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Deficiency Records for Elizabethtown Nursing and Rehabilitation
A list of the most recent deficiencies for Elizabethtown Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Elizabethtown Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-29 | 2024-08-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-07-29 | 2024-08-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-29 | 2024-08-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-29 | 2024-08-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-29 | 2024-08-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-07-29 | 2024-08-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-29 | 2024-08-28 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2024-07-18 | 2024-08-14 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-07-18 | 2024-08-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-07-18 | 2024-08-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-07-18 | 2024-08-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-07-18 | 2024-08-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-18 | 2024-08-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-07-18 | 2024-08-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-18 | 2024-08-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-18 | 2024-08-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-18 | 2024-08-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-07-18 | 2024-08-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-07-18 | 2024-08-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-18 | 2024-08-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-07-18 | 2024-08-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-18 | 2024-08-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-07-18 | 2024-08-14 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-07-18 | 2024-08-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-18 | 2024-08-14 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-07-18 | 2024-08-14 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-09-28 | 2023-10-09 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-08-17 | 2023-09-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-17 | 2023-09-29 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-08-17 | 2023-09-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-17 | 2023-09-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-17 | 2023-09-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-17 | 2023-09-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-17 | 2023-09-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-17 | 2023-09-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-17 | 2023-09-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-17 | 2023-09-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-09-29 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-08-17 | 2023-09-29 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-08-28 | 2023-09-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-28 | 2023-09-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-28 | 2023-09-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-28 | 2023-09-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-05 | 2023-07-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-08 | 2023-05-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-08 | 2023-05-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-08 | 2023-05-22 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-08 | 2023-05-22 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-08 | 2023-05-22 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-31 | 2023-05-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-31 | 2023-05-09 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-31 | 2023-05-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-16 | 2023-01-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-16 | 2023-01-13 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-09-09 | 2022-10-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-09 | 2022-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-09 | 2022-10-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-09 | 2022-10-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-09-09 | 2022-10-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-09 | 2022-10-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-09-09 | 2022-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-09 | 2022-10-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-20 | 2022-09-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-20 | 2022-09-29 | N |
| Meet other general requirements. | Fire Safety | 2022-09-20 | 2022-09-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-14 | 2022-07-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-14 | 2022-07-26 | Y |
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