Elizabethtown Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Elizabethtown Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF725May 8, 2023

  Based on policy review, state professional standards, clinical record review, document review, and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services for each resident, resulting in the absence of a Registered Nurse in the facility to assess and pronounce a resident who was found with no pulse or respirations (Resident 4). This failure placed all residents who reside at the facility requiring services from a Registered Nurse in an Immediate Jeopardy situation (34 residents). Findings Include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. […]

• No harm, potential for more than minimal, widespreadF880Jul 18, 2024

  Based on staff interview and facility policy review, it was determined the facility failed to maintain a data collection system of surveillance for 10 of 12 months reviewed (October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, and July 2024). Findings include: Review of the facility policy, titled Infection Control, last reviewed June 2024, revealed the facility will maintain a monthly line list of residents with infections for trending and outbreak potential, follow-up review of lab data is compared, and a monthly review is completed to identify trends to facilitate infection control surveillance. […]

• No harm, potential for more than minimal, widespreadF882Jul 18, 2024

  Based on staff interviews and state regulations, it was determined that the facility failed to have an Infection Preventionist (IP) that completed an approved program for specialized training in infection prevention and control. Findings include: The Centers for Medicare and Medicaid Services regulation S483.80(b)(4) stated, The facility must designate one or more individual(s) as the Infection Preventionist(s) (IP(s) who are responsible for the facility's IPCP (Infection Prevention Control Program) that have completed specialized training in infection prevention and control. During an interview with the Director of Nursing (DON) on July 15, 2024, at 10:00 AM, Employee 4's (Registered Nurse) IP credentials were requested. […]

• No harm, potential for more than minimal, patternF812Jul 16, 2026

  Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to distribute and serve food under sanitary conditions during the lunch meal on June 13, 2026.Findings include: Review of facility policy, titled Employee Hygiene and Sanitary Practices, revised October 2017, read, in part, hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment utensil sand linens. Observation on July 13, 2026, at 12:10 PM, revealed Employee 6 (Dietary Manager) was serving on the tray line without wearing a hair net, and Employee 5 (Director of Dietary and Housekeeping) was observing the tray line and wasn't wearing a beard net. […]

• No harm, potential for more than minimal, patternF628Jun 18, 2025

  Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident/resident representative of the resident transfer, in writing, to include the following: the reason for the transfer or discharge, date of transfers, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long Term Care Ombudsman; and failed to provide the resident/resident representative written notice of the bed hold policy at time of transfer for four of four residents reviewed for hospitalizations (Residents 10, 23, 32, and 43). […]