Inspection Reports for
Elizabethtown Nursing and Rehabilitation Center
1101 WOODLAND DRIVE, ELIZABETHTOWN, KY, 42701
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Abbreviated Survey
Census: 50
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
An abbreviated survey was conducted from 01/13/2025 through 01/14/2025 to investigate complaints KY00044110, KY00044154, KY00044532, and KY00044666.
Complaint Details
An abbreviated survey initiated on 01/13/2025 and concluded on 01/14/2025 to investigate complaint # KY00044532. The Division of Health Care unsubstantiated the allegation with no deficiencies cited.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B. No deficiencies were issued related to the complaints investigated, and the Division of Health Care unsubstantiated the allegation with no deficiencies cited.
Report Facts
Survey Census: 50
Sample Size: 9
Supplemental Resident: 1
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 29, 2024
Visit Reason
The inspection was conducted following complaints and observations related to resident abuse, neglect, inadequate assistance with activities of daily living, and medication errors at the nursing facility.
Complaint Details
The complaint investigation substantiated that a resident was left unattended and exposed during a shower, causing fear and potential harm. Multiple residents did not receive scheduled showers or grooming due to staffing shortages. One resident did not receive prescribed pain medication for over two days, leading to hospital transfer.
Findings
The facility failed to protect a resident from abuse by leaving her unattended during a shower, failed to provide scheduled showers and grooming for multiple residents due to staffing issues, and failed to ensure timely administration of prescribed pain medication for a resident, resulting in hospitalization.
Deficiencies (3)
F 0600: The facility failed to protect a resident from abuse and neglect by leaving her unattended and exposed during a shower, causing fear and potential harm.
F 0677: The facility failed to provide necessary assistance with activities of daily living, including regularly scheduled showers and grooming, for 10 of 21 sampled residents.
F 0760: The facility failed to ensure one resident received prescribed pain medications timely, resulting in significant medication error and hospital transfer.
Report Facts
Residents affected: 1
Residents affected: 10
Residents sampled: 21
Medication delay days: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN8 | Licensed Practical Nurse | Named in medication error finding for documentation and administration issues |
| LPN5 | Licensed Practical Nurse | Named in medication error finding for admission and prescription faxing errors |
| CNA14 | Certified Nursing Assistant | Named in abuse finding for leaving resident unattended during shower |
| RN1 | Registered Nurse | Named in medication error finding for communication and medication ordering |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Aug 29, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity related to catheter bag covers, failure to update electronic clinical records for advance directives, inadequate assistance with activities of daily living including bathing and grooming, incomplete employee performance evaluations and training, failure to post daily nurse staffing, infection prevention and control deficiencies including improper handling of catheter bags and oxygen tubing, and ineffective pest control program with ongoing gnat infestations.
Deficiencies (8)
F 0557: The facility failed to ensure catheter drainage bags had dignity covers for four sampled residents, exposing urine bags and compromising resident dignity.
F 0578: The facility failed to update electronic clinical records to reflect resident code status per signed advance directives for two sampled residents, causing discrepancies between paper and electronic records.
F 0677: The facility failed to provide necessary assistance with activities of daily living including bathing and grooming for ten sampled residents, resulting in missed showers and poor personal hygiene.
F 0730: The facility failed to complete annual performance evaluations for two sampled CNAs, limiting oversight of employee job performance.
F 0732: The facility failed to post daily nursing staffing information for two of five days during the survey, reducing transparency of staffing levels.
F 0880: The facility failed to maintain an effective infection prevention and control program, including improper handling of catheter bags and oxygen tubing, and lack of catheter care and respiratory policies.
F 0925: The facility failed to maintain an effective pest control program, resulting in persistent gnat infestations in resident areas and common spaces.
F 0947: The facility failed to ensure CNAs received the required 12 hours of yearly training, impacting staff knowledge and resident care.
Report Facts
Number of sampled residents with bathing/grooming deficiencies: 10
Number of sampled residents with catheter dignity cover deficiencies: 4
Number of sampled residents with advance directive discrepancies: 2
Number of sampled CNAs without annual performance evaluations: 2
Number of days daily nurse staffing was not posted: 2
Number of sampled residents affected by infection control issues: 6
Number of sampled CNAs without required yearly training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 5 | LPN | Interviewed regarding catheter bag dignity covers, advance directive discrepancies, infection control, and oxygen tubing practices. |
| Unit Manager | Unit Manager | Interviewed regarding catheter bag dignity covers, shower assistance, infection control, and staffing postings. |
| Assistant Director of Nursing/Infection Preventionist | ADON/IP | Interviewed regarding infection control program and oxygen tubing change frequency. |
| Director of Nursing | DON | Interviewed regarding catheter bag dignity covers, advance directive discrepancies, shower assistance, staffing postings, infection control, and CNA training. |
| Administrator | Administrator | Interviewed regarding catheter bag dignity covers, advance directive discrepancies, shower assistance, staffing postings, infection control, pest control, and CNA training. |
| Human Resource and Payroll Manager | HR Manager | Interviewed regarding employee performance evaluations. |
| Staff Development Coordinator | SDC | Interviewed regarding CNA training and education. |
| Housekeeper 1 | Housekeeper | Interviewed regarding infection control practices related to catheter bags on the floor and pest control. |
| Maintenance Director | Maintenance Director | Interviewed regarding pest control and plumbing issues contributing to gnat infestations. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 6, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to notify the physician and guardian of significant changes in a resident's condition and refusals of care, and to assess the completeness and accuracy of medical record documentation for Resident #1.
Complaint Details
The complaint investigation focused on Resident #1, who had multiple refusals of medications, meals, and vital signs. The facility did not notify the physician or guardian timely about these refusals or changes in condition. Interviews with staff and the resident's guardian confirmed failures in notification and documentation.
Findings
The facility failed to notify the physician and guardian promptly about Resident #1's significant changes in condition, refusals of medications, meals, and vital signs. Additionally, the facility did not maintain complete and accurate medical records, including missing physician orders for diet changes and incomplete documentation of vital signs, medication administration, and pain levels.
Deficiencies (2)
F 0580: The facility failed to immediately inform the resident's physician and guardian of significant changes in Resident #1's physical status and refusals of medications, meals, and vital signs.
F 0842: The facility failed to maintain complete and accurate medical records for Resident #1, including missing documentation of weights, meal intake/output, bowel and bladder care, medication administration, vital signs, and physician orders for diet changes.
Report Facts
Resident refusals dates: 15
Resident weight: 106
Oxygen saturation: 77
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 13, 2019
Visit Reason
The inspection was conducted following complaints regarding resident dignity, grievance handling, care plan updates, and hydration practices at Elizabethtown Nursing and Rehabilitation Center.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed in multiple areas including resident dignity, grievance communication, care plan updates, and hydration accessibility.
Findings
The facility failed to treat a resident with dignity, did not properly report grievance findings to the Resident Council, failed to update a resident's comprehensive care plan to reflect behaviors, and did not ensure accessible hydration for a resident using a hydration pack.
Deficiencies (4)
F 0550: The facility failed to ensure Resident #7 was treated with dignity and respect during a discussion about room relocation, resulting in the resident feeling demeaned and upset.
F 0565: The facility failed to report grievance findings and actions to the Resident Council and did not follow up on grievances at subsequent meetings.
F 0657: The facility failed to revise Resident #9's comprehensive care plan to reflect behaviors of entering other residents' rooms without consent.
F 0692: The facility failed to provide accessible hydration for Resident #7 by not ensuring the hydration pack was within reach at all times.
Report Facts
Residents sampled: 32
Residents affected: 1
Residents affected: 1
Resident Council members interviewed: 9
Grievance forms dated: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in dignity deficiency and grievance process interviews |
| Administrator | Facility Administrator | Named in grievance process and dignity deficiency interviews |
| Staff Development Director | Staff Development Director | Interviewed regarding staff training on dignity and respect |
| Activity Director | Activity Director (AD) | Named in grievance process deficiencies and interviews |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed regarding hydration and grievance processes |
| Licensed Practical Nurse #4 | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #9 behavior |
| Unit Manager | Unit Manager (UM) | Interviewed regarding grievance and care plan processes |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding grievance, care plan, and hydration processes |
| Advanced Practice Registered Nurse | Advanced Practice Registered Nurse (APRN) | Interviewed regarding care plan and resident safety |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 28, 2018
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, including compliance with policies on cleaning, labeling, and storage of clinical equipment such as bedpans, urine hats, and gastrostomy tube (G-tube) procedures.
Findings
The facility failed to maintain an effective infection control program, evidenced by soiled, unlabeled, and uncovered bedpans and urine hats in resident bathrooms, and improper handling of G-tube medication administration equipment. Staff training on infection control was provided but not consistently followed, posing a risk of infection spread among residents.
Deficiencies (2)
F 0880: The facility failed to maintain an effective infection prevention and control program, as soiled, unlabeled, and uncovered bedpans and urine hats were found in resident bathrooms, risking cross-contamination and infection.
F 0880: Staff failed to maintain cleanliness during medication administration for Resident #14's gastrostomy tube, including placing the feeding tube syringe plunger on a soiled bedside table, posing an infection risk.
Report Facts
Residents Affected: 14
Date of Survey Completed: Jun 28, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Examined soiled bedpans and described infection risk |
| CNA #1 | Certified Nursing Assistant | Described proper labeling and cleaning procedures for bedpans |
| CNA #4 | Certified Nursing Assistant | Described procedures for cleaning and labeling urine hats and bedpans |
| LPN #4 | Licensed Practical Nurse | Administered medications through G-tube and described infection control issue |
| Assistant Director of Nursing | ADON | Described infection control standards and risks related to equipment handling |
| Staff Development Coordinator | Provided staff training on infection control and described facility practices | |
| Certified Medication Technician #1 | CMT | Responsible for rounds and bathroom cleanliness |
| Administrator | Oversaw facility infection control policies and staff supervision |
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