Cycle 1
Health 2026-01-23 · Fire 2024-12-05
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Elizabethtown, PA
Masonic Village At Elizabethtown
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
One Masonic Drive, Elizabethtown, PA
(717) 367-1121
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
434
Certified beds
Average residents
298
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-03-15
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
Hours and turnover
RN hours / resident day
0.77
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.91
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.64
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.94
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
5.37
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
109
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
84.99
Composite VBP score used to determine payment impact.
Payment multiplier
1.0267
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.02
Baseline 16.27% · Performance 17.72% · Measure score 8.02 · Achievement 8.02 · Improvement 0
Healthcare-associated infections
10
Baseline 4.22% · Performance 4.61% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
8.72
Baseline 28.12% · Performance 28.02% · Measure score 8.72 · Achievement 8.72 · Improvement 0
Adjusted total nurse staffing
7.25
Baseline 4.53 hours · Performance 5.14 hours · Measure score 7.25 · Achievement 7.25 · Improvement 4.37
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.64% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 236 · Observed rate 8.47% · Lower 95% interval 7.02% |
| Discharge to community | 47.01% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 202 · Observed rate 41.58% · Lower 95% interval 40.19% |
| Medicare spending per beneficiary | 0.6 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 80.67% |
95.27%
14.6 pts worse
|
Numerator 121 · Denominator 150 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 150 |
| Discharge self-care score | 43.15% |
53.69%
10.5 pts worse
|
Numerator 63 · Denominator 146 |
| Discharge mobility score | 34.25% |
50.94%
16.7 pts worse
|
Numerator 50 · Denominator 146 |
| Pressure ulcers or injuries, new or worsened | 0.67% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 150 · Adjusted rate 0.78% |
| Healthcare-associated infections requiring hospitalization | 4.61% |
7.12%
2.5 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 0.76% · Lower 95% interval 2.42% |
| Staff COVID-19 vaccination coverage | 3.13% |
8.2%
5.1 pts worse
|
Numerator 24 · Denominator 768 |
| Staff flu vaccination coverage | 87.37% |
42%
45.4 pts better
|
Numerator 761 · Denominator 871 |
| Discharge function score | 62.33% |
56.45%
5.9 pts better
|
Numerator 91 · Denominator 146 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 64 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 44.3% |
25.2%
19.1 pts better
|
Numerator 35 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.7
1.1 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.2
1 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
86.9%
11.3 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 97.9% · Q3 98.9% · Q4 97.1% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
93.5%
5.2 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.2%
0.9 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.5% · Q3 3.9% · Q4 4.7% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
6.5%
2.7 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.9% · Q3 2.3% · Q4 4.8% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
6.5%
3.6 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.6% · Q3 0.9% · Q4 4.4% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
19.9%
4.9 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 17.0% · Q3 16.0% · Q4 12.2% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
18.7%
1.1 pts better
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 20.9% · Q3 17.1% · Q4 17.1% · 4Q avg 17.6% · 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 | 22.5% |
19.6%
2.9 pts worse
|
16.3%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 22.1% · Q3 20.1% · Q4 20.2% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.5% |
18.3%
9.2 pts worse
|
14.9%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 27.1% · Q3 23.8% · Q4 24.3% · 4Q avg 27.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.0% · Q3 1.2% · Q4 0.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.4% · Q3 1.4% · Q4 1.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
26.4%
1.5 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 29.9% · Q3 29.1% · Q4 26.0% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.3%
3.8 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 2.2% · Q4 0.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.7% |
68.9%
17.8 pts better
|
81.7%
5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.4% · Q2 84.8% · Q3 87.1% · Q4 90.2% · 4Q avg 86.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.2% |
9.8%
4.6 pts better
|
12.0%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 5.0% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.1% |
68.7%
15.4 pts better
|
79.7%
4.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.2% |
23.1%
6.9 pts better
|
23.9%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 14.2% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-05 · Fire 2024-01-25
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2024-01-25 · Fire 2023-02-10
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-05
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-05
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-01
F · Potential for more than minimal harm
2024-01-25
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-01-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-01-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-02-10
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-10
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-10
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-03-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
D · Potential for more than minimal harm
2025-08-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-23
D · Potential for more than minimal harm
2024-12-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-01-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-23
Penalties and ownership
What sits behind the stars
Ownership
Masonic Villages Of The Grand Lodge Of Pennsylvania
5% Or Greater Direct Ownership Interest · Organization
Bahney, Thomas
Corporate Director · Individual
Baker, Lynn
Corporate Director · Individual
Brink, Robert
Corporate Director · Individual
Cepielik, Robert
Corporate Director · Individual
Deshong, Leigh
Operational/Managerial Control · Individual
Downs, Eric
Corporate Director · Individual
Formica, Pamela
Operational/Managerial Control · Individual
Formica, Pamela
Corporate Officer · Individual
Heese, Adam
Corporate Director · Individual
Kingsbury, William
Corporate Officer · Individual
Kraus, Peter
Corporate Director · Individual
Mayo, Matthew
Operational/Managerial Control · Individual
Miller, Glenn
Corporate Director · Individual
Ockovic, Todd
Corporate Director · Individual
Roup, Paul
Corporate Director · Individual
Saylor, Stanley
Corporate Director · Individual
Snyder, Robert
Corporate Director · Individual
Spence, Brenda
Corporate Director · Individual
Wheeler, Frederic
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Emerald Nursing And Rehabilitation
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
#2
Elizabethtown Nursing And Rehabilitation
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
#3
Mt Hope Nazarene Retirement Community
Manheim, PA
5-star overall rating with 4-star inspections with 2 recent health deficiencies
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