Health inspection·July 5, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on policy review, clinical record review, facility document review, and staff interviews, it was determined that the facility failed to provide care and services in accordance with professional standards for one of three residents reviewed (Resident 3). Residents Affected - Few Findings include: Review of facility policy, titled Accidents and Incidents - Investigating and Reporting last revised July 2017, revealed that the policy stated, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Review of policy section, titled Policy Interpretation and Implementation revealed subsections included, 1. The nurse supervisor/charge nurse and/or the department director of supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; .k. Any corrective action taken .l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. Subsection 5 of the aforementioned policy stated, The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. Review of Resident 3's clinical record on July 3, 2023, at approximately 10:00 AM, revealed diagnoses including dementia (irreversible, progressive degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living) and atrial fibrillation (irregular heart rhythm). Review of Resident 3's nursing progress note by Employee 1, entered on May 11, 2023, at 8:53 AM, stated, Nurse called into resident's room Resident presented with old [Right Lower Extremity] laceration that was bleeding through dressing and onto bed, blood in clotting formation, significant amounts of blood on bed. Site cleansed with soap /water and steri-strips applied and pressure dressing applied. MD [provider] and family notified. Review of Resident 3's clinical record revealed no injury or laceration to Resident 3's right lower (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395844 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)