Pennsylvania Department of Health
ELIZABETHTOWN NURSING AND REHABILITATION
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ELIZABETHTOWN NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on July 30, 2026, at Elizabethtown Nursing and Rehabilitation, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: SNF - Component: 02 - Tag: 0000
Facility ID #123202

Component 02

New Building, A Building

Based on a Medicare/Medicaid Recertification Survey completed on July 30, 2026, it was determined that Elizabethtown Nursing and Rehabilitation was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: SNF - Component: 02 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain unobstructed access to the means of egress, affecting one of two floors within the component. Findings include: 1. .Observation on July 30, 2026, at 10:53 AM, revealed the exterior exit door, located at the basement Receiving area, was lockable against egress. Interview with the Maintenance Director on July 30, 2026, at 10:53 AM, confirmed the exit door was able to be locked against egress.

Plan of Correction - To be completed: 08/25/2026

Lock will be removed from the exterior exit door, unobstructing access to the means of egress.

Lock was removed on 7/31/26.

Maintenance Director was provided education on ensuring means of egress continuously remain free of all obstructions.

Audits to ensure observed exterior exit door maintains unobstructed access to the means of egress will occur monthly.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: SNF - Component: 02 - Tag: 0345 Based on document review and interview, it was determined the facility failed to provide documentation verifying the sensitivity of zoned smoke detectors had been tested within the previous two years, affecting one of two floors within the component. Findings include: 1. Review of documentation on July 30, 2026, at 9:51 AM, revealed the facility lacked documentation verifying the zoned smoke detector, located within the elevator shaft, had been tested for sensitivity, within the previous two years. Interview with the Maintenance Director on July 30, 2026, at 9:51 AM, confirmed the lack of documentation verifying all zoned smoke detectors had been tested for sensitivity, within the previous two years.

Plan of Correction - To be completed: 09/11/2026

Documentation will be obtained verifying the sensitivity of zoned smoke detector, located within the elevator shaft.

Documentation verifying the sensitivity of smoke detector in elevator shaft will be obtained at the soonest possible date the company providing these services is available.

Maintenance Director was provided education on ensuring documentation verifying the sensitivity of all zoned smoke detectors are tested within the previous two years.

Annual audit of the life safety book to confirm smoke sensitivity test has been performed for all smoke detectors will be completed by maintenance director/designee.

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