Inspection Reports for Masonic Village at Lafayette Hill
801 Ridge Pike, Lafayette Hill, PA 19444, United States, PA, 19444
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Inspection Report
Complaint Investigation
Census: 36
Capacity: 51
Deficiencies: 14
Jun 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 06/05/2025.
Findings
Multiple deficiencies were identified including unsigned resident contracts, lack of background checks for contractors, sanitary issues, damaged ceiling tiles, malfunctioning equipment, food safety violations, obstructed egress routes, uninspected fire extinguishers, menu change notification failures, medication self-administration errors, improper medication storage, and failure to educate residents on their right to refuse medication. All deficiencies had plans of correction accepted and were implemented by 07/25/2025.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating 'Reason: Complaint'.
Deficiencies (14)
| Description |
|---|
| Resident-home contract was not signed by the resident. |
| Exterminator moved unsupervised without a completed background check. |
| Uncovered trash can with food debris and open trash area door with pest control issues. |
| Ceiling tile in dining area had significant water damage and a hole. |
| Air conditioner in resident room was not working properly; room temperature was high. |
| Light cover on ceiling partially hanging off. |
| Uncovered food (oatmeal, bacon, eggs, sausages) stored in kitchen warmers without staff present. |
| Keypad locks blocked egress from fire exits without conspicuous code posting. |
| Fire extinguishers in pantry kitchen and main kitchen had not been inspected by a fire safety expert. |
| Menu substitution (fish served instead of meatloaf) without advance resident notice. |
| Resident unable to distinguish medications in disposable cups; self-administration assessment inadequate. |
| Medication left in clear plastic cup on resident's dresser beyond allowed time. |
| Prescription medications and syringes unlocked, unattended, and accessible in resident bathroom and room. |
| Resident not educated on right to refuse medication if medication error suspected. |
Report Facts
License Capacity: 51
Residents Served: 36
Staffing Hours: 36
Waking Staff: 27
Residents Diagnosed with Mental Illness: 10
Residents 60 Years or Older: 36
Inspection Report
Renewal
Census: 31
Capacity: 51
Deficiencies: 16
Aug 8, 2024
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The facility had multiple deficiencies including staff qualifications, training, environmental safety issues, medication storage, emergency procedures, fire safety, and resident record content. All deficiencies had plans of correction accepted and were implemented by the time of the report.
Deficiencies (16)
| Description |
|---|
| Staff member A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff person A began providing unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
| There was a full, uncovered, unattended trash can in the main kitchen. |
| The bathroom in bedrooms 2109, 2111, and 2112 does not have an operable window or ventilation fan. |
| Hot water temperature in bedrooms 2109 and 2112 measured 141.0°F, and at bedroom 2111 it measured 142.1°F, exceeding the maximum allowed 120°F. |
| Broken pipe dripping water in the facility's boiler room with a wet puddle on the ground. |
| Two bags of bread and a tray of pastries on the main kitchen refrigerator were opened, unsealed, and uncovered; three trays of pastries in the personal care kitchenette were uncovered. |
| The home’s written emergency procedures do not include the contact information for each resident’s designated person. |
| The home does not have documentation of written notification to the local fire department of the address of the home, location of the bedrooms, and the assistance needed to evacuate in an emergency. |
| No fire safety inspection or fire drill observed by a fire safety expert in 2023; last was on 10/06/2022. |
| Fire drill records from 9/19/2023 and 12/7/2023 show evacuation times exceeding the maximum safe evacuation time of 8 minutes specified in 2022. |
| Exits 1, 2, and 4 were repeatedly used during fire drills, limiting use of alternate exit routes. |
| Staff person B who provided transportation to residents has not completed the initial new hire direct care staff person training, nor has any staff person who accompanied residents on the trip. |
| Lotion and prescribed medication for resident 4 were unlocked, unattended, and accessible in the resident's bedroom. |
| Medications prescribed for residents 4, 5, and 6 were expired or had packaging defects (opened foil on blister cards). |
| Residents 1, 2, and 3 records do not include hair color or eye color. |
Report Facts
Residents Served: 31
License Capacity: 51
Staff Total Daily: 31
Staff Waking: 23
Evacuation Time: 8
Inspection Report
Renewal
Census: 34
Capacity: 51
Deficiencies: 2
Jul 3, 2023
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The submitted plan of correction was found to be fully implemented. Two deficiencies were noted related to emergency telephone numbers and furniture safety, both of which were corrected with plans of correction accepted and implemented.
Deficiencies (2)
| Description |
|---|
| No emergency telephone numbers including nearest hospital and fire department posted on or by the telephone in Resident Bedroom 2131. |
| Resident Bedroom 2111 has an enabler without a cover over the opening at the top of the bar, posing risk of strangulation, suffocation, entrapment, or serious injury. |
Report Facts
License Capacity: 51
Residents Served: 34
Total Daily Staff: 34
Waking Staff: 26
Inspection Report
Renewal
Census: 35
Capacity: 51
Deficiencies: 4
Mar 23, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the Masonic Village of Lafayette Hill facility on 03/23/2022.
Findings
The inspection found multiple deficiencies including exceeding designated fire evacuation times, unsecured medications in a resident's room, an uncalibrated glucometer, and lack of conspicuous posting of directions for key-locking devices. Plans of correction were accepted and implemented with follow-up audits scheduled.
Deficiencies (4)
| Description |
|---|
| The home exceeded the designated fire evacuation time of 8 minutes during drills on 12/14/21 and 3/9/22. |
| Several unlocked, unattended medications were found in Resident #1's bedroom, not stored securely as required. |
| Resident #2's glucometer was not calibrated to the correct date and time. |
| Directions for operating electronic numeric keypad locking mechanisms at stairwell doors were not conspicuously posted. |
Report Facts
License Capacity: 51
Residents Served: 35
Staffing: 35
Waking Staff: 26
Fire evacuation time: 8
Fire evacuation drill dates: 2
Notice
Capacity: 51
Deficiencies: 0
Sep 16, 2021
Visit Reason
This document serves as a renewal notification and license issuance for the Masonic Village of Lafayette Hill 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 an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Total licensed capacity: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Follow-Up
Census: 31
Capacity: 51
Deficiencies: 6
Feb 25, 2021
Visit Reason
The inspection was a full, unannounced review conducted on 02/25/2021 and 02/26/2021 to verify that the facility's submitted plan of correction was fully implemented.
Findings
The facility was found to have fully implemented the submitted plan of correction. Several deficiencies were noted related to incident reporting delays, sanitary conditions, trash receptacle coverage, bathroom ventilation, furniture maintenance, and medication storage procedures, all of which were corrected or addressed with plans for ongoing monitoring.
Deficiencies (6)
| Description |
|---|
| Failure to report multiple incidents to the Department within required timeframes, including falls, medication omissions, COVID-19 positive test, hospitalizations, and death notifications. |
| Pink residue and brownish substance found inside the ice maker in the second floor dining room kitchen. |
| Trash can in the second floor dining room kitchen was uncovered and unattended. |
| Bathrooms in specified rooms lacked operable windows or ventilation fans; exhaust fan was inoperable but restored during inspection. |
| Bathroom sink in a bedroom was clogged, causing water to fill the sink quickly. |
| Inaccurate and incomplete recording of glucometer readings on the MAR log for resident #7. |
Report Facts
License Capacity: 51
Residents Served: 31
Inspection Dates: 2
Plan of Correction Completion Date: Mar 31, 2021
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