Elizabethtown Healthcare & Rehab Center

In the surveyor’s words

From the most serious findings on record at Elizabethtown Healthcare & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 16, 2025

  Based on observations, record review, and staff, Nurse Practitioner and the Medical Director's interviews, the facility failed to use the mechanical lift to transfer a non-weight bearing resident from a chair to the bed and instead used the stand and pivot method for transferring (A technique for moving where a resident stands with assistance and pivots on their feet then sits. This technique requires the ability to bear most of their body weight.) which resulted in a comminuted (the bone is broken into multiple small pieces) mildly displaced (bone fragments are slightly out of alignment) fracture of the distal tibia (large bone of the lower leg near the ankle) and proximal fibula (upper section of smaller bone in the lower leg just below the knee). […]

• No harm, potential for more than minimal, isolatedF812Sep 16, 2025

  Based on observations, and staff interviews the facility failed to discard expired nutritional supplements stored for use in 1 of 1 reach-in refrigerator in the kitchen. This practice had the potential to affect residents with physician ordered nutritional supplements. The findings included:An observation of the reach-in refrigerator in the kitchen was completed on 9/2/25 at 11:15 AM and revealed 10 bottles of a nutritional supplement with the expiration date 04/2025. The DM stated the nutritional supplement was expired and should not have been in the reach-in refrigerator. She further stated the staff must have just missed them when checking for expired food that morning. An interview was completed with the Administrator on 9/5/25 at 11:00 AM. […]

• No harm, potential for more than minimal, isolatedF880Sep 16, 2025

  Based on observation, record review, and staff interviews, the facility failed to follow their infection control policy and procedures for Enhanced Barrier Precautions (EHB) during high contact care for a resident with a pressure ulcer, when a nurse and the Wound Aide were providing wound care without wearing gowns for 2 of 6 staff observed for infection control (Nurse #1 and the Wound Aide).The findings included:The facility policy titled, Enhanced Barriers dated 9/22 stated in part: EBP requires the use of gown and gloves when providing high contact care activities for residents identified as requiring EBP. […]

• No harm, potential for more than minimal, isolatedF919Sep 16, 2025

  Based on observations, and resident and staff interviews, the facility failed to ensure the bedside call light system was functioning and provide an alternate means of communicating with staff for 2 of 2 residents who were dependent on staff for assistance with activities of daily living (ADL) (Resident #59, and Resident #20). Findings included: Resident #20 was admitted to the facility on [DATE] with diagnoses including congestive heart failure. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #20 was cognitively intact. He required limited one-person assistance with transfers and was wheelchair bound. Resident #59 was admitted to the facility on [DATE] with diagnoses including right lower leg fracture. […]

• No harm, potential for more than minimal, isolatedF607Sep 26, 2024

  Based on record review and staff interviews, the facility failed to implement their abuse policy for staff to promptly report an allegation of staff to resident abuse to the facility management as soon as the allegation was communicated to the staff member. This occurred for 1 of 2 residents (Resident #21) reviewed for abuse. Findings included: The facility policy titled, Abuse Prohibition, last reviewed on 02/2024, indicated it was the responsibility of their employees, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property, to facility management. […]