Elizabethtown Nursing and Rehabilitation

Inspectors wroteBased 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).

Inspectors wroteBased on policy review, observations, clinical record review, and resident and staff interviews, the facility failed to review and revise the resident plan of care for five of 13 residents reviewed (Residents 2, 19, 26, 27, and 30).

Inspectors wroteBased on employee handbook review, review of select facility documentation, and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for five of five nurse aides reviewed (Employees 1, 2, 3, 4, and 5).

Inspectors wroteBased on Resident Assessment Instrument (RAI - a standardized approach for applying a problem identification process in nursing homes, adopted to examine nursing home quality and to improve nursing home regulation), clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 13 residents reviewed (Residents 2, 26, and 27).

Inspectors wroteBased on clinical record review, observation, staff and resident interviews, and facility policy review, it was determined that the facility failed to develop a baseline plan of care for one of two residents reviewed for new admission (Resident 95).

Inspectors wroteBased on facility policy review, review of select facility fall reports, clinical record review, and staff interviews, it was determined that the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents and failed to conduct thorough fall investigations for one of two residents reviewed for falls (Resident 10).

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide a physician ordered nutritional supplement, per physician's order, for two of four residents reviewed for nutritional status (Residents 2 and 26), and failed to notify the physician of significant weight changes for two of four residents reviewed for nutritional status (Residents 10, and 26).

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to complete a timely assessment for trauma, and then develop and implement an individualized person-centered care plan to render trauma-informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of one resident reviewed with PTSD (Resident 2).

Inspectors wroteBased on observation, facility policy review, and staff interviews, it was determined that the facility failed to ensure opened vials were labeled in accordance with currently accepted professional principles for one of one medication rooms reviewed.

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure clinical records were complete and accurately documented for one of 13 residents (Resident 8).

Inspectors wroteBased on observation, policy review, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the transmission of diseases and infections for two of two resident rooms observed (Residents 1 and 2). Findings Include: An entrance interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on March 4, 2025, at approximately 8:50 AM, revealed the facility has several residents who tested positive for COVID-19, and the facility is following its COVID-19 infection policy and procedures. Visitors are encouraged to wear surgical masks and screen for signs and symptoms of infection while in the building, and staff providing direct care to those infected residents to wear the required personal protective equipment (PPE). [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interview, it was determined that the facility failed to offer the option to formulate an advance directive, as evidenced by utilization of only the POLST (Pennsylvania Orders for Life-Sustaining Treatment) and no documentation of the resident's choices pertaining to advanced directives or documenting how the resident was informed of his or her right to develop a living will or advance directive for four of 35 records reviewed (Residents 1, 20, 33, and 45).

Inspectors wroteBased on observation, document review, policy review, and staff interviews, it was determined that the facility failed to make prompt efforts to resolve resident grievances for two of 10 grievances reviewed, and failed to post in prominent locations the contact information of the identified Grievance Official, including the name, business address (mailing and email), and business phone number in one facility area observed (facility bulletin board). Findings Include: A review of the facility's policy, titled Resident and Family Concerns and Grievances Policy and Procedure, dated 2022, defines its purpose as To provide for the prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with applicable federal and state statutes and regulations. [...]

Inspectors wroteBased on observation, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and in one of one nourishment pantries observed and for one of one meal observed.

Inspectors wroteBased on a review of clinical records, the facility's infection prevention and control policy, and staff interview, it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by two of three residents reviewed (Residents 6 and 23).

Inspectors wroteBased on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents were offered influenza and pneumococcal as required for two of five residents reviewed (Residents 33 and 41).

Inspectors wroteBased on clinical record review, facility policy, and interview, it was determined that the facility failed to ensure that residents were offered any current COVID-19 vaccinations as required for four of five residents reviewed (Residents 1, 12, 33, and 41).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies, advocacy groups, and a statement that the resident may file a complaint with the State Survey Agency concerning suspected violations of state or federal nursing facility regulations for one area observed (facility bulletin board). Findings Include: An observation of the facility's bulletin board, containing information for resident review, on July 15, 2024, at 11:04 AM, revealed no information listing resident advocacy groups, the State agency information, including mailing and email addresses, telephone numbers, and statements regarding the resident's right to file complaints with State and Federal agencies. [...]

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure its residents the right to examine the results of the most recent survey and that those results are posted in a place readily accessible to its residents for one area observed (facility lobby). Findings Include: An observation in the facility's lobby, on July 15, 2024, at 10:32 AM, revealed the facility's survey results book in an area accessible only by using a code to gain entrance and exit. Observations in resident areas, beyond the locked lobby area, revealed no survey books for resident review in the dining area, the resident common area, the nurses' station, or the designated activities area. [...]

Inspectors wroteBased on document review and staff interviews, it was determined that the facility failed to ensure each resident is periodically informed of any charges for services not covered under Medicare for two of three residents reviewed at the end of a Medicare stay (Residents 1 and 148). Findings Include: A review of Resident 1's Skilled Nursing Facility Beneficiary Notification Review form revealed the last covered day of Medicare A coverage on April 30, 2024. A review of the facility-provided Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form (SNF-ABN), revealed Resident 1 would no longer receive Medicare covered therapy services after April 30, 2024, and the estimated cost of those non-covered services was not provided to Resident 1 or her responsible party. [...]

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing to include to include the following: the reason for the transfer or discharge, date of transfer, 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, for two of three resident records reviewed for hospital transfers (Residents 19 and 46 ).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of transfer for one of three resident records reviewed for hospital transfers (Resident 19). Findings Include: [...]

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one of three residents receiving oxygen therapy reviewed (Resident 40). Findings Include: A review of the facility's policy, titled Care Planning-Interdisciplinary Team, revised September 2013, read, in part, Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. A review of Resident 40's physician orders revealed diagnoses that included chronic obstructive pulmonary disease (COPD - A group of lung diseases that block airflow and make it difficult to breathe) and muscle weakness. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards regarding medication and treatment administration for two of 23 residents reviewed (Residents 24 and 40). Findings Include: Review of facility policy, Administering Medication, revised April 2019, read, in part, medications are administered in a safe and timely manner and as prescribed. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR- recording of physician orders being administered or completed) space provided for that drug and dose. [...]

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided care consistent with professional standards of practice for one of three residents receiving oxygen therapy reviewed (Resident 40). Findings Include: A review of Resident 40's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - A group of lung diseases that block airflow and make it difficult to breathe) and muscle weakness. An observation of Resident 40, on July 15, 2024, at approximately 11:00 AM, revealed the use of an oxygen concentrator while in bed in her room. A review of Resident 40's physician orders revealed none documenting the Resident's need and use of oxygen. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for one of five residents reviewed for unnecessary medications (Resident 24).

Inspectors wroteBased on observations, staff interviews, and policy review, it was determined that the facility failed to ensure adherence to appropriate labeling of medication for one of two medication carts (front hall cart).

Inspectors wroteBased on state regulations, review of facility documents, and staff interview, it was determined that the facility failed to ensure that the Medical Director and Infection Preventionist (IP) was in attendance at least quarterly at the Quality Assurance Process Improvement (QAPI) Committee meetings, and failed to provide sign-in records for QAPI Committee meetings for one of four quarters (first quarter).

Inspectors wroteBased on document review and staff interviews, it was determined that the facility failed to implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation, and the transition to post-discharge care for one of three residents reviewed (Resident 2). Findings Include: Review of the facility's Social Services/Social Worker job description, described the essential duties and responsiblities as, Works with the resident, family and other members of the health care team to formulate a discharge plan that provides the resident services in the appropriate post-acute setting. Review of Resident 2's clinical record revealed diagnoses that included cerebral cysts (fluid filled sacs in the brain) and Diabetes Mellitus Type II (a disease that occurs when your blood glucose, also called blood sugar, is too high). [...]

Inspectors wroteBased on review of employee files, review of facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure residents were free from abuse by failing to conduct license verification for new employees for three of four employees (Employees 2, 3, and 6)

Inspectors wroteBased on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for four of 16 residents reviewed (Resident 29, 32, 145, and 146).

Inspectors wroteBased on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure there were sufficient staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for eight of 16 residents reviewed (Residents 3, 4, 7, 17, 19, 23, 26, and 30). Findings Include: During the initial pool process on August 14, 2023, Residents 3, 7, and 17 expressed concern to the survey team about call bell response time and/or staffing. Review of resident council meeting minutes and interviews with Residents 4, 19, 23, 26, and 30 during the group meeting, revealed concerns with call bell response times and insufficient staff. Review of Resident 3's clinical record revealed diagnoses including hypertension (elevated blood pressure) and anxiety disorder (a feeling of worry, nervousness, or unease). [...]

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for five of five nurse aide performance evaluations reviewed (Employees 7, 8, 9, 10, and 11). Findings Include: Review of annual performance reviews for the following Nursing Assistant Employees 7, 8, 9, 10, and 11 revealed no annual performance reviews were completed. During an interview with Assistant Nursing Home Administrator on August 17, 2023, at 8:50 AM, it was revealed that the facility doesn't have proof that performance reviews were completed for the aforementioned employees. 28 Pa. Code 201.19 Personnel policies and procedures

Inspectors wroteBased on review of facility temperature logs and records, observations, and staff interviews, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness (Walk-in Refrigerator).

Inspectors wroteBased staff interview, select policy review, and documents reviewed for implementation of a water management program, it was determined the facility failed to implement their water management program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease [a serious type of pneumonia]).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage appropriately, in advance of changes for Medicare covered services, to one of three residents reviewed whose Medicare coverage was discontinued (Resident 36).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that a significant change MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) assessment was completed timely after election of hospice care for two of 16 residents reviewed (Residents 29 and 32).

Inspectors wroteBased on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide care and services necessary for care-dependent residents for two out of 16 residents reviewed (Residents 3 and 19). Findings Include: Review of Resident 3's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and anxiety disorder (a feeling of worry, nervousness, or unease). Review of Resident 3's most recent quarterly Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, emotional, and psychosocial needs), dated August 2, 2023, revealed that under section C, Cognitive Patterns, more specifically subsection C0500. BIMS Summary Score, Resident 3 is coded to have a BIMS of 14 out of 15. [...]

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of 16 residents reviewed (Resident 21). Findings Include: Review of facility policy, titled Wound Care with a revised date of October 2010, under the Documentation section revealed, The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. Review of Resident 21's clinical record revealed diagnoses that included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and hypertension ( high blood pressure). [...]

Inspectors wroteBased on clinical record review, and resident and staff interviews, it was determined the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for one of 16 residents reviewed (Resident 7).

Inspectors wroteBased on facility policy review, observation, staff interview, and clinical record review, it was determined that the facility failed to ensure a medication error rate of less than five percent (two errors in 28 observations, 7.14%).

Inspectors wroteBased on review of nurse aide in-service records and staff interview, it was determined that the facility failed to ensure that Nursing Assistants received a minimum of 12 hours of in-service education training each year that include the following topics: infection control, dementia, communication, and behavioral health, for five of five nurse aide performance evaluations reviewed (Employees 7, 8, 9, 10, and 11).