Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Elizabeth Care Center during CMS and state inspections, most recent first.
The facility failed to provide a way for residents to file grievances anonymously without staff assistance. During a Resident Council meeting, residents said they did not know how to submit their own complaints and believed they had to go through a nurse or administrative staff member. The Administrator acknowledged there was no anonymous grievance procedure in the building, although a 1-800 number and Ombudsman information were posted.
A nurse aide’s annual performance review was missed after the facility’s software changed the aide’s hire date when the aide returned from time off. Staff confirmed the aide was still working as a per diem employee and that the last performance review remained the prior review on file.
A facility failed to ensure the daily staffing post was displayed every day in a prominent, readily accessible location. Surveyors observed the staffing sheet at the nurse's station was still dated for the prior day, and the Administrator stated the DON had the sheet in hand that morning before it was later found placed behind yesterday's posting.
Food storage and sanitation deficiencies were identified when surveyors found missing temp logs for food, fridge/freezer, dishwasher, and 3-comp sink equipment, along with unlabeled and undated food items in the freezer and pantry. They also observed dented cans, outdated relish, a dirty can opener, a dusty knife rack, and wet nesting in the drying rack, all confirmed by the DSD.
Dining Room Meal Service Not Coordinated for Tablemates. During a lunch observation, two residents seated at the same table were served while a third resident at the same table was left waiting as several other tables were served first. The resident told nursing staff she was hungry and still waiting for her meal, and the cook later stated they did not realize she was sitting there.
Failure to provide needed grooming assistance: A resident reported that staff had not recently shaved unwanted facial hair on her chin, despite her preference for it to be done. The surveyor observed visible chin hair, and the Administrator acknowledged the issue. The facility policy stated residents unable to perform ADLs independently would receive services necessary to maintain grooming and personal hygiene.
The facility failed to ensure ordered eating assistive devices were available and properly used for two residents. One resident with cognitive deficits, malnutrition risk, low BMI, and partial assistance needs for eating and drinking did not have a Kennedy cup at bedside despite an order and care plan intervention. Another resident with an order for a suction divided plate was served with the plate set inside the cover so it was not suctioned to the table, and the CNA later acknowledged it should have been suctioned when served.
Incomplete resident records were identified for two residents when required consent and billing forms were left with unchecked option boxes. One resident’s SNF-ABN did not show how the resident or POA wanted Medicare billed after Part A stopped paying, and another resident’s psychotropic medication informed consent form had no statement of consent selected; the BOM and DON confirmed the omissions.
The facility failed to serve breakfast at adequate temperatures, as observed during a survey. Two residents reported receiving cold breakfasts, and an observation confirmed that scrambled eggs and pancakes were served below the recommended temperature. Dietary staff acknowledged the issue.
The facility's QAPI Committee meetings lacked attendance from all required members, including the IP, DON, and Medical Director, across multiple months. This failure was confirmed by the DON and Administrator.
A resident with a full code status was found unresponsive and exhibiting signs of death, but the nurse on duty did not initiate CPR, believing the resident's condition indicated irreversible signs of death. The resident's advanced directives were not followed, leading to a deficiency citation.
Anonymous Grievance Process Not Available
Penalty
Summary
The facility failed to honor residents’ right to voice grievances without discrimination or reprisal by not providing a way for residents to file grievances anonymously without asking staff for assistance. Review of the facility’s Grievances/Complaints policy showed that grievances and complaints may be submitted orally or in writing and may be filed anonymously. During a Resident Council meeting, residents reported they did not know how to file their own grievances and stated that if they had a complaint they would talk to staff, who would file the complaint and generally resolve the issue. The residents were not aware of any way to file a complaint anonymously and said they had to go through a nurse or administrative staff directly, with no access to forms or another anonymous method. The Administrator acknowledged there was no anonymous grievance procedure in the building and stated the facility had never had any anonymous grievances, although she noted a 1-800 number and Ombudsman information were posted for grievances.
Missed Annual Performance Review for Nurse Aide
Penalty
Summary
The facility failed to complete a performance review of nurse aides at least once every 12 months for one of five nurse aides reviewed in the area of sufficient and competent nurse staffing. Record review showed Nurse Aide #56 had a performance review completed on 11/14/24, and staff confirmed on 03/25/2026 at 1:05 PM that the nurse aide was still working in the facility as a per diem employee. The Office Coordinator also confirmed that the last performance review remained 11/14/24 and stated the nurse aide had required some time off work. When the nurse aide returned, the office software changed the hire date, which caused the yearly performance review to be missed. No further information was provided through the completion of the survey.
Daily Staffing Post Not Updated
Penalty
Summary
The facility failed to ensure that staffing information was posted every day in a prominent place readily accessible to residents, staff, and visitors. During observation on 03/24/2026 at 10:35 AM, the daily staffing post at the nurse's desk was found dated 03/23/26. In an interview at 10:45 AM, the Administrator stated the DON had the staffing sheet in her hand that morning and she was unsure what had occurred. The Administrator later reported at about 10:55 AM that the staffing sheet had been placed behind the prior day's posting and had been corrected, and that the nurse's station was the only location in the facility where daily staffing was posted.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food safety. During an initial kitchen tour, surveyors found missing temperatures on the food temperature log, including no temperatures recorded for meals served on 03/01/26 and 03/02/26. They also found the refrigerator and freezer temperatures for 03/02/26 missing from the logs, as well as missing dishwasher and three-compartment sink temperatures for 03/01/26 and 03/02/26. In addition, curly fries in the freezer were in a Ziploc bag with no label or date, and two dented cans, one of spaghetti sauce and one of cheddar cheese sauce, were on the shelf to be used. Surveyors also observed a jar of outdated pickle relish in the refrigerator with a best-by date of 03/19/26. During a pantry tour, a bag of grapes was found with no resident name, received date, or use-by date. On a second kitchen tour, the knife rack had dust layered on top and crumbs inside, and wet nesting was observed in the drying rack with several wet cups stacked on top of each other. The can opener had leftover food on the cutting edge, and all of these findings were confirmed by the Dietary Services Director.
Dining Room Meal Service Not Coordinated for Tablemates
Penalty
Summary
The facility failed to ensure resident dignity during dining by not serving all tablemates at the same time. During a lunch dining observation, Resident #16, Resident #5, and Resident #3 were seated together at the same table, but only Resident #16 and Resident #5 were initially served while Resident #3 remained waiting. Four more tables were served before Resident #3 received her meal, and at 12:13 PM Resident #3 told nursing staff she was hungry and still waiting for her food. Nursing staff then informed the cook that Resident #3's meal tray was needed. When asked why Resident #3 was not served with the other residents at her table, [NAME] #63 stated, "It was on me. I did not realize she was sitting there."
Failure to Provide Needed Grooming Assistance
Penalty
Summary
The facility failed to ensure that one resident received the assistance needed with activities of daily living, specifically personal grooming. Resident #6 stated during interview that staff had previously shaved the facial hair on her chin, but they had not done so lately, and she wanted it taken care of. The surveyor observed multiple hairs growing from her chin. During a later interview, the Administrator acknowledged that Resident #6 had unwanted facial hair and stated, "I will take care of it." The facility policy stated that residents unable to perform ADLs independently would receive services necessary to maintain grooming and personal hygiene.
Failure to Provide Ordered Eating Assistive Devices
Penalty
Summary
The facility failed to ensure residents had appropriate assistive devices for eating and drinking. Resident #12 had an order for a Kennedy cup and the care plan listed the Kennedy cup as an intervention for nutrition, with the resident identified as being at risk for altered nutritional status related to cognitive deficits, moderate protein calorie malnutrition, vitamin D deficiency, a mechanically altered diet, therapeutic diet, low BMI, and a history of nausea. Section GG of the annual MDS showed impairment in one upper extremity requiring partial assistance with eating and drinking, yet the resident was observed lying in bed with a regular cup and straw on the bedside table, and a CNA confirmed the Kennedy cup was not in the room. Resident #14 had an order for a suction divided plate with meals, but during dining observation the plate was placed inside the plate cover and was not suctioned to the table. The plate base could still move around the table. Later, the CNA removed the suction divided plate from the base and suctioned it directly to the table, and the resident stated that this was better. When asked whether it should have been suctioned to the table when served, the CNA replied, "As far as I know, it should have been."
Incomplete Resident Consent and Billing Records
Penalty
Summary
The facility failed to ensure complete and accurate medical records for Resident #13 and Resident #4. For Resident #13, a review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form showed that the boxes under the options category were not checked. These options were intended to show how the resident or POA wanted the facility to bill Medicare for the continued stay after Medicare A stopped paying. The Business Office Manager confirmed that the boxes were not checked and should have been. For Resident #4, a review of the Psychotropic Medication Informed Consent form showed that the statement of consent boxes were not checked. The missing selections included statements indicating consent to the medication, acknowledgment of non-pharmacological interventions, receipt of education about the medication and its side effects and Black Box Warnings, consent only on a temporary basis for life-threatening symptoms, or refusal of the medication intervention. The DON confirmed during interview that none of the boxes were checked.
Inadequate Breakfast Food Temperatures
Penalty
Summary
The facility failed to maintain adequate and appetizing temperatures for breakfast foods served in resident rooms, as observed during a Long Term Care Survey process. During a resident council meeting, two residents reported that their breakfast was often delivered cold, affecting its taste. On a subsequent morning, an observation of breakfast tray delivery revealed that the last tray was served at 7:36 AM, with scrambled eggs and pancakes measured at temperatures of 103.5 degrees Fahrenheit and 93.8 degrees Fahrenheit, respectively. These temperatures were below the recommended 120 degrees Fahrenheit at the point of service. Dietary Staff #12 acknowledged that the food temperatures were not within the recommended range.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assurance and Performance Improvement Committee (QAPI) attended the quarterly meetings as mandated. The facility's QAPI Committee is scheduled to meet every second Tuesday of each month, with a list of required attendees including the Medical Director, Consultant Pharmacists, Director of Nursing (DON), Administrator, and other key personnel. However, a review of the QAPI meeting sign-in sheets for four quarters starting in September 2023 revealed that not all required members were present at any meeting during the specified periods. Specifically, in March, April, and May 2024, the Infection Preventionist (IP) was absent from all meetings, with additional absences of the Medical Director and Administrator in April and May, respectively. Similarly, in June, July, and August 2024, the IP, DON, and Medical Director were absent from multiple meetings. The Director of Nursing and the Administrator confirmed the absence of required personnel for two of the four quarterly meetings.
Failure to Implement Advanced Directives for Full Code Resident
Penalty
Summary
The facility failed to implement advanced directives for a resident who had completed a Physician Order for Scope of Treatment (POST) form indicating her wishes to be a full code. The resident was found unresponsive, not breathing, with no pulse, and exhibiting signs of death such as fixed and non-reactive pupils, cold extremities, and a rigid torso. Despite the resident's full code status, the nurse on duty did not initiate CPR and instead monitored the resident for signs of life for five minutes. The nurse aide initially reported the resident's difficulty breathing and nausea to the registered nurse, who then assessed the resident and found her unresponsive. The nurse attempted sternal rubs and called the resident's name, but these actions were ineffective. The nurse did not initiate CPR, as she believed the resident's condition indicated irreversible signs of death, and she was in the mode of pronouncing death rather than considering resuscitation efforts. The incident was substantiated by the facility, and the nurse was later terminated following an investigation. The failure to follow the resident's advanced directives and initiate CPR as per the full code status was identified as a deficiency during the survey.
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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 Elizabeth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ohio Valley Health Care | 13 mi | ★★★★★ | 21 | 0 |
| Parkersburg Center | 15.4 mi | ★★★★★ | 34 | 1 |
| Roane General Hospital | 16.7 mi | ★★★★★ | 14 | 0 |
| Willows Center | 16.7 mi | ★★★★★ | 31 | 0 |
| Miletree Center | 17 mi | ★★★★★ | 10 | 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.