Providence St Elizabeth Care Center
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.

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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (2/5 stars)
- Above-median deficiencies (29 vs median 13.0)
Below average in CA · Below recommended RN staffing · Low staff turnover (stable workforce) · $59,441 in fines
What this means for your family
This facility has areas of concern that warrant careful consideration. The facility has 31 deficiencies, which is above the state average. This facility is on Medicare Special Focus status, indicating a pattern of serious quality issues. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
Staffing
Staffing Hours
per resident/day · Medicare 2026This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
11
measures
4
measures
2
measures
Residents whose bladder or bowel control got worse
Residents on antipsychotic medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents vaccinated for pneumonia
Residents on anti-anxiety or sleep medication
Residents whose walking got worse
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Providence St Elizabeth Care Center shows concerning patterns with 94 deficiencies across 14 surveys, with families filing 22 complaints. The facility repeatedly struggles with medication management and safety issues, including high medication error rates exceeding 5 percent. Problems with care planning, nursing staff competency, infection control, and food safety appear persistently across multiple inspections. While the facility reports correcting violations, the recurring nature of similar deficiencies suggests ongoing quality concerns.
Apr 2, 2026Complaint2
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Jan 12, 2026Complaint6
Resident Rights Deficiencies
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Jan 2, 2026Routine22
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Environmental Deficiencies
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Dec 10, 2025Complaint1
Environmental Deficiencies
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Dec 4, 2025Complaint1
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nov 25, 2025Complaint1
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Federal Penalties
Fine
Nov 25, 2025
$30,846
Fine
Oct 4, 2024
$23,186
Ownership & Operations
Who Operates This Facility
Providence St Elizabeth Care Center
for profit
Chain Affiliation
Providence Health & Services
9 facilities nationwide
Chain avg rating: 2.4/5 · Rank 4 of 7
Ownership & Management
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
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Google Reviews
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Official Website
Visit tolucalakecare.com
Medicare data downloads
Original nursing home datasets
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