Inspection Reports for
Masonic Village at Elizabethtown
ONE MASONIC DRIVE,, ELIZABETHTOWN, PA, 17022
Back to Facility Profile23 Reports
Inspection Report — May 12, 2026
Renewal
Date: May 12, 2026
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for the facility.
Findings
The inspection identified multiple deficiencies including breaches in resident record confidentiality, lack of required fire safety training, improper storage of poisonous materials, unprotected food storage, medication administration errors, incomplete medication administration records, incomplete staff training documentation, and failure to update resident assessments following significant changes.
Citations (8)
17 - Resident records were unlocked, unattended, and accessible in the dining room, violating confidentiality requirements.
65g - Staff members A, B, and C did not receive required fire safety training by a qualified expert in the 2025 training year.
82a - Two spray bottles containing clear liquid were labeled only as 'Soap + Water' in black marker and not in original containers.
103c - Plates of salad, applesauce, and pudding were unprotected from contamination while stored in the kitchen refrigerators.
182c - Staff Member E placed medications in front of Resident #3 but did not observe ingestion, resulting in Resident #4 taking the wrong medications and requiring hospital evaluation.
187b - Resident #7’s medication administration record lacked the initials of the staff person who administered medication on 5/6/26 morning.
190c - Staff Member F’s 2025 Medication Administration Summary and Requalification document lacked indication of requalification and missing student signature and date.
225c - Resident #6’s assessment was not updated to reflect a significant change in dietary needs following a new diet order.
Report Facts
Residents Served: 113
Total Daily Staff: 128
Waking Staff: 96
Current Hospice Residents: 1
Residents Age 60 or Older: 120
Residents Diagnosed with Mental Illness: 11
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 15
Residents Receiving Supplemental Security Income: 2
Inspection Report — Nov 14, 2024
Renewal
Date: 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.
Citations (5)
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
Total Daily Staff: 120
Waking Staff: 90
Inspection Report — Mar 13, 2024
Plan of Correction
Date: 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.
Citations (1)
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
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 — Jan 24, 2024
Renewal
Date: 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.
Citations (5)
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
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 — Oct 5, 2023
Complaint Investigation
Date: 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.
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.
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.
Citations (1)
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
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
Notice — May 3, 2023
Date: May 3, 2023
Visit Reason
The document serves to grant a waiver request allowing advanced notice of planned nighttime fire drills at Masonic Village of Elizabethtown under specified conditions.
Findings
The waiver permits the facility to provide advanced notice of nighttime fire drills with the condition that residents are reminded not to share this notice. The Department will review compliance with this waiver during the annual inspection.
Inspection Report — Mar 14, 2023
Renewal
Date: 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.
Citations (8)
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
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 — Nov 14, 2022
Complaint Investigation
Date: 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.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff - Total Daily Staff: 122
Resident Support Staff - Waking Staff: 92
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 — Jun 14, 2022
Plan of Correction
Date: 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.
Citations (2)
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
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 — May 11, 2022
Renewal
Date: 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 — Mar 1, 2022
Renewal
Date: 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.
Citations (14)
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
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 — Sep 16, 2021
Date: 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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Notice — Nov 18, 2020
Date: Nov 18, 2020
Visit Reason
This document serves as a license renewal notification and certificate of compliance for Masonic Village at Elizabethtown, a Personal Care Home, confirming the facility's authorized capacity and informing about the upcoming annual inspection.
Findings
The Department has issued a regular license in response to the renewal application and will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Inspection Report — Jul 8, 2020
Renewal
Date: Jul 8, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 07/08/2020 and 07/09/2020.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Feb 4, 2020
Date: Feb 4, 2020
Visit Reason
The document serves to notify Masonic Village at Elizabethtown of a granted waiver related to admission, resident medical evaluation, health care, and preadmission screening under Pennsylvania Code 2600.
Findings
The waiver allows the facility to use alternative documentation forms for medical evaluation and preadmission screening, subject to annual review during inspections to ensure compliance with waiver conditions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Parisi | Director | Signed the waiver approval letter |
Inspection Report — Oct 15, 2019
Renewal
Date: Oct 15, 2019
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing (Office of Long-term Living) on October 15 and 16, 2019.
Findings
The facility was found to be in compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Notice — Sep 18, 2019
Date: Sep 18, 2019
Visit Reason
This document serves as a renewal notification and license issuance for the Masonic Village at Elizabethtown Personal Care Home. It informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document as it is a license renewal notice and certificate of compliance.
Report Facts
Inspection Report — Nov 14, 2018
Annual Inspection
Date: Nov 14, 2018
Visit Reason
The visit was an annual inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with the applicable regulations during the annual inspection conducted on November 14, 2018.
Notice — Sep 17, 2018
Date: Sep 17, 2018
Visit Reason
This document serves as a renewal license notification for Masonic Village at Elizabethtown and informs about 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 notification and certificate of compliance.
Inspection Report — Nov 29, 2017
Annual Inspection
Date: Nov 29, 2017
Visit Reason
The document reports the results of the Department of Human Services' annual licensing inspections conducted on November 29 and November 30, 2017, for the Masonic Village at Elizabethtown.
Findings
The facility was found to be in compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes following the annual licensing inspections.
Inspection Report — Sep 19, 2017
Renewal
Date: Sep 19, 2017
Visit Reason
The document is a renewal application and license issuance for Masonic Village at Elizabethtown, with a required annual onsite inspection to be conducted within the next twelve months as part of the renewal process.
Findings
No inspection findings are reported in this document. It is a license renewal notification and certificate issuance without noted deficiencies or compliance issues.
Report Facts
Inspection Report — Nov 30, 2016
Annual Inspection
Date: Nov 30, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections and included renewal and complaint triggers.
Findings
Violations of 55 Pa.Code Chapter 2600 were found related to Personal Care Homes. Deficiencies included issues with stairwell door locking mechanisms and lack of exit signs in the Terrace Kitchen.
Citations (2)
2600.121(a): Stairways, hallways, doorways, passageways and egress routes must be unlocked and unobstructed. The stairwell doors had locking mechanisms that residents did not know how to open, blocking access to the stairwell.
2600.139(a)(1): If the home serves nine or more residents, exit signs must be posted in plain legible letters. The Terrace Kitchen lacked exit signs identifying egress routes.
Report Facts
Number of Residents Served: 128
Total Daily Staff: 128
Waking Staff: 96
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 6
Inspection Report — Sep 21, 2016
Complaint Investigation
Date: Sep 21, 2016
Visit Reason
The inspection was conducted as a licensing inspection triggered by complaint and incident reports at the Masonic Village at Elizabethtown.
Complaint Details
The inspection was complaint-related and incident-related. Specific substantiation status is not stated.
Findings
Violations related to 55 Pa.Code Chapter 2600 were found, including failure to document a resident's refusal or inability to sign the support plan. A plan of correction was submitted and partially implemented.
Citations (1)
55 Pa.Code §2600.227(b) requires documentation if a resident or designated person is unable or refuses to sign the support plan. The support plan for Resident 1 was not signed by the resident and no notation of refusal or inability to sign was made.
Report Facts
Number of Residents Served: 110
Number of Current Hospice Residents: 0
Number of Hospice Residents in past year: 5
Residents 60 Years of Age or Older: 107
Residents with Supplemental Security Income: 5
Residents with Intellectual Disability: 3
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Residents with Mental Illness: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hershey | Director | Named in relation to the plan of correction for the support plan violation |
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