Inspection Reports for Masonic Village at Elizabethtown
ONE MASONIC DRIVE,, PA, 17022
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
91% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/year
Deficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
89% occupied
Based on a November 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 120
Capacity: 135
Deficiencies: 5
Nov 14, 2024
Visit Reason
The inspection was conducted as a renewal review of the Masonic Village at Elizabethtown facility on 11/14/2024 and 11/15/2024 to verify compliance and implementation of the submitted plan of correction.
Findings
The inspection identified multiple medication storage, labeling, and documentation deficiencies, including improper medication storage, discrepancies between medication administration records and pharmacy labels, blood glucose documentation errors, and missing medications. A repeat violation was noted regarding medication storage procedures. The facility submitted and implemented a plan of correction by 12/04/2024.
Deficiencies (5)
| Description |
|---|
| Improper storage of prescription and OTC medications with loose pills found in medication carts and undated opened medication. |
| Medication labels did not match prescribed dosages and instructions on the medication administration record for multiple residents. |
| Discrepancies between blood glucose readings on residents' glucometers and medication administration records, leading to incorrect insulin administration. |
| Medication not available in the home resulting in missed doses for residents. |
| Resident assessment did not include use of bedside mobility device as required. |
Report Facts
Residents Served: 120
License Capacity: 135
Total Daily Staff: 120
Waking Staff: 90
Inspection Report
Plan of Correction
Census: 129
Capacity: 135
Deficiencies: 1
Mar 13, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit related to an incident, specifically a plan of correction submission review.
Findings
The facility was found to have fully implemented the submitted plan of correction regarding a failure to immediately report an allegation of sexual abuse as required by the Older Adult Protective Services Act.
Deficiencies (1)
| Description |
|---|
| Failure to immediately report an allegation of sexual abuse involving a resident to the Pennsylvania Department of Aging as required by the Older Adult Protective Services Act. |
Report Facts
License Capacity: 135
Residents Served: 129
Current Hospice Residents: 3
Residents Receiving Supplemental Security Income: 3
Residents 60 Years or Older: 129
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 5
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Total Daily Staff: 141
Waking Staff: 106
Inspection Report
Renewal
Census: 124
Capacity: 135
Deficiencies: 5
Jan 24, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the Masonic Village at Elizabethtown facility on 01/24/2024 and 01/25/2024.
Findings
The inspection found several deficiencies including uncovered trash receptacles in the kitchen, fire drill evacuation times exceeding the maximum safe time, incomplete medical evaluations, and issues with medication storage and documentation. Plans of correction were submitted and fully implemented by February 2024.
Deficiencies (5)
| Description |
|---|
| Two half-full, uncovered, unattended trash cans in the kitchen by the handwash stations. |
| Fire drill evacuation time of 12 minutes and 10 seconds exceeded the maximum safe evacuation time of 10 minutes specified by a fire safety expert. |
| Resident #1's most recent medical evaluation was missing the Date Resident Evaluated, Date Form Completed, and Medical Professional License Number. |
| Resident #2's most recent medical evaluation was incomplete and previous evaluation date was missing. |
| Resident #2 had a blood glucose level recorded on the Medication Administration Record with an incorrect glucometer reading documented. |
Report Facts
License Capacity: 135
Residents Served: 124
Total Daily Staff: 135
Waking Staff: 101
Fire Drill Evacuation Time: 12.17
Fire Drill Evacuation Time: 9.78
Residents Evacuated: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deirdre Mojica | Lead Inspector | Named as lead inspector for the inspection on 01/24/2024. |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 135
Deficiencies: 1
Oct 5, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the Masonic Village at Elizabethtown facility on 10/05/2023.
Findings
The investigation found that Staff Person A was verbally abusive to Resident #1 and other residents, using inappropriate tone, volume, and language. The staff member was suspended and subsequently terminated. Education on Resident Rights and Abuse was completed for all personal care staff.
Complaint Details
The visit was complaint-related, investigating allegations of verbal abuse by Staff Person A towards Resident #1 and others. The complaint was substantiated as evidenced by the staff suspension and termination.
Deficiencies (1)
| Description |
|---|
| Staff Person A was seen and heard yelling at Resident #1 and using inappropriate and intimidating tone and volume towards multiple residents in the common room. |
Report Facts
License Capacity: 135
Residents Served: 120
Current Residents in Hospice: 1
Residents Receiving Supplemental Security Income: 3
Residents Diagnosed with Mental Illness: 5
Residents Aged 60 or Older: 120
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 106
Capacity: 135
Deficiencies: 8
Mar 14, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation at the Masonic Village at Elizabethtown.
Findings
The inspection found multiple deficiencies including failure to post required documents, fall hazards due to non-skid mats missing, missing emergency telephone numbers, lint accumulation in dryer traps, overdue fire drills during sleeping hours, incomplete menu postings, and discrepancies in medication storage and documentation. All deficiencies had plans of correction submitted and were implemented by the end of March 2023.
Deficiencies (8)
| Description |
|---|
| Failure to post the 2600 regulations in a conspicuous and public place in the home. |
| Failure to post a regulatory waiver related to admission, medical evaluation, and pre-admission screening in a conspicuous and public place. |
| Bathrooms in certain bedrooms had decorative mats lacking non-skid backing, creating a fall hazard. |
| No emergency telephone numbers posted on or by telephones in a resident bedroom and common areas on the second and third floors. |
| Approximate 1/8 inch accumulation of lint in lint traps of large dryers on first and third floors. |
| Fire drill during sleeping hours was overdue; last conducted on 10/14/22 instead of every 6 months. |
| Only the menu for the current week was posted instead of menus prepared 1 week in advance. |
| Discrepancies between glucometer readings and medication administration record (MAR) for two residents. |
Report Facts
License Capacity: 135
Residents Served: 106
Staffing Hours: 115
Waking Staff: 86
Hospice Residents: 1
Residents Age 60 or Older: 106
Residents Diagnosed with Mental Illness: 11
Residents Diagnosed with Intellectual Disability: 5
Residents with Mobility Need: 9
Residents with Physical Disability: 1
Repeat Violation Date: Mar 1, 2022
Inspection Report
Complaint Investigation
Census: 120
Capacity: 135
Deficiencies: 0
Nov 14, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced notice on 11/14/2022 and 11/15/2022 at the Masonic Village at Elizabethtown.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
Resident Support Staff - Total Daily Staff: 122
Resident Support Staff - Waking Staff: 92
License Capacity: 135
Residents Served: 120
Current Hospice Residents: 1
Residents Receiving Supplemental Security Income: 4
Residents Age 60 or Older: 120
Residents Diagnosed with Mental Illness: 8
Residents Diagnosed with Intellectual Disability: 5
Residents with Mobility Need: 2
Residents with Physical Disability: 2
Inspection Report
Plan of Correction
Census: 120
Capacity: 135
Deficiencies: 2
Jun 14, 2022
Visit Reason
The inspection was conducted as a follow-up review to verify that the submitted plan of correction was fully implemented following previous deficiencies.
Findings
The submitted plan of correction was determined to be fully implemented. The report details two specific deficiencies related to abuse and support plan documentation, both of which have corrective actions and staff education planned or completed.
Deficiencies (2)
| Description |
|---|
| Failure to immediately separate Resident 1 and Resident 2 during a non-consensual sexual act, constituting abuse and neglect. |
| Resident's support plan did not document the need for enabler bars and a C-Pap machine observed in the resident's room. |
Report Facts
License Capacity: 135
Residents Served: 120
Resident Supplemental Security Income: 5
Residents Age 60 or Older: 120
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 4
Resident Current Hospice: 0
Resident Current with Mobility Need: 0
Resident Current with Physical Disability: 0
Inspection Report
Renewal
Deficiencies: 0
May 11, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Census: 121
Capacity: 135
Deficiencies: 14
Mar 1, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the Masonic Village at Elizabethtown facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to immediately report suspected resident abuse, breaches in resident record confidentiality, unsanitary conditions in resident bathrooms, improper food protection, unsecured medications, medication administration errors, incomplete resident assessments, and incomplete support plans. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (14)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident in accordance with the Older Adult Protective Services Act. |
| Failure to report the incident of suspected abuse to the Department’s personal care home regional office or complaint hotline within 24 hours. |
| Resident records were left unsecured and accessible to unauthorized persons, violating confidentiality requirements. |
| Toilet in resident bedroom found with multiple smears of dried and wet feces, indicating inadequate sanitary conditions. |
| Food item (chocolate ice cream) stored with a torn cardboard lid exposing contents, risking contamination. |
| Prescription medications found unsecured in resident rooms. |
| Medication found in resident's bathroom without a current physician order. |
| Medication administration records contained inaccurate transcription of medication readings. |
| Certified nursing assistants not trained as Medication Technicians were administering medications and insulin injections. |
| Initial resident assessments were not completed within 15 days of admission for some residents. |
| Resident assessments were not updated to reflect significant changes in condition. |
| Resident support plans were not revised within 30 days of annual assessment or changes in resident needs. |
| Resident support plans did not document medical, dental, vision, hearing, mental health or other behavioral care services or referrals. |
| Resident record did not include a photograph of the resident that is no more than 2 years old. |
Report Facts
License Capacity: 135
Residents Served: 121
Total Daily Staff: 121
Waking Staff: 91
Hospice Residents: 2
Residents 60 Years or Older: 121
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Intellectual Disability: 6
Residents with Physical Disability: 2
Residents Receiving Supplemental Security Income: 5
Notice
Capacity: 135
Deficiencies: 0
Sep 16, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Masonic Village at Elizabethtown Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice confirming the facility's compliance to operate and the Department's intent to conduct a future inspection.
Report Facts
Total licensed capacity: 135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
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