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Complaint Investigation

Emerald Nursing And Rehabilitation

December 22, 2025 · Elizabethtown, PA · 320 South Market Street
Citations 2
CMS Rating 2/5
Beds 73
Provider ID 395469
Healthcare Facility
Emerald Nursing And Rehabilitation
Elizabethtown, PA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

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

FF0689
Quality of Life and Care Deficiencies

November 9, 2025.

The facility failed to ensure appropriate supervision of a resident, exhibiting exit

jeopardy to resident health or family member's home.

Facility staff were unaware of resident's elopement until the family member safety 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)

services28 Pa.

Code 211.12(d)(2) Nursing services

395469 12/22/2025

Emerald Nursing and Rehabilitation 320 South Market Street Elizabethtown, PA 17022

(NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ELIZABETHTOWN, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EMERALD NURSING AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.