failure to Provide 48-Hour Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) was given 48 hours prior to the end of Medicare benefits for two residents. For Resident 38, the NOMNC indicated that Medicare services would end on 3/13/24, but the resident signed the notice on 3/12/24, providing only a 24-hour notice. Similarly, for Resident 101, the NOMNC indicated that Medicare services would end on 3/5/24, but the resident signed the notice on 3/4/24, also providing only a 24-hour notice. During an interview, the Executive Director (ED) was unable to explain the reason for the insufficient notice period, as the staff responsible for completing the notices was on leave. The facility's current policy, last reviewed on 12/31/23, requires the NOMNC to be issued 2 calendar days prior to the actual discharge from Medicare.
Failure to Complete Revised PASARR Level I After Prescribing Psychotropic Medication
Penalty
Summary
The facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) level I was completed after psychotropic medications were prescribed for a resident. The clinical record for the resident indicated diagnoses including depression, anxiety disorder, dementia, congestive heart failure, and hypertension. A PASARR level I, dated earlier in the month, indicated the resident did not require a level II and was not taking any mental health medications. However, a physician's order later in the month prescribed duloxetine, an antidepressant, for the resident's depression. The care plan was updated to reflect the risk of adverse effects from the antidepressant medication, but a new PASARR level I was not completed within the required 14-day period after the medication was prescribed. The facility's Executive Director and Clinical Support Nurse confirmed the oversight during interviews, noting that the facility did not have a specific PASARR policy and relied on the Indiana PASARR Standard Operating Procedure Revenue & Collections.
Expired and Unlabeled Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from the medication cart and that medications were properly labeled. During an observation, a partial bottle of Robitussin DM with an expiration date of 2/22/24 and a partial bottle of Geri tussin Liquid 100/5 with an expiration date of 3/18/24 were found in the 500 back hall medication cart. Additionally, the bottom drawer contained a partial bottle of Tums and two tubes of Diclofenac sodium topical gel 1%, all of which were unlabeled. A partial bottle of Children's Tylenol was also found with a resident's name written in marker but not properly labeled. During an interview, a Qualified Medication Aide (QMA) indicated she did not know which resident(s) were receiving the Tums and Diclofenac gel and acknowledged that the expired medications should have been removed. She subsequently took the expired medications to the Director of Nursing Services for destruction. The facility's current policy on medication storage, received from the Clinical Support Nurse, indicated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or with insecure closures should be immediately removed from inventory and disposed of according to procedures for medication disposal. Another policy on medication administration guidelines emphasized the importance of checking the label, container, and contents for integrity and comparing them against the medication administration record before administering any medication. The facility's failure to adhere to these policies resulted in the presence of expired and unlabeled medications in the medication cart, posing a potential risk to resident safety.
Facility Fails to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to ensure that resident rooms and hallways were in good repair and free of odors. Observations revealed that the doorway of one room was missing approximately 18 inches of carpet, and the hallway between two rooms had missing pieces of carpet around gold floor plates. Additionally, one room's bed was very loud when moving up and down due to dried grease on the bed frame, and the beds were old with the manufacturer no longer in business. The Maintenance Director confirmed that there were no purchase orders for the carpet or the beds. Several rooms had a strong urine odor that extended into the hallway. Interviews with staff indicated that the 500 hall always had a strong odor, and the Assistant Director of Nursing Services was unaware of any actions being taken to address the issue. The Maintenance Support mentioned that exhaust fans had been changed, but the odor persisted, possibly due to a resident spilling urine on the carpet. The facility did not provide an environmental policy at the time of the exit conference, although a policy on Resident Rights indicated that residents have the right to a safe, clean, comfortable, and homelike environment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Delphi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Milner Community Health Care | 12 mi | — | 0 | 0 |
| White Oak Health Campus | 12.8 mi | — | 0 | 0 |
| Indiana Veterans Home | 13.2 mi | — | 4 | 0 |
| Monticello Healthcare | 13.5 mi | — | 0 | 0 |
| Heritage Healthcare | 14.1 mi | — | 1 | 0 |
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