Emerald Nursing And Rehabilitation
EMERALD NURSING AND REHABILITATION in ELIZABETHTOWN, PA — inspection on December 22, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
December 22, 2025, the implementation of the action plan was verified.
Eleven staff members were interviewed from various units and departments.
Facility staff were able to answer questions on recognizing signs of exit seeking behaviors and who to report them to, missing resident response, how often are elopement assessments completed, LOA process, Visitor badges, signing out resident process.Following the verification of the completion of the immediate action plan the Immediate Jeopardy was lifted on December 22, 2025, at 7:15 p.m. and the Immediate Jeopardy situation was determined to exist at the facility from the time of the elopement on November 5, 2025, until the completion of the action plan on November 9, 2025.
The facility failed to ensure appropriate supervision of a resident, exhibiting exit seeking behavior and who exited the door of the facility to cross multiple busy streets to arrive at a family member's home.
Facility staff were unaware of resident's elopement until the family member contacted the facility.
The deficient practice is being cited as past non compliance. 28 Pa.
Code 201.14(a) Responsibility of licensee28 Pa.
Code 201.18(b)(1) Management28 Pa.
Code 201.18(e)(1) Management28 Pa.
Code 211.10(d) Resident care policies28 Pa.
Code 211.12(d)(1)(5) Nursing services28 Pa.
Code 211.12(d)(2) Nursing services
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Emerald Nursing and Rehabilitation
320 South Market Street Elizabethtown, PA 17022
SUMMARY STATEMENT OF DEFICIENCIES
Based on the review of clinical records, job descriptions, review of facility policy, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of one of twelve residents reviewed (Resident R1) with a diagnosis of Dementia who eloped from the facility.
This failure resulted in an Immediate Jeopardy situation for Resident R1. (Resident R1)Findings Include:
Review of the job description for the Nursing Home Administrator (NHA) states, Position Summary-this position is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet resident's needs in accordance with federal, state and local regulations.
Also, develop and maintain systems that are effective and efficient to operate the facility in a financially sound manner.Further review of the NHA job description revealed, Essential Duties and Responsibilities-.
Develop, maintain and implement operational policies and procedures to meet residents need in compliance with federal, state and local requirements.
Determine the personnel requirements of the facility in collaboration with Department Managers and hire or arrange for sufficient staff to provide for sound resident care and implement the facility policies and procedures.
Review of the job description for the Director of Nursing (DON) states, Position Summary- The Director of Nursing functions as the administrative authority for the Department of Nursing.
This Director will be responsible for the organization and oversight of all nursing operations and for the supervision of care for all residents at the facility.
Further review of the DON job essential requirements revealed, must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality of care.The findings in this report identified the facility failed to maintain the safety of the residents from elopement by ensuring elopement assessments were completed correctly and residents exhibiting behaviors for elopement were prevented from leaving the facility without proper supervision.Refer to F68928 Pa Code 201.14(a) Responsibility of licensee28 Pa.
Code 201.18(b)(1) Management28 Pa.
Code 201.18(b)(3) Management
Facility ID: