Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Elizabethtown Healthcare & Rehab Center
Elizabethtown, NC · 94 certified beds · Last Life Safety survey September 26, 2024
CMS Certification Number 345210 · first certified October 1981
Ownership
Operated by LIBERTY SENIOR LIVING · For profit - Corporation
- Ownership changed February 1, 2020 (change of ownership)to ELIZABETHTOWN HEALTHCARE AND REHABILITATION CENTER from ELIZABETHTOWN NURSING CENTER, INC.
Position within NC
11 citations — more than 56% of the 419 certified nursing homes in NC. Compared within NC rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 1. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (November 2025 to January 2026), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was September 2024. Facilities in NC are typically surveyed 14–16 months after the last one (median 15), measured over 412 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 11 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 11 |
| Median facility in NC | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 3, 2022 | 1 |
| June 22, 2023 | 1 |
| September 26, 2024 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-09-26 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-09-26 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-09-26 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-09-26 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2023-06-22 |
| K-0344 | Have an alternate power supply for its alarm system. | 1 | 2024-09-26 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2024-09-26 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2024-09-26 |
What the citations cover
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Services Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Services Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 26, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 7, 2024) |
| K-0344 | Have an alternate power supply for its alarm system. | Deficient, Provider has date of correction (December 7, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 7, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 7, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 7, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 7, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 7, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 7, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 7, 2024) |
June 22, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (August 29, 2023) |
March 3, 2022 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 30, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.