Elizabethtown Nursing and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF727Jan 31, 2026

  Based on interview and review of the facility's Payroll Based Journal Data Report, the facility failed to ensure there was a Registered Nurse (RN) on duty at least 8 consecutivc hours a day, 7 days a week. There was no documented evidence there was a RN working at the facility on 07/12/2025, 07/20/2025, 09/06/2025, and 09/07/2025.The findings include:Review of the document signed by the Administrator, dated 01/29/2026, revealed, The facility does not have a specific policy on staffing.Review of the facility's Payroll Based Journal (PBJ) Data Report, for the timeframe from 07/01/2025 to 09/30/2025, revealed no Registered Nurse (RN) hours were submitted for 07/12/2025, 07/20/2025, 09/06/2025, and 09/07/2025.During an interview, on 01/31/2026 at 9:12 AM, the Payroll Manager stated she… […]

• No harm, potential for more than minimal, widespreadF812Jan 31, 2026

  Based on observation, interview, and review of facility policy, the facility failed to prepare, distribute and serve food in accordance with professional standards for food safety. Observation on 01/30/2026 revealed Cook1 failed to remove soiled gloves and wash hands when appropriate while preparing and serving food. Further, Cook1 failed to use tongs to place bread on the meal trays, and instead handled the bread with his gloved hands.The findings include:Review of the facility policy titled, Food: Preparation, revised 02/2023, revealed, All foods are prepared in accordance with the FDA [Food and Drug Administration] Food Code. Procedures - 1. All staff will practice proper hand-washing techniques and glove use. 2. […]

• No harm, potential for more than minimal, widespreadF880Jan 31, 2026

  Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failure had the potential to affect all 59 residents in the building. The facility failed to ensure fit testing for employees. Fit testing refers to a mandatory Occupational Safety and Health Administration (OSHA) regulated procedure that verifies a tight-fitting respirator (such as an N95 mask) properly seals to an employee's face in order to minimize contaminants entering the mask through gaps between the seal and the skin. […]

• No harm, potential for more than minimal, widespreadF925Aug 29, 2024

  The facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. Gnats were observed in common areas and resident rooms throughout the survey process. Interview with residents indicated this had been an ongoing issue, with multiple resident reporting concerns with gnats getting on their food or drinks at meal times (R3, R9, R10, R15, R42, R45, R48). The findings include: Interview with Maintenance Director on 08/29/2024 at 10:45 AM and Administrator on 08/29/2024 at 3:37 PM revealed facility did not have a pest control plan or policy. […]

• No harm, potential for more than minimal, patternF557Aug 29, 2024

  The facility failed to protect resident dignity related to a catheter bag cover for four of four sampled residents. Observation of R7, R8, R14, and R11 during survey revealed the catheter urine bag did not have a privacy cover and contained liquid. Observation of R7 included lunch time in the dining room with other residents present. R11 and R14 expressed they would prefer to have their catheter covered. R8 was vulnerable and catheter without dignity bag was visible from the doorway. The findings include: Review of the facility policy Resident Rights Under Federal Law not dated, revealed the facility would protect and promote the rights of each resident. […]