The state Department of Health Services issued a citation to St. Elizabeth Nursing Home after an investigation into a COVID-19 outbreak at the facility.


The state Department of Health Services has determined St. Elizabeth Nursing Home had an inadequate screening protocol after an investigation into a COVID-19 outbreak at the facility, but the nursing home disputes that.

A state report released Tuesday states St. Elizabeth failed to ensure all staff members were screened for COVID-19 symptoms at the beginning of their shifts to prevent exposure to residents.

In a plan of correction mandated by the state, the nursing home said it “objects to the allegation of noncompliance in the statement of deficiency and disagrees with both the findings of noncompliance and the level of deficiency cited.”

The nursing home says its submission of a plan of correction is not a “legal admission” to the findings in the state’s report.

State officials began an offsite investigation May 5 and concluded June 8 with an onsite investigation, according to the report.

The Rock County Public Health Department announced April 27 that two residents at St. Elizabeth had tested positive for COVID-19.

The Gazette was unable to reach health department spokeswoman Kelsey Cordova on Tuesday to ask whether more residents or staff members have tested positive since then.

In May, state health officials said a single case of COVID-19 prompts the state to open a facility-wide investigation.

State investigators found St. Elizabeth was not ensuring staff members were abiding by its infection control policy for COVID-19 and that the policy itself was unclear, according to the report.

A St. Elizabeth policy dated April 21 dictates that all employees should be screened at the beginning of their shifts for fever and other COVID-19 symptoms, according to the report.

The policy says temperatures and the absence of symptoms should be documented. Those with symptoms should leave the facility, according to the report.

During interviews with state officials, the nursing home’s interim director of nursing and the assistant nursing home administrator said each staff member was supposed to complete an online screening via Survey Monkey, a website for creating surveys and polls, and have his or her temperature taken by a nurse at the door before each shift.

Those interviewed were identified by title. No names were given.

Staff members had access to the survey website at onsite computers and on their phones starting March 11, according to the report.

All staff members had the potential to be in contact with any or all of the nursing home’s 23 residents, the assistant administrator said in the report.

State investigators found the nursing home’s screening policy did not specifically outline the Survey Monkey process, who was supposed to take temperatures, when screenings were completed or how to document the screenings, according to the report.

After a review of COVID-19 screening logs, investigators found no documentation of screening entries or temperatures on the log for:

  • Eight out of 11 nursing staffers working June 4.
  • Seven out of 10 nursing staffers working June 5.
  • Four out of 10 nursing staffers working June 6.
  • Six out of 11 nursing staffers working June 7.
  • One out of four nursing staffers working June 8.

In interviews with staff members, investigators learned:

  • A registered nurse did not complete screenings on the survey website for June 4, 5, 6 and 7 but did a temperature check at home and submitted it to the nursing home. The nurse was not told temperatures were to be taken onsite. The nurse did not present symptoms those days.
  • A certified nursing assistant said staff members typically had their temperatures taken by a nurse but sometimes took their own temperatures. The nursing assistant admitted to “slacking” on filling out the screening surveys and took his or her temperature but failed to record it.
  • A graduate nurse took his or her own temperature and forgot to record the screening during two shifts.
  • A medication administration assistant did not record his or her temperature and screening during three shifts. The assistant said the survey website did not work on his or her phone and only one computer was available for the survey at the nursing home.

The assistant nursing home administrator and a previous director of nursing had been monitoring screening data, and the screenings should have been completed but were not, the administrator said.

Failure to clearly define the screening policy and ensure compliance daily could expose residents to COVID-19 infection, according to the report.

In its plan for correction, St. Elizabeth said no residents suffered because of the incidents in the report.

The nursing home is now auditing the screening logs and ensuring temperatures are taken by staff upon entry.

All staff members are given masks before entering the facility, and education and training are provided on the screening process, according to the plan of correction.

Six Rock County nursing homes have been investigated by the state for COVID-19 outbreaks, according to a state database.

Rock Haven, which reported its first COVID-19 case May 14, is the only nursing home with an active investigation as of Tuesday.

Other nursing homes investigated include Autumn Lake Healthcare at Beloit, Evansville Manor, Green Knolls at Beloit and Oak Park Place in Janesville.

The Oak Park Place investigation yielded no violations or evidence of wrongdoing, according to a state report.

Reports for the other facilities have not yet been made public.