Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elizabethtown Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Maintain Required RN Coverage: The facility failed to ensure an RN was on duty for at least 8 consecutive hours each day, 7 days a week. PBJ data showed multiple days with no RN hours submitted, and staff stated there was no RN available to work those shifts. The Administrator said the prior DON may have worked on an on-call basis, but those hours were not coded as RN coverage, and the facility had no specific staffing policy.
Cook1 failed to follow proper hand hygiene and glove-use practices while preparing and serving food. He touched his beard cover and ball cap with gloved hands, handled food and serving items with the same soiled gloves, used his hands instead of tongs to place bread on trays, and later rinsed his hands without soap before returning to meal service. The DON, District Manager, and Administrator stated staff should wash hands and change gloves after contamination or touching the face, hair, or person.
The facility failed to maintain an effective infection control program, including lack of documented annual N95 fit testing and staff entering a resident’s COVID-19 room without the full PPE expected by policy and CDC guidance. A resident with stroke-related deficits and moderate cognitive impairment tested positive for COVID-19, yet staff were observed providing care and meal assistance without the required respirator and eye protection. The facility also could not provide documented evidence that the resident’s roommate was tested for COVID-19 after the exposure.
The facility failed to maintain an effective pest control program, resulting in a persistent gnat issue in common areas and resident rooms. Residents reported gnats landing on their food and drinks, and the facility lacked a pest control plan. Observations confirmed the presence of gnats, and sanitation issues in the kitchen contributed to the problem. Despite efforts to address the issue, the gnat infestation persisted, affecting residents' living conditions.
The facility failed to provide dignity covers for catheter bags of four residents, compromising their privacy and dignity. Despite having an ample supply of covers and staff awareness of the importance of using them, observations revealed that catheter bags were visible in communal areas and from hallways. Residents expressed a preference for having their bags covered, highlighting the personal impact of this oversight.
The facility failed to maintain an effective infection control program, with catheter bags found on the floor and improper use of contact precautions. Staff inconsistencies were noted in handling catheter care and oxygen tubing, with no clear policies in place. Observations and interviews revealed lapses in protocol adherence, contributing to infection risks.
The facility failed to provide the required 12 hours of annual training for CNAs, as revealed by a review of personnel files for two CNAs. The Staff Development Coordinator, new to her role, could not locate the training records, and the Director of Nursing was unaware of the issue. The Administrator learned of the deficiency during the survey, noting that the lack of training could impact CNAs' ability to provide adequate care.
The facility failed to provide necessary hygiene care, including scheduled showers and nail care, to residents unable to perform activities of daily living. This affected ten residents, some with conditions like multiple sclerosis and Parkinson's disease, who did not receive regular showers or baths due to staffing issues. Residents expressed feelings of depression and frustration, while staff acknowledged the challenges in completing showers due to insufficient staffing.
A resident with multiple health conditions was left unattended on a shower table by a CNA, who became frustrated and left the room with the water running. The resident, unable to call for help, felt scared and was left alone for about fifteen minutes. The facility's policies on preventing neglect and ensuring safety were not followed.
A resident experienced a significant medication error when her prescribed pain medications, Oxycodone and Lyrica, were not administered for over two days after admission. Despite having a physician's order, the facility staff failed to obtain and administer the medications, leading to the resident being sent to the hospital for pain control. The issue arose from a lack of communication and procedural errors among the staff, with emergency stock of medication not being utilized.
The facility failed to update electronic records to reflect the correct code status for two residents, leading to discrepancies between signed CPR consent forms and electronic DNR orders. Staff interviews revealed reliance on incorrect electronic records, risking non-compliance with residents' wishes.
The facility failed to complete annual performance evaluations for two CNAs, leading to a deficiency in assessing and documenting their performance. Interviews revealed a lack of clarity and communication among staff regarding the responsibility for these evaluations, contributing to the oversight.
The facility did not post daily nursing staffing information for two days during a survey. The DON and Staff Scheduler/CNA 6 were responsible for posting, but it was not done due to the Scheduler's CNA duties. The Administrator confirmed the Scheduler's dual role and the Unit Manager as backup, highlighting a lapse in transparency and access to staffing details.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure there was a Registered Nurse (RN) on duty at least 8 consecutive hours a day, 7 days a week. Review of the facility’s Payroll Based Journal (PBJ) Data Report for 07/01/2025 through 09/30/2025 showed no RN hours submitted for 07/12/2025, 07/20/2025, 09/06/2025, and 09/07/2025. Review of the document signed by the Administrator and dated 01/29/2026 also revealed the facility did not have a specific staffing policy. During interview, the Payroll Manager stated she submitted PBJ hours for all employees but could not record any RN hours on four days in the previous quarter because there was not an RN available to work a shift. She stated the prior DON may have worked those days on an on-call basis, but those hours were not submitted as RN coverage because on-call availability was already part of the DON’s job description. The current DON stated there were four weekend days before her hire date when the facility did not have RN coverage per the PBJ report, and the Administrator stated the previous DON did work at some point during the days in question but the facility did not know how to code the hours correctly. The Administrator also stated she expected an RN to work in the facility 8 hours per day, 7 days a week.
Food Handling and Hand Hygiene Lapses During Meal Service
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food safety. Review of the facility policy titled, Food Preparation, revised 02/2023, showed that all foods were to be prepared in accordance with the FDA Food Code and that staff were to practice proper hand-washing techniques and glove use to avoid contamination. During observation on 01/30/2026, Cook1 was seen blending vegetables and then touching his beard covering with gloved hands, but he did not remove the gloves or wash his hands before continuing to prepare the pureed vegetables. During the same meal service, Cook1 repeatedly handled food and serving items while wearing the same soiled gloves, including removing pans of baked fish from the oven, placing serving utensils on the steam table, handling fish for mechanical soft diets, and placing bread on meal trays with his gloved hand instead of using tongs. He also touched his beard cover and adjusted his ball cap while plating bread without removing his gloves and washing his hands. Later, after handling oven mitts and food, he rinsed his hands without soap, donned new gloves, and returned to the steam table. In interviews, Cook1 stated he should have washed his hands more often and changed gloves when they became soiled or after touching himself, while the District Manager, DON, and Administrator stated staff should immediately change gloves and wash hands after contamination, touching the face or hair, or using mitts.
Infection Control Program, PPE Use, and COVID-19 Testing Failures
Penalty
Summary
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. The deficiency involved all 59 residents in the building and included failure to ensure fit testing for employees, as well as staff entering a resident’s room without the appropriate PPE while the resident had COVID-19. Review of the facility’s infection control policy showed that personnel were to be trained on infection control policies upon hire and periodically thereafter. During interview, the SDC/IP stated she could not find a policy for staff fit testing for N95 respirators and the facility could not provide documented evidence of annual N95 fit testing. She stated the facility did not have the needed supplies to conduct fit testing and instead visually inspected the mask and seal. The DON stated she was not aware fit testing had not occurred and expected it to be completed upon hire and annually. The Administrator stated the last fit testing was conducted in 2022 and that supplies had been ordered so testing could be done when they arrived. R29 was admitted with a stroke diagnosis with residual hemiplegia and hemiparesis and had a BIMS score of 10, indicating moderate cognitive impairment. After R29 developed coughing and congestion, a respiratory panel was ordered and later returned positive for COVID-19. The resident was placed on droplet precautions, and the physician order directed staff to wear a gown and gloves when entering the room. However, observations showed CNA2 entered the room wearing a gown, surgical mask, and gloves but without a face shield or N95 respirator, and CNA3 delivered and set up the meal tray wearing a gown and gloves but without a mask, face shield, eye protection, or N95 respirator. The SDC/IP stated staff were expected to wear a face shield or goggles, an N95 respirator, gown, and gloves for a resident positive for COVID-19, while the DON stated staff should follow the signage and CDC guidance. R37, who was R29’s roommate, had a BIMS score of 12 and a right femur fracture diagnosis. The facility was unable to provide documented evidence that R37 was tested for COVID-19 after R29 tested positive. The SDC/IP believed R37 had been tested with a rapid test, while the DON stated the resident was tested on day one with a negative result or symptoms and that symptoms improved after that test. The APRN and Administrator both stated they expected staff to follow CDC guidance for COVID-19 testing, but the facility did not produce documentation of the testing.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent issue with gnats in common areas and resident rooms. Residents reported ongoing concerns about gnats landing on their food and drinks during meal times. Interviews with the Maintenance Director and Administrator revealed that the facility did not have a pest control plan or policy in place, and a Pest Control Agreement was not provided during the survey. Observations confirmed the presence of gnats in various areas, including resident rooms and the kitchen. The facility's Homelike Environment Standard of Practice, dated October 2020, emphasized the importance of providing a safe, clean, and comfortable environment. However, the facility's failure to address sanitation issues in the kitchen, such as broken tiles around the dish machine and unclean drains, contributed to the gnat problem. Ecolab pest control reports indicated treatments for large and small flies, but the issue persisted, with glueboards showing significant pest activity. Interviews with residents and staff highlighted the ongoing nature of the problem and the lack of effective measures to eliminate the gnats. The Maintenance Director acknowledged a plumbing issue contributing to the gnat problem and mentioned efforts to address it, including replacing parts of the drain line. However, the problem persisted, with residents continuing to report gnats in their living areas. The Administrator, who joined the facility in June 2024, was aware of the gnat issue and had initiated contact with pest control and plumbing services to address it. Despite these efforts, the facility had not yet resolved the gnat infestation, impacting the residents' living conditions.
Failure to Provide Dignity Covers for Catheter Bags
Penalty
Summary
The facility failed to protect the dignity of four residents by not providing privacy covers for their catheter drainage bags. Observations during the survey revealed that the catheter bags of residents were visible and without dignity covers, even in communal areas such as the dining room. This lack of privacy was noted despite the facility's policies under both federal and Kentucky law, which emphasize the importance of treating residents with dignity and respect. Resident 7, who was cognitively intact, expressed a preference for having their catheter bag covered, highlighting the personal impact of this oversight. Similarly, Resident 11 and Resident 14, who were moderately cognitively impaired, also expressed a desire for their catheter bags to be covered. Resident 8, who was severely cognitively impaired, had their catheter bag visible from the hallway, further indicating a lack of privacy and dignity. Interviews with staff, including CNAs, LPNs, the Unit Manager, the Director of Nursing, and the Administrator, revealed a general understanding that catheter bags should be covered for dignity and privacy. However, there was a disconnect between this understanding and the actual practice, as evidenced by the uncovered catheter bags. The facility had an ample supply of dignity covers, yet they were not consistently used, leading to the deficiency noted in the report.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. One significant issue was the improper handling of catheter bags, which were observed on the floor in several instances. For example, a resident's catheter bag was found on the floor while housekeeping staff cleaned around it without notifying nursing staff. Interviews with staff, including housekeepers and CNAs, confirmed that catheter bags should not be on the floor due to infection risks, yet this practice was not consistently followed. Another deficiency involved the failure to adhere to contact precautions for residents with transmissible infections. A unit manager was observed entering a resident's room, who was on contact precautions, without donning the required gown, despite a sign on the door indicating the need for such precautions. This lapse in protocol was acknowledged by the unit manager during an interview, highlighting a gap in adherence to infection control measures designed to prevent the spread of infections within the facility. Additionally, the facility lacked specific policies for catheter care and oxygen tubing management, leading to inconsistencies in practice. Oxygen tubing for several residents was either not labeled or dated, and staff interviews revealed uncertainty about the frequency of tubing changes. The absence of a clear policy contributed to the inconsistent application of infection control practices, as staff relied on physician orders or personal judgment rather than standardized procedures.
Deficiency in CNA Annual Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required 12 hours of annual training, as evidenced by a review of personnel files for two CNAs. CNA 10, hired on May 12, 2017, and CNA 13, hired on December 10, 2015, did not have documentation of the required training hours. The Staff Development Coordinator (SDC), who had been in her position for three weeks, was unable to locate the training records and stated that the expectation was for training to be completed monthly and within a year of hire. The SDC mentioned that the training covered important topics such as the facility's abuse policy, resident rights, and safety protocols. The Director of Nursing (DON), who had been in her role for two weeks, was unaware of the missing training hours and emphasized the importance of these hours for maintaining CNAs' knowledge and certification. The Administrator, employed since June 2024, was first made aware of the deficiency during the survey. She acknowledged that the SDC was new and filled a previously vacant position. The lack of training hours was noted to potentially impact the CNAs' ability to provide adequate care, as they might not be up to date with necessary skills and knowledge.
Deficiency in Providing Scheduled Showers and Hygiene Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. This deficiency affected ten residents out of a sample of 21, who did not receive regularly scheduled showers, baths, or grooming services such as nail care. The facility's policy on activities of daily living, dated October 2020, emphasized providing person-centered care and services to maintain or improve residents' ability to carry out these activities. However, the policy lacked specifics on the provision of these services, leading to inconsistencies in care. Several residents, including those with diagnoses such as multiple sclerosis, Parkinson's disease, quadriplegia, and type 2 diabetes, were affected by this deficiency. For instance, one resident with multiple sclerosis and morbid obesity did not receive documented showers or baths over several weeks, despite being dependent on staff for bathing and not refusing care. Another resident with Parkinson's disease and quadriplegia had long, dirty fingernails and reported not being offered a bath for about six months. These residents expressed feelings of depression and frustration due to the lack of personal hygiene care. Interviews with staff, including CNAs and the Director of Nursing, revealed that staffing issues were a significant factor in the missed showers and baths. CNAs reported difficulties in completing showers due to insufficient staff, especially when mechanical lifts required two staff members. The Director of Nursing and the Administrator acknowledged the staffing challenges and the need for an action plan to address the issue. Despite these acknowledgments, the deficiency persisted, impacting the residents' overall hygiene and well-being.
Resident Left Unattended During Shower
Penalty
Summary
The facility failed to protect a resident from neglect during a shower, as evidenced by the incident involving a quadriplegic resident who was left unattended. The resident, who was cognitively intact, reported feeling scared when a Certified Nursing Assistant (CNA) left her alone on a shower table with the water running. The resident was unable to call for help due to her condition, which included lymphedema, morbid obesity, and multiple sclerosis. The incident occurred after the resident requested the CNA to wash under her arm, leading to the CNA leaving the room in frustration. The CNA admitted to leaving the resident unattended and acknowledged that she should have taken measures to ensure the resident's safety, such as stopping the shower and using the emergency pull cord. The Director of Nursing and the Administrator both confirmed that the CNA's actions were inappropriate and that residents should not be left alone in the shower room. The facility's policies on abuse prohibition and safety supervision emphasize the importance of preventing neglect and ensuring resident safety, which were not adhered to in this case.
Resident's Pain Medication Delay Leads to Hospital Visit
Penalty
Summary
The facility failed to ensure that a resident, identified as R203, was free from significant medication errors. R203 was admitted to the facility with a history of chronic pain and had routine orders for Oxycodone and Lyrica, which were not administered for over two days after admission. The resident was sent to the hospital for pain control after not receiving her prescribed medications, despite having a physician's order dated the day of admission. The deficiency was primarily due to a breakdown in communication and procedure among the facility staff. The admitting nurse, LPN5, did not obtain the necessary hard copy prescriptions to order the medications from the pharmacy, assuming the administration team would handle it. Subsequent staff, including LPN8 and RN1, attempted to rectify the situation by contacting the medical director, but the medications were still not received in a timely manner. The facility had emergency stock of Oxycodone available, but it was not utilized for R203. The Director of Nursing and the Administrator were not made aware of the issue until after the resident was sent to the hospital. The DON stated that the physician had initially sent the prescription to the wrong pharmacy, and the Administrator acknowledged a lack of communication between staff, the physician, and the pharmacy. The failure to administer the prescribed medications resulted in the resident experiencing uncontrolled pain, necessitating a hospital visit.
Failure to Update Advance Directives in Electronic Records
Penalty
Summary
The facility failed to update the electronic clinical records to accurately reflect the code status of two residents, R38 and R45, as per their signed advance directives. Both residents had signed forms indicating their choice for CPR in the event of cardiac arrest, but their electronic medical records incorrectly showed a Do Not Resuscitate (DNR) status. This discrepancy was not identified or corrected by the facility staff, leading to a potential risk of not honoring the residents' wishes. Resident R38 was admitted with diagnoses including Congestive Heart Failure and Mild Neurocognitive Disorder. Despite having a signed CPR consent form, the electronic record showed a DNR status. Interviews with facility staff, including an LPN, the Admissions Director, the Unit Manager, and the Director of Nursing, revealed a lack of access to the signed paper copies and reliance on the electronic system, which contained the incorrect information. The staff acknowledged the potential for not following the resident's wishes due to this discrepancy. Similarly, Resident R45, who had Congestive Heart Failure and Left Ventricular Failure, also had a signed CPR consent form, but the electronic record indicated a DNR status. Interviews with the resident and staff confirmed the resident's preference for no resuscitation, yet the electronic record did not match the signed directive. The facility's process for reviewing and updating code status upon readmission from the hospital was inadequate, as evidenced by the failure to reconcile the discrepancies between the paper forms and electronic records.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two Certified Nurse Aides (CNAs), CNA 10 and CNA 13, who had been employed for over a year. CNA 10 was hired on May 12, 2017, and their last evaluation was completed on August 28, 2018. CNA 13 was hired on December 10, 2015, with their last evaluation completed on April 6, 2021. The absence of these evaluations indicates a lapse in the facility's process for assessing and documenting the performance of its CNAs, which is essential for ensuring quality care. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for completing these evaluations. The Human Resource (HR) and Payroll Manager, who has been in her role since December 2023, stated that the facility uses a computer program to track when evaluations are due, but it does not flag overdue evaluations. The Director of Nursing (DON), who started in her role two weeks prior to the survey, was unaware of the evaluation process for CNAs and stated that the nurses supervised the CNAs. The Administrator, who began in June 2024, was also unaware of the backlog in evaluations until the survey. This lack of awareness and communication among the staff contributed to the deficiency in completing the required performance evaluations.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that daily nursing staffing information was posted for two out of five days during the survey period. On 08/29/2024, it was observed that the last posted staffing information was dated 08/27/2024. The Director of Nursing (DON) acknowledged that the Staff Scheduler/Certified Nurse Aide (CNA) 6 was responsible for posting the staffing information each morning during the week. However, the DON admitted that she did not verify whether the staffing information was posted on the morning of 08/29/2024. The DON emphasized the importance of posting staffing information to demonstrate adequate staffing levels for patient care. The Staff Scheduler/CNA 6 confirmed that she did not post the staffing information on 08/29/2024, as she was preoccupied with her duties as a CNA and concerned about resident care. She also mentioned that the Administrator had informed her on 08/28/2024 that someone else would handle the posting. The Administrator corroborated that the Scheduler was working as a CNA on both 08/28/2024 and 08/29/2024, and that the Unit Manager was the designated backup for posting staffing information. The Administrator noted that the Scheduler typically worked as a CNA about once a week, and acknowledged that the absence of posted staffing information could hinder transparency and access to staffing details.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Elizabethtown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Helmwood Healthcare | 0.5 mi | ★★★★★ | 0 | 0 |
| Kensington Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Elizabethtown | 2 mi | ★★★★★ | 2 | 1 |
| Baptist Health Hardin | 5.2 mi | ★★★★★ | 4 | 0 |
| Signature Healthcare At North Hardin Rehab & Welln | 8 mi | ★★★★★ | 0 | 0 |
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