Above 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 Masonic Village At Elizabethtown during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and fragile skin was found to have a sizable bruise on the right axilla and upper arm, with the resident unable to explain its cause. Facility policy required complete incident documentation, including detailed circumstances and staff statements, but only one staff statement was obtained, documenting that a nursing assistant had reported the bruise to another employee. No additional statements were collected from staff who had provided care before the bruise was identified, and no further investigation was conducted because licensed staff and the DON believed the bruise location was consistent with contact from a bed enabler.
A resident with severe cognitive impairment and multiple medical conditions fell from a whirlpool chair and sustained injuries after a nurse aide failed to properly secure the chair's safety belt and locking bars. The resident required maximal assistance for bathing and transfers, and the aide had previously received training on whirlpool safety. Facility staff confirmed that the safety mechanisms were not engaged at the time of the incident, leading to the substantiated finding of neglect.
The facility failed to maintain the fire resistance rating of exit stairtower enclosures, affecting two smoke compartments. Observations revealed that doors to the Clinics South Stairtower and West Stairtower did not positively latch within their frames, compromising the fire resistance rating. These issues were confirmed by the Assistant Director of Facilities and Grounds.
The facility did not conduct functional testing of smoke detectors in three of 43 smoke compartments within the past year. Specific rooms affected include 2981, 2998, 3918, 4917, 4965, and 4966. The Assistant Director of Facilities and Grounds confirmed the oversight.
The facility did not maintain the automatic sprinkler system as required, with an electrical cable zip-tied to the sprinkler piping in the 4th floor IT Mechanical Room, affecting one smoke compartment.
The facility failed to maintain unobstructed access to a portable fire extinguisher on the Washington 3rd floor, as it was blocked by a wheelchair and a chair. This was confirmed by the Assistant Director of Facilities and Grounds, highlighting a deficiency in maintaining clear access to fire safety equipment.
The facility failed to ensure that the Washington 3rd floor Supply Room door, next to a resident room, positively latched within the door frame. This deficiency was observed and confirmed by the Assistant Director of Facilities and Grounds, affecting one of the 43 smoke compartments in the facility.
The facility failed to ensure the unobstructed closing of smoke barrier doors, as observed on the Roosevelt 2nd floor near a resident room, where a patient lift obstructed the door. This deficiency was confirmed by the Assistant Director of Facilities and Grounds, affecting two of 43 smoke compartments.
A deficiency was identified when a broken electrical outlet was observed in the corridor on the Roosevelt 3rd floor, between a resident room and the Laundromat. The Assistant Director of Facilities and Grounds confirmed the compromised condition of the receptacle.
The facility failed to maintain the fire resistance of linen chute enclosure doors, affecting two smoke compartments. Observations revealed that the linen chute doors on the 4th and 2nd floors of the Roosevelt building did not positively latch within their frames. This deficiency was confirmed by the Assistant Director of Facilities and Grounds.
The facility failed to monitor the use of surge suppressors and extension cords, leading to deficiencies in three smoke compartments. High-draw appliances were improperly plugged into a surge suppressor in a conference room, and daisy-chained surge suppressors were found at a care base. Additionally, an extension cord was supplying power to a surge suppressor in a provider's room, all confirmed by the Assistant Director of Facilities and Grounds.
The facility failed to maintain accurate MDS assessments for two residents. One resident's MDS inaccurately reported falls with major injury, while another's MDS incorrectly indicated significant weight changes. These inaccuracies were confirmed by the DON, highlighting deficiencies in clinical record maintenance.
A resident with anxiety and emotional distress expressed a desire to die on multiple occasions, yet did not receive a behavioral health evaluation until over a month after it was ordered. The delay in providing necessary mental health services was confirmed by the DON, highlighting a deficiency in timely care.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. Facility policy on Occurrence Prevention, Documentation, and Reporting, last reviewed July 21, 2026, required that all sections of the incident report be completed to the best of staff’s ability, including details surrounding the incident and statements from staff or individuals involved in the resident’s care or the situation prior to or during the incident, as well as those involved in the incident response. The resident’s quarterly MDS dated September 16, 2025, showed a BIMS score of 9, indicating moderate cognitive impairment. On October 6, 2025, progress notes documented a bruise to the right front axilla measuring 3.56 cm by 4.34 cm, and an additional note the same day documented that an LPN observed a dark bruise to the resident’s right upper arm, with the resident unsure how the bruise occurred. Review of facility documentation showed that only one staff statement was obtained, from Employee E4, indicating that a nursing assistant from the outgoing shift had reported the bruise to Employee E4. No other statements were obtained from staff who had provided care prior to identification of the bruise. The documentation also noted that the resident was independent with self-propelling a wheelchair, able to move upper and lower extremities independently, and had thin, fragile skin that increased the risk for skin injury. In an interview on January 23, 2025, licensed staff (Employee E3) and the Director of Nursing confirmed that no additional staff statements were collected and that no further investigation was conducted because the bruise’s location was considered consistent with contact from a bed enabler.
Failure to Secure Safety Mechanisms During Bathing Results in Resident Fall and Injuries
Penalty
Summary
A deficiency occurred when a nurse aide failed to properly secure the safety mechanisms of a whirlpool chair, resulting in a resident falling forward from the chair and sustaining multiple injuries. The resident, who had severe cognitive impairment and required maximal assistance for bathing and transfers, was found face down and wet in the empty whirlpool tub by nursing staff. The safety features of the chair, including a seatbelt and locking safety bars, were not properly engaged at the time of the incident, as confirmed by a re-enactment conducted by licensed staff. The nurse aide involved was unable to provide a clear account of the events leading up to the fall and only stated that the incident happened quickly. The resident involved had significant medical conditions, including Alzheimer's disease, dementia with psychotic disturbances, anxiety, psychosis, chronic atrial fibrillation, and chronic heart failure. The resident's clinical record indicated a need for substantial or maximal assistance with bathing and transfers, and a BIMS score reflecting severe cognitive impairment and inability to direct care. After the fall, the resident was assessed and found to have a hematoma to the forehead, abrasions to the left knee and fifth toe, and bruises to both calves, but did not report pain or discomfort and did not require pain medication. Facility documentation and staff interviews confirmed that the nurse aide had received training on whirlpool safety and had demonstrated the required technique prior to the incident. However, the investigation determined that the aide failed to follow established procedures and the resident's care plan, resulting in the resident's fall and injuries. The facility substantiated the occurrence of neglect based on these findings.
Failure to Maintain Fire Resistance Rating of Stairtower Enclosures
Penalty
Summary
The facility failed to maintain the fire resistance rating of exit stairtower enclosures, affecting two of 43 smoke compartments. On December 16, 2024, an observation revealed that the door to the Clinics South Stairtower on the 4th floor of the Roosevelt Building did not positively latch within the door frame. This issue was confirmed through an interview with the Assistant Director of Facilities and Grounds. Similarly, on December 17, 2024, it was observed that the door to the West Stairtower on the 2nd floor of the Clinics also failed to positively latch. This was again confirmed by the Assistant Director of Facilities and Grounds, indicating a compromised fire resistance rating of the stairtower.
Plan Of Correction
1. The door to the 4th floor door to the Clinics and Clinic's 2nd floor was repaired on 12/18/2024 to ensure positive latching within the door frame. 2. Maintenance staff will be educated that stair tower doors will be maintained to ensure positive latching within the door frame. General education to staff to report doors not latching for appropriate work orders. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that stair tower doors will positively latch within the door frame. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Failure to Test Smoke Detectors
Penalty
Summary
The facility failed to conduct functional testing of smoke detectors within the previous twelve months, affecting three out of 43 smoke compartments. This deficiency was identified during a document review and interview conducted on December 16, 2024. The specific rooms where smoke detectors were not functionally inspected include rooms 2981, 2998, 3918, 4917, 4965, and 4966. The Assistant Director of Facilities and Grounds confirmed during the interview that the smoke detectors in these rooms had not been tested within the required timeframe.
Plan Of Correction
1. The smoke detectors were functionally inspected in the previous twelve months, in the following rooms on 07/03/2024 and placed in the Life Safety book: a) 2981; b) 2998; c) 3918; d) 4917; e) 4965; f) 4966; 2. Maintenance staff will be educated that smoke detectors will be functionally inspected every twelve months. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building to ensure that smoke detectors are functionally inspected every twelve months as well as the Life Safety book is reviewed semi-annually. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Improper Maintenance of Sprinkler System
Penalty
Summary
The facility failed to maintain the automatic sprinkler protection system in accordance with NFPA 25 standards. During an observation on December 17, 2024, at 10:47 AM, it was discovered that an electrical cable was improperly zip-tied to the sprinkler piping within the Clinics 4th floor IT Mechanical Room. This deficiency affected one of the 43 smoke compartments within the facility, indicating a lapse in maintaining the sprinkler system free from extraneous weight.
Plan Of Correction
1. The electrical cable zip-tied to the sprinkler piping within Clinic's 4th floor IT Mechanical Room was corrected on 12/19/2024. 2. Maintenance staff will be educated that the automatic sprinkler protection system will be free of extraneous weight. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that the automatic sprinkler protection system will be free of extraneous weight. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Obstructed Access to Fire Extinguisher
Penalty
Summary
The facility failed to maintain unobstructed access to portable fire extinguishers, as required by NFPA 101 and NFPA 10 standards. During an observation on December 17, 2024, at 10:33 AM, it was noted that the portable fire extinguisher on the Washington 3rd floor, located next to the East Mini Care Base, was obstructed by a wheelchair and a chair. This obstruction was confirmed in an interview with the Assistant Director of Facilities and Grounds at the same time, indicating a lapse in ensuring clear access to essential fire safety equipment within one of the 43 smoke compartments in the facility.
Plan Of Correction
1. The Washington 3rd floor portable fire extinguisher, located next to the East Mini Care Base, obstructed by a wheelchair and a chair was corrected on 12/17/2024. 2. Staff will be educated in maintaining unobstructed portable fire extinguishers. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that portable fire extinguishers are unobstructed. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain the corridor doors to positively latch, which is a requirement for ensuring the safety and security of the smoke compartments. During an observation on December 17, 2024, at 9:49 AM, it was noted that the door to the Washington 3rd floor Supply Room, located next to Resident Room 3911, did not positively latch within the door frame. This deficiency affects one of the 43 smoke compartments within the facility. The Assistant Director of Facilities and Grounds confirmed during an interview at the same time and date that the corridor door did not latch properly. This failure to maintain the door's positive latching mechanism is a violation of the regulations that require doors protecting corridor openings to resist the passage of smoke and to have positive latching hardware, especially in areas that are not fully sprinklered.
Plan Of Correction
1. The Washington 3rd Supply Room door, next to Resident Room 3911, was corrected on 12/18/2024 to ensure that it positively latched within the door frame. 2. Maintenance staff will be educated that corridor doors protecting corridor openings in other than required enclosures of vertical openings, exits, hazardous areas will be maintained to ensure positive latching within the door frame. General staff education to initiate work orders when doors are not latching appropriately. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that corridor doors protecting corridor openings in other than required enclosures of vertical openings, exits, hazardous areas will be maintained to ensure positive latching within the door frame. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Obstructed Smoke Barrier Door Due to Patient Lift
Penalty
Summary
The facility failed to maintain the unobstructed closing of smoke barrier doors, which is a requirement for ensuring fire safety within the building. During an observation, it was noted that the smoke barrier door on the Roosevelt 2nd floor, near Resident Room 2648, was obstructed by a patient lift, preventing it from closing properly. This deficiency was confirmed through an interview with the Assistant Director of Facilities and Grounds, who acknowledged the obstruction of the smoke barrier door. This issue affected two out of 43 smoke compartments within the facility.
Plan Of Correction
1. The Roosevelt 2nd floor smoke barrier door, by Resident Room 2648, obstructed from closing by a patient lift was corrected on 12/16/2024. 2. Staff will be educated in maintaining the unobstructed closing of smoke barrier doors. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that smoke barrier doors are unobstructed. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Electrical Receptacle Integrity Deficiency
Penalty
Summary
The facility failed to maintain the physical integrity of an electrical receptacle, which was identified as a deficiency during a survey. On December 16, 2024, at 1:06 PM, an observation revealed that an electrical outlet located in the corridor on the Roosevelt 3rd floor, between Resident Room 3801 and the Laundromat, was physically broken. This finding was confirmed through an interview with the Assistant Director of Facilities and Grounds, who acknowledged the compromised condition of the electrical receptacle.
Plan Of Correction
1. The Roosevelt 3rd floor outlet, located within the corridor, between Resident Room 3801 and the Laundry, was replaced on 12/18/2024. 2. Maintenance staff will be educated in maintaining the physical integrity of electrical receptacles. Staff education will include initiating work orders when receptacles are physically broken. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure the physical integrity of electrical receptacles. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Linen Chute Doors Fail to Latch Properly
Penalty
Summary
The facility failed to maintain the fire resistance of linen chute enclosure doors, affecting two smoke compartments. During an observation on December 16, 2024, it was noted that the linen chute doors on the 4th and 2nd floors of the Roosevelt building did not positively latch within their frames. This deficiency was confirmed through interviews with the Assistant Director of Facilities and Grounds, who acknowledged the compromised fire resistance rating of the linen chute enclosures.
Plan Of Correction
1. (Observation 1) -- The Roosevelt 4th floor Linen Chute door that failed to positively latch was corrected on 12/18/2024. (Observation 2) -- The Roosevelt 2nd floor Linen Chute door that failed to positively latch was corrected on 12/18/2024. 2. Maintenance staff will be educated in maintaining the fire resistance rating for Linen Chute doors. Staff has been educated to initiate a work order when a linen chute door is not latching appropriately. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure the fire resistance rating for Linen Chute doors. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Improper Use of Surge Suppressors and Extension Cords
Penalty
Summary
The facility failed to properly monitor the use of surge suppressors and extension cords, leading to deficiencies in three of the 43 smoke compartments. On December 16, 2024, a surge suppressor was observed supplying electrical power to two refrigerators and a coffee machine in the Roosevelt 2nd floor West Conference Room. This setup was confirmed by the Assistant Director of Facilities and Grounds, indicating that high-draw appliances were improperly plugged into a surge suppressor. Further observations on December 17, 2024, revealed additional issues. A surge suppressor was found supplying power to another surge suppressor at the Washington 3 Care Base, confirmed by the Assistant Director of Facilities and Grounds as a daisy-chained setup. Additionally, an extension cord was supplying power to a surge suppressor in the Clinics 3rd floor LGH Providers Room, which was also confirmed by the Assistant Director. These findings indicate a failure to adhere to proper electrical safety standards as outlined by NFPA guidelines.
Plan Of Correction
1. (Observation 1) The surge suppressor supplying electrical power to two refrigerators and a coffee machine, within the Roosevelt 2nd floor West Conference Room, was corrected on 12/26/2024. Staff will be educated on not having high draw appliances plugged in to surge suppressors. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that high draw appliances are not plugged in to surge suppressors. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment. (Observation 2) The surge suppressor supplying power to another surge suppressor, at the Washington Care Base was corrected on 12/16/2024. Staff will be educated on not using a surge suppressor to supply electrical power to another surge suppressor. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that a surge suppressor is not used to supply electrical power to another surge suppressor. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment. (Observation 3) The extension cord supplying electrical power to a surge suppressor, within the Clinic's 3rd floor office was corrected on 12/17/2024. Staff will be educated on not using extension cords to supply electrical power to a surge suppressor. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that an extension cord is not used to supply electrical power to a surge suppressor. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to maintain accurate assessments for two residents, leading to deficiencies in their clinical records. For Resident 97, the Quarterly Minimum Data Set (MDS) inaccurately indicated that the resident had experienced two falls with major injury since admission or the prior assessment. However, a review of the clinical record revealed no evidence of such falls. This discrepancy was confirmed by the Director of Nursing, who acknowledged the inaccurate coding of the MDS. Similarly, Resident 108's Quarterly MDS inaccurately reported both significant weight loss and gain. Upon reviewing the clinical record and weight summaries, no evidence of significant weight loss was found. The Director of Nursing confirmed the inaccuracy in the MDS coding for Resident 108 as well. These inaccuracies in the MDS assessments were identified as deficiencies under the relevant Pennsylvania Code sections for clinical records and nursing services.
Plan Of Correction
1. R97 had no evidence of falls with major injury - her MDS was corrected during the survey. R108's MDS has been corrected. 2. November's QM Report was reviewed for residents who had been coded as having had weight loss and falls with major injury. 3. The RNAC and Nutritional Service teams have been re-educated on accurate MDS. 4. Weekly audits will be conducted by the RNAC manager and Nutritional Service manager / designee to confirm accurate MDS in weight loss and falls with major injury for (4) weeks. These audits will be reviewed, trended, and determined for the need for future audits deemed by the QAPI team.
Delay in Behavioral Health Services for Resident
Penalty
Summary
The facility failed to provide timely behavioral health services to a resident with a history of anxiety and emotional distress. The resident, who was admitted with diagnoses including anxiety, expressed feelings of wanting to die on multiple occasions, as documented in nurse's notes on August 14 and October 4, 2024. Despite these expressions of distress, the resident did not receive a behavioral health evaluation until November 27, 2024, which was over a month after the physician ordered a psychology evaluation on October 18, 2024. The delay in obtaining the psychology evaluation was confirmed by the Director of Nursing on December 5, 2024. The resident's condition, characterized by statements of not wanting to live and difficulty getting out of bed, was acknowledged by the physician, who noted the resident's preference for conversation over medication. However, the lack of timely intervention from behavioral health services represents a deficiency in the facility's obligation to provide necessary care and services to address the resident's mental health needs.
Plan Of Correction
1. R97 has been seen by the psychologist. 2. A comprehensive review has been conducted for any upcoming psychology appointments with appropriate appointment dates. 3. The clinic staff has been re-educated on scheduling Behavioral Health appointments in an appropriate time frame. 4. Weekly audits will be conducted by the director of ancillary services to confirm appropriate time frames with Behavioral Health appointments for (4) weeks. These audits will be reviewed, trended, and determined for the need for future audits deemed by the QAPI team.
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What surveyors actually found near you
We read the 368 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Elizabethtown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerald Nursing And Rehabilitation | 0.3 mi | ★★★★★ | 25 | 1 |
| Elizabethtown Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 0 | 0 |
| Mt Hope Nazarene Retirement Community | 8 mi | ★★★★★ | 0 | 0 |
| Oak Hill Center For Rehabilitation And Nursing | 8.3 mi | ★★★★★ | 11 | 0 |
| Susquehanna Health And Wellness Center | 8.7 mi | ★★★★★ | 1 | 0 |
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