Masonic Village at Elizabethtown

In the surveyor’s words

From the most serious findings on record at Masonic Village at Elizabethtown, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF610Jan 23, 2026

  Based on review of facility policy, review of the clinical record, review of facility documentation, and interviews with staff, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 40 residents reviewed (Resident 203).Findings include:Review of facility policy, Occurrence Prevention, Documentation, and Reporting, reviewed July 21, 2026, revealed that all sections of the incident report will be completed to the best of staff's ability to include details surrounding the incident including statements from staff/individuals involved in resident care/situation prior to or during incident and those involved with incident response.Review of Resident 203's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) of September… […]

• No harm, potential for more than minimal, isolatedF600Aug 25, 2025

  Based on review of clinical record, facility documentation, and staff interviews it was determined the facility failed to ensure Resident CL1 was free from neglect for one out of four residents reviewed (Resident CL1). Findings Include: Observation conducted on August 25, 2025, at approximately 10:45 am of the [NAME] nursing unit spa room and whirlpool bath chair. Observation was conducted in the company of licensed staff, RN Supervisor, Employee E2 and RN Nurse Manager, Employee E3. The chair has a large width strap that is strung through a loop positioned between resident's legs and then fastened on opposing side. there are two padded metal bars positioned in front and behind resident. the front bar snaps into place, secure, once resident is positioned into place. […]

• No harm, potential for more than minimal, isolatedF641Dec 5, 2024

  Based on clinical record review, it was determined that the facility failed to maintain accurate assessments for two of 35 residents reviewed (Residents 97 and 108). Findings include: Review of Resident 97's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) dated November 12, 2024, revealed under Section J - Health Conditions that the resident had two falls with major injury (bone fractures, joint dislocations, closed head injuries, or subdural hematomas) since admission/readmission or the prior assessment. Review of Resident 97's clinical record since the resident's admission to the facility on [DATE], failed to reveal evidence of any falls with major injury. Interview with the Director of Nursing on December 5, 2024, at approximately 11:00 a.m. […]

• No harm, potential for more than minimal, isolatedF740Dec 5, 2024

  Based on clinical record review, it was determined that the facility failed to ensure behavioral health services were offered in a timely manner for one of two residents reviewed for mood and behaviors (Resident 97). Findings include: Review of Resident 97's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including, but not limited to, anxiety and other symptoms and signs involving emotional state. Review of Resident 97's progress notes revealed a nurse's note on August 14, 2024, which stated, Resident was resting in recliner, resident was crying earlier stating that she was ready to die, she does not want to harm herself but just ready to die. […]

• No harm, potential for more than minimal, isolatedF757Jan 25, 2024

  Based on clinical record review, policy and procedure review, and staff interview it was determined the facility failed to administer as needed pain medications for appropriate pain levels and prior to non-pharmaceutical interventions for two of 40 residents reviewed. (Residents 42 and 270) Findings include: Review of facility policy and procedure titled Pain Assessment and Management Record Procedure, undated, revealed evaluation of pain (pain scale) and alternative interventions are used and documented in conjunction with oral medications. […]