Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Elizabeth Care Center during CMS and state inspections, most recent first.
Facility staff failed to deliver resident mail on Saturdays, violating residents' rights to receive unopened mail. The activities department is responsible for mail distribution, but there was confusion about weekend delivery. The activity director and administrator confirmed mail is not delivered on weekends due to contraband checks, suggesting an RN could distribute mail instead.
The facility failed to update care plans for several residents, resulting in unaddressed needs such as PTSD triggers, hospice care, and dental issues. Observations and interviews revealed a lack of awareness among staff about the importance of care plan updates, with new staff still acclimating to their roles.
The facility failed to maintain professional standards by not accurately transcribing physician's orders for several residents, leading to discrepancies in medication administration and incomplete orders for hospice services. A resident's Divalproex Sodium order was not updated, causing confusion about the correct dosage. Another resident's Nystatin order lacked the route of administration, and three residents receiving hospice care did not have corresponding physician orders. The DON acknowledged the responsibility for ensuring accurate eMARs and complete orders.
The facility failed to obtain informed consent for bed rail use for two residents, despite policy requirements. Both residents, who were cognitively intact and independent with ADLs, were observed using bed rails without documented consent. Interviews revealed that the DON and Administrator were unaware of the missing consents, although they acknowledged the necessity of obtaining them prior to installation.
Facility staff failed to properly sanitize blood glucose monitors for multiple residents, contrary to the facility's infection control policy. A CMT did not adequately cover the glucometer's collection strip insertion site with disinfectant wipes for the required time, and in one case, did not disinfect the device at all. Interviews confirmed these lapses, despite staff training on proper procedures.
Facility staff failed to educate and offer the COVID-19 vaccine to residents, as required by CDC guidelines. Medical records for several residents lacked documentation of vaccination consent or declination. Interviews with the Infection Preventionist and administrator revealed no policy or educational efforts regarding COVID-19 vaccinations, citing remote location as a barrier.
A resident with PTSD and other mental health conditions was subjected to verbal and emotional abuse by a CNA who refused to leave the resident's room despite repeated requests. The CNA blocked the doorway, threatened the resident, and engaged in a verbal altercation, causing the resident to feel trapped and unsafe. Witnesses confirmed the CNA's inappropriate behavior, and the facility's administration recognized the need for an abuse investigation.
Facility staff failed to report an allegation of emotional abuse involving a CNA and a resident to the DHSS within the required two-hour timeframe. The incident involved the CNA refusing to leave the resident's room, leading to a confrontation. Despite staff awareness of reporting requirements, the DON and administrator did not report the incident promptly, treating it as a behavioral issue instead.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
Facility staff failed to ensure residents received their mail on Saturdays, which is a violation of the residents' rights to privacy in written communications. The facility's policy, revised in July 2023, states that residents have the right to send and promptly receive unopened mail. During a resident group meeting, residents reported that staff does not deliver their mail on Saturdays. Interviews with facility staff revealed that the activities department is responsible for distributing mail, but there was confusion about who delivers mail on Saturdays. The activity director stated that mail is not delivered on weekends because a department head must be present to check for contraband. The administrator confirmed that mail is not delivered on weekends and suggested that the RN on duty could distribute mail, but preferred a department head to handle packages due to contraband concerns.
Failure to Update Resident Care Plans
Penalty
Summary
The facility staff failed to review and revise the care plans for seven residents, leading to deficiencies in addressing their specific needs. For Resident #4, the care plan did not include details about PTSD triggers, assistance required for personal hygiene, or the resident's unsteadiness and dizziness, despite a documented fall. Observations showed the resident was unsteady and experienced involuntary movements, yet these issues were not reflected in the care plan. Resident #31's care plan did not address the use of bed rails, although observations confirmed the presence of a bed rail, which the resident used due to their size and swollen legs. Similarly, Resident #34's care plan lacked information on hospice and ostomy care, even though hospice care had been initiated. Resident #40's care plan did not include dental issues, despite the resident having dental problems since August and undergoing a tooth extraction in January. Residents #42, #48, and #55 were on hospice care, but their care plans did not reflect this change. Interviews with staff, including the CNA, MDS Coordinator, DON, and the administrator, revealed a lack of awareness and understanding of the importance of updating care plans to reflect current resident needs. The MDS Coordinator and DON were new to their positions and were still acclimating, which contributed to the oversight in care plan updates.
Deficiencies in Transcribing Physician Orders and Hospice Coordination
Penalty
Summary
The facility staff failed to maintain professional standards of care by not accurately transcribing and updating physician's orders for several residents. For Resident #10, the staff did not discontinue a previous order for Divalproex Sodium Direct Release 250 mg, which was supposed to be replaced by a new order for 500 mg. This discrepancy was not resolved, leading to confusion among staff about the correct dosage to administer. The Director of Nursing (DON) acknowledged the error and stated it was their responsibility to ensure the electronic Medication Administration Record (eMAR) was accurate. Resident #20's physician order for Nystatin oral suspension lacked the route of administration, leaving staff uncertain whether the medication should be swallowed or spit out. The DON and the administrator both emphasized the importance of complete and accurate orders, with the responsibility falling on the nurse taking the order to clarify any missing information with the physician. This oversight in the order transcription process led to potential confusion in medication administration. Additionally, the facility failed to obtain physician orders for hospice services for Residents #34, #42, and #55, despite documentation indicating they were receiving such services. Resident #34 also had an incomplete oxygen order without a specified flow rate. The DON stated that nurses are responsible for transcribing orders from hospital paperwork and obtaining clarification if needed. These deficiencies highlight a lack of coordination and communication in ensuring accurate and complete physician orders for residents receiving hospice care and other medical treatments.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for two residents, despite the facility's policy requiring such consent. Resident #31, who is cognitively intact and independent with activities of daily living, was observed with a bed rail up on multiple occasions. The resident, diagnosed with traumatic brain injury, anxiety, depression, psychotic disorder, and schizophrenia, did not have a documented informed consent for bed rail use in their medical record. The resident mentioned requesting the bed rail for assistance but could not recall being informed about the risks and benefits associated with its use. Similarly, Resident #48, also cognitively intact and independent with activities of daily living, was observed using grab bars on both sides of the bed. The resident, with diagnoses including heart failure, hypertension, stroke, depression, and respiratory failure, did not have an informed consent documented for the use of bed rails. The resident stated that they requested the bed rails for assistance with repositioning and getting out of bed. Interviews with the Director of Nursing and the Administrator revealed that they were unaware of the lack of consent documentation, despite acknowledging that consents should be signed before bed rail installation.
Improper Glucometer Disinfection Practices
Penalty
Summary
Facility staff failed to adhere to infection control practices by not properly sanitizing the blood glucose monitor for four residents. The facility's policy requires glucometers to be cleaned and disinfected after each use with EPA-registered disinfectant wipes, ensuring the device remains visibly wet for one minute to achieve complete disinfection. However, observations revealed that a Certified Medication Technician (CMT) did not follow these procedures. The CMT loosely wrapped the glucometer with a disinfectant wipe, failing to cover the collection strip insertion site for the required duration, and in one instance, did not disinfect the glucometer at all before placing it back in the medication cart drawer. Interviews with the CMT and the Director of Nursing (DON) confirmed the lapses in protocol. The CMT acknowledged the improper cleaning of the glucometer and admitted to not realizing the oversight in one instance. The DON and the facility administrator both stated that staff are expected to thoroughly cleanse the glucometer between each resident to prevent cross-contamination, and that all staff had received training on the proper disinfection procedures. Despite this, the observed practices did not align with the facility's infection control policy, leading to the deficiency.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility staff failed to educate and offer the COVID-19 vaccination to five residents, as required by the CDC guidelines for long-term care settings. The residents involved were both under and over the age of 65, and their medical records lacked documentation of COVID-19 vaccination consent or declination forms. There was no evidence that these residents received or refused the COVID-19 vaccine, indicating a lapse in the facility's vaccination protocol. Interviews with the Infection Preventionist and the administrator revealed that the facility did not provide COVID-19 education or vaccinations to residents. The Infection Preventionist, who started in July 2024, was unaware of any policy regarding COVID-19 vaccinations and cited the facility's remote location as a barrier to vaccine access. The administrator, also new to the position as of July 2024, confirmed the absence of a policy and the lack of educational efforts related to the COVID-19 vaccine.
Resident Subjected to Verbal and Emotional Abuse by CNA
Penalty
Summary
The facility staff failed to protect a resident from verbal and emotional abuse by a Certified Nurse Aide (CNA). The incident involved CNA E, who threatened to take the resident to the floor and refused to leave the resident's room despite repeated requests. The resident, who has intact cognition and a history of PTSD, anxiety, bipolar disorder, and depression, reported feeling trapped and unsafe when CNA E blocked the doorway and refused to leave. The resident's care plan emphasized the need for a safe environment free from perceived danger and highlighted the importance of calm interactions to prevent agitation. The facility's investigation revealed that CNA E and the resident engaged in a verbal altercation, with CNA E refusing to leave the room even after being instructed by a Licensed Practical Nurse (LPN) to do so. Witnesses, including another Nurse Aide and the LPN, confirmed that CNA E stood face to face with the resident and made comments that could further agitate the resident. The resident expressed feeling like a prisoner in their own room due to CNA E's actions. Interviews with facility staff, including the Director of Nursing (DON) and the administrator, indicated that CNA E's behavior was inappropriate and contributed to the resident's distress. The administrator acknowledged that the situation should have been investigated as abuse and noted that CNA E's actions could exacerbate the resident's agitation. Despite these acknowledgments, the report does not explicitly state whether CNA E's actions were officially classified as abuse.
Failure to Timely Report Alleged Abuse
Penalty
Summary
Facility staff failed to report an allegation of employee-to-resident emotional abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The incident involved a resident who reported that a Certified Nurse Aide (CNA) refused to leave their room after being asked multiple times and blocked the doorway. The situation escalated to yelling between the resident and the CNA, with the CNA standing abdomen to abdomen with the resident. Despite the Licensed Practical Nurse (LPN) instructing the CNA to leave, the CNA did not comply immediately. The Director of Nursing (DON) was notified the following day, and the state agency was not informed within the mandated timeframe. Interviews revealed that staff members, including the Nursing Assistant (NA) and LPN, were aware of the two-hour reporting requirement for abuse allegations. However, the DON and the administrator were unclear about their responsibilities in reporting the incident to the state. The administrator admitted to investigating the incident as a behavioral issue rather than abuse and failed to report it to the state agency promptly. The administrator also mentioned consulting with a regional administrator but did not receive guidance in time to meet the reporting requirements.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Elizabeth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miller County Care And Rehabilitation Center | 9.3 mi | ★★★★★ | 0 | 0 |
| Maries Manor | 17.6 mi | ★★★★★ | 9 | 0 |
| Eldon Nursing & Rehab | 17.8 mi | ★★★★★ | 15 | 0 |
| Stonebridge Lake Ozark | 18.8 mi | ★★★★★ | 1 | 0 |
| Dixon Nursing & Rehab | 19.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.