Elizabethtown Nursing and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteThe 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).

Inspectors wroteThe 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.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming and personal hygiene for ten (Resident (R) 9, R14, R25, R26, R35, R39, R40, R42, R108, and R254) of 21 sampled residents. Residents did not receive regularly scheduled showers and/or baths, and grooming/hygiene, including nail care, as needed.

Inspectors wroteBased on observation, interview, 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 for 6 (six) of 21 sampled residents (R8, R11, R30, R31, R36, R45). Observation on 08/26/2024 at 2:23 PM revealed R45's catheter bag on the floor. Additionally, observation of a unit manager not donning a gown prior to entering R9's room, which was in contact precautions.

Inspectors wroteThe facility failed to ensure CNAs received 12 hours of yearly training for two of three sampled CNA personnel files. The facility did not provide the required 12 hours of yearly training for the three CNAs reviewed.

Inspectors wroteThe facility failed to update the electronic clinical record to reflect resident code status per signed advanced directive for two of five sampled residents, R38 and R45. The Advanced Directives forms were signed for CPR, however, the electronic record revealed DNR.

Inspectors wroteThe facility failed to ensure performance evaluations were completed for two of two sampled CNAs. The facility did not provide evaluations for CNAs employed over one year and trained based on those evaluation results.

Inspectors wroteThe facility failed to ensure daily nursing staffing was posted in the facility for two of five days during the survey. The last posted daily staffing 08/27/24.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the resident(s) right to be free from abuse and neglect for one of one sampled resident. (R9) R9 stated staff left the room while providing her a shower, which made her feel scared. R9 was a quadriplegic and unable to call for help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident (R) 203) of 21 sampled residents was free from a significant medication error. R203 was sent to the hospital for pain control after not receiving her routinely ordered controlled pain medication for over two days after admission.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to immediately inform the resident's physician and guardian when there was a significant change in the resident's physical status for one (1) of three (3) sampled residents (Resident #1). On 01/09/2024, Resident #1's diet was downgraded by the Speech Therapist (ST) to a pureed diet with nectar thick liquids. Record review revealed the resident did receive a pureed diet beginning 01/09/2024; however, there was no evidence to support the physician or the resident's guardian were notified, or a physicians order written for the diet change. Further review revealed the facility did not notify the physician and guardian each time Resident #1 refused medications or meal/fluid intake.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain medical records on each resident that was complete and accurately documented for one (1) of three (3) sampled residents (Resident #1). On 01/09/2024, Resident #1's Nutrition Assessment revealed a recommendation from the Dietician for the resident to have fortified foods; however, there was no evidence this recommendation was relayed to the physician and an order obtained for fortified foods. On 01/09/2024, the Speech Therapy downgraded Resident #1's diet to a pureed diet with nectar thick liquids; however, there was no evidence an order was obtained from the physician regarding the diet change. [...]

Inspectors wroteBased on interview, review of grievance forms and logs, and facility policy review, it was determined the facility failed to report the findings and actions of the facility to the Resident Council. Interviews with resident council members revealed the monthly meetings with the facility representative, the Activity Director (AD), did not include review of the previous grievances, and the facility resolution. In addition department heads responsible for the grievance review, investigation and resolution did not meet the next month with the resident council members to discuss findings, resolution and to follow up on the facility continued audit of the grievance.

Inspectors wroteBased on observation, interview and facility policy review it was determined the facility failed to ensure a resident was treated in a dignified and respectful manner for one (1) of thirty-two (32) sampled residents, Resident #7. Observations revealed the Director of Nursing (DON) conversed with Resident #7 at the resident's bedside. Interview with Resident #7 revealed the resident cried because he/she was angry and stated he/she felt the DON was rude and was treated the resident as a child.

Inspectors wroteBased on observation, record review, and interview it was determined the facility failed to revise a comprehensive care plan for one (1) resident out of thirty-two (32) residents, Resident #9. Resident #9 had behaviors of entering resident's room without consent and watching them sleep. Resident #9's comprehensive care plan was not updated to reflect this behavior.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide accessible water to encourage hydration for one (1) of thirty-two (32) sampled residents, Resident #7. Observations for four (4) of four (4 ) survey days revealed no [NAME] water container within access for Resident #7.