11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Elizabethtown, PA
1-star overall rating with 1-star inspections with $88,614 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
141 Heisey Avenue, Elizabethtown, PA
(717) 367-1831
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
45
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.44
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.66
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
2,710
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.17
Composite VBP score used to determine payment impact.
Payment multiplier
1.0019
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.57
Baseline 18.45% · Performance 17.92% · Measure score 7.57 · Achievement 7.57 · Improvement 3.20
Healthcare-associated infections
6.46
Baseline 6.53% · Performance 5.91% · Measure score 6.46 · Achievement 6.46 · Improvement 3.56
Total nurse turnover
2.67
Baseline 98.25% · Performance 75.00% · Measure score 2.67 · Achievement 0 · Improvement 2.67
Adjusted total nurse staffing
2.57
Baseline 3.49 hours · Performance 3.81 hours · Measure score 2.57 · Achievement 2.57 · Improvement 0.91
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.98% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 186 · Observed rate 16.67% · Lower 95% interval 9.99% |
| Discharge to community | 57.87% |
50.57%
7.3 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 48.47% · Lower 95% interval 50.48% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.92% |
95.27%
2.7 pts better
|
Numerator 94 · Denominator 96 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 96 |
| Discharge self-care score | 51.67% |
53.69%
2 pts worse
|
Numerator 31 · Denominator 60 |
| Discharge mobility score | 38.33% |
50.94%
12.6 pts worse
|
Numerator 23 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 6.25% |
2.29%
4 pts worse
|
Numerator 6 · Denominator 96 · Adjusted rate 5.72% |
| Healthcare-associated infections requiring hospitalization | 5.9% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 4% · Lower 95% interval 3.5% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 82 |
| Staff flu vaccination coverage | 76.34% |
42%
34.3 pts better
|
Numerator 71 · Denominator 93 |
| Discharge function score | 56.67% |
56.45%
0.2 pts better
|
Numerator 34 · Denominator 60 |
| Transfer of health information to provider | 98.15% |
95.95%
2.2 pts better
|
Numerator 53 · Denominator 54 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 1.69% |
25.2%
23.5 pts worse
|
Numerator 1 · Denominator 59 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 58.9% |
86.9%
28 pts worse
|
93.4%
34.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 52.0% · Q2 64.0% · Q3 63.3% · Q4 56.2% · 4Q avg 58.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 6.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
6.5%
0.2 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 0.0% · Q3 13.8% · Q4 3.3% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
6.5%
1.1 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.5% · Q3 0.0% · Q4 15.4% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
19.9%
8.9 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 13.6% · Q3 7.7% · Q4 10.3% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.4% |
18.7%
11.7 pts worse
|
16.7%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 28.6% · 4Q avg 30.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.9% |
19.6%
8.7 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
18.3%
11.2 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 13.6% · Q3 3.8% · Q4 6.9% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.7%
0.2 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.9% |
26.4%
7.5 pts worse
|
19.8%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.9% · Q2 33.3% · Q3 22.4% · Q4 36.0% · 4Q avg 33.9% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.3%
1.4 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 6.3% · Q4 2.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 46.3% |
68.9%
22.6 pts worse
|
81.7%
35.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.5% · Q2 42.3% · Q3 50.0% · Q4 48.2% · 4Q avg 46.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
9.8%
2.7 pts worse
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 14.9% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.5% |
68.7%
11.2 pts worse
|
79.7%
22.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
23.1%
4.5 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 20.9% · Expected 26.7% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Resident Rights (7 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Assessment and Care Planning (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-08-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-15
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-08-28
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-28
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-28
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-28
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-08-28
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-09-22
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-09-22
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-22
Inspection history
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-01
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-01
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-08-01
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-01
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-08-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-01
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-01
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-08-01
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-08-01
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-01
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-19
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-14
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-08-14
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-08-14
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-08-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-14
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-14
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-08-14
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-08-14
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-08-14
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-08-14
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-14
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-14
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-08-14
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-14
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-14
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-14
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-14
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-08-14
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-08-14
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-10-09
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-29
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-09-29
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-09-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-29
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-29
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-29
Health
Assess the resident when there is a significant change in condition
Corrected 2023-09-29
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-29
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-29
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-29
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-29
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-09-29
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-25
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-05-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-22
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-22
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-05-22
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-05-22
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-09
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-09
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-05-09
Penalties and ownership
Fine · fine $88,614
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Elizabethtown, PA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Elizabethtown, PA
1-star overall rating with 2-star inspections with $29,537 in total fines with 19 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Columbia, PA
3-star overall rating with 3-star inspections with $132,901 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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