Inspection Reports for
Masonic Village at Lafayette Hill
801 Ridge Pike, Lafayette Hill, PA 19444, United States, PA, 19444
Back to Facility Profile16 Reports
Inspection Report — Jun 5, 2025
Complaint Investigation
Date: Jun 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 06/05/2025.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating 'Reason: Complaint'.
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.
Citations (14)
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
Residents Served: 36
Staffing Hours: 36
Waking Staff: 27
Residents Diagnosed with Mental Illness: 10
Residents 60 Years or Older: 36
Inspection Report — Aug 8, 2024
Renewal
Date: 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.
Citations (16)
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
Staff Total Daily: 31
Staff Waking: 23
Evacuation Time: 8
Inspection Report — Jul 3, 2023
Renewal
Date: 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.
Citations (2)
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
Residents Served: 34
Total Daily Staff: 34
Waking Staff: 26
Inspection Report — Mar 23, 2022
Renewal
Date: 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.
Citations (4)
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
Residents Served: 35
Staffing: 35
Waking Staff: 26
Fire evacuation time: 8
Fire evacuation drill dates: 2
Notice — Sep 16, 2021
Date: 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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report — Feb 25, 2021
Follow-Up
Date: 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.
Citations (6)
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
Residents Served: 31
Inspection Dates: 2
Plan of Correction Completion Date: Mar 31, 2021
Notice — Nov 18, 2020
Date: Nov 18, 2020
Visit Reason
This document serves as a renewal notice and certificate of compliance for the Masonic Village of Lafayette Hill Personal Care Home. It informs the facility that a regular license is issued and that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the Department's requirement to conduct an annual inspection.
Report Facts
Inspection Report — Oct 1, 2020
Complaint Investigation
Date: Oct 1, 2020
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with applicable health and safety laws and to evaluate the submitted plan of correction.
Complaint Details
The inspection was triggered by a complaint regarding staff not wearing facemasks appropriately in the nursing station. The complaint was substantiated as staff were observed and reported not wearing masks properly.
Findings
The facility was found to have staff routinely not wearing facemasks appropriately in the nursing station, posing an infection control risk related to COVID-19. Additionally, the home's record of direct care staff training lacked specific training dates, only listing the year.
Citations (3)
Applicable Health and Safety Laws - Staff were routinely not wearing facemasks while in the nursing station, posing an infection control and sanitation issue related to COVID-19.
Training Record - The home's record of direct care staff training did not include the actual date of training, only the year.
Sanitary Conditions - Direct care and nursing staff were routinely not wearing facemasks in the nursing station, posing an infection control and sanitation issue related to COVID-19.
Report Facts
Residents Served: 31
Total Daily Staff: 31
Waking Staff: 23
Notice — Feb 27, 2020
Date: Feb 27, 2020
Visit Reason
The document serves to notify Masonic Village at Lafayette Hill of a granted waiver related to admission, resident medical evaluation, and preadmission screening under Pennsylvania Code 2600 regulations.
Findings
The waiver is granted with conditions including use of specific documentation forms and is subject to annual review during the facility's annual inspection to ensure compliance.
Notice — Sep 18, 2019
Date: Sep 18, 2019
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home, Masonic Village of Lafayette Hill, confirming compliance and outlining the requirement for annual onsite inspections.
Findings
The Department has approved the renewal application and issued a regular license. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable laws and regulations.
Inspection Report — Jun 12, 2019
Renewal
Date: Jun 12, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an annual inspection on June 12 and 13, 2019, as part of the renewal process for the Personal Care Home license of Masonic Village of Lafayette Hill.
Findings
Violations of 55 Pa. Code Chapter 2600 were found related to emergency evacuation diagrams, fire drill exit routes, medical evaluations, glucometer calibration, medication administration, and follow prescriber’s orders. Plans of correction were submitted addressing these issues with partial implementation noted.
Citations (6)
Regulation 123c: Emergency evacuation diagrams were not posted on the second floor of the Personal Care Home serving 37 residents.
Regulation 132f: The home used the same exit routes #1 and #4 during fire drills from 12/2018 to 04/2019, limiting exit route variety.
Regulation 141a: The medical evaluation for resident #1 admitted 11/27/2017 was completed late on 06/13/2017, not within 60 days of admission.
Regulation 185a: On 06/13/2019, the glucometer for resident #2 was not calibrated to the correct date and time.
Regulation 186b: On 03/30/2019, resident #3 was administered medications prescribed for resident #4, indicating improper medication use.
Regulation 187d: Resident #5 was not administered prescribed medications on 06/10/2019 because medications were not available in the home.
Report Facts
Inspection Dates: 2
Residents Served: 37
Staffing Hours: 37
Waking Staff: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terrie Gulliver | NHA | Signed multiple plans of correction as Legal Entity Representative and Personal Care Administrator |
Notice — Sep 19, 2018
Date: Sep 19, 2018
Visit Reason
This document serves as a renewal notice and license issuance for the Masonic Village of Lafayette Hill Personal Care Home, confirming the facility's compliance and renewal application as of September 19, 2018.
Findings
The Department of Human Services has approved the renewal application and issued a regular license for the facility. The Department will conduct an onsite annual inspection within the next twelve months as required by state code.
Inspection Report — May 21, 2018
Renewal
Date: May 21, 2018
Visit Reason
The inspection was a renewal inspection conducted by the Department of Human Services Bureau of Human Services Licensing on May 21 and May 23, 2018, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations of the Personal Care Homes regulations were found, including failure to develop a plan of supervision for alleged abuse, incomplete resident contracts, missing resident rights signatures, privacy violations, inadequate staff training, fire safety training deficiencies, temperature control issues, and medication administration record discrepancies.
Citations (16)
Regulation 55 Pa.Code 2600.15(b): The home failed to develop and implement a plan of supervision or suspend staff person B after an allegation of abuse involving residents #4, #5, and #6.
Regulation 55 Pa.Code 2600.16(c): The home failed to notify the Department regarding the allegation of abuse involving residents #4, #5, and #6.
Regulation 55 Pa.Code 2600.25(b): The contracts for residents #1 and #2 were not signed by the residents.
Regulation 55 Pa.Code 2600.41(e): Resident #1 and #2 records did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
Regulation 55 Pa.Code 2600.42(s): Staff person B entered resident #5's room without knocking, violating resident privacy.
Regulation 55 Pa.Code 2600.65(e): Direct care staff person A received only 7 hours of annual training instead of the required 12 hours in 2017.
Regulation 55 Pa.Code 2600.65(g): Direct care staff persons C and D did not receive required fire safety and Older Adult Protective Services training during 2017.
Regulation 55 Pa.Code 2600.89(b): The water temperature in bedroom 2112 measured 123.4°F, exceeding the maximum allowed 120°F.
Regulation 55 Pa.Code 2600.103(f): The produce refrigerator, walk-in freezer, and bakery freezer did not maintain required temperatures but were repaired and monitored.
Regulation 55 Pa.Code 2600.105(g)(1): Lint accumulation was found in the lint traps of three commercial dryers; lint was removed during inspection.
Regulation 55 Pa.Code 2600.105(g)(2): The home failed to provide documentation of maintenance and cleaning of the ductwork for clothes dryers as required.
Regulation 55 Pa.Code 2600.107(d): The home's written emergency procedures were last updated on 11/9/16 and require annual review and update.
Regulation 55 Pa.Code 2600.184(a): The medication label for resident #1 did not match the medication administration record or physician order.
Regulation 55 Pa.Code 2600.187(a): The home failed to document administration of morning medications for residents #1, #2, and #3 on 5/4/18 due to electronic medical record downtime.
Regulation 55 Pa.Code 2600.191: Residents #1 and #2 were not educated on their right to refuse medication, and did not sign forms acknowledging this right.
Regulation 55 Pa.Code 2600.224(a): Residents #1 and #3 did not have completed pre-admission screening forms documenting determination of service needs.
Report Facts
Number of Residents Served: 37
Total Daily Staff: 37
Waking Staff: 28
Hot water temperature: 123.4
Annual training hours: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hartnett | Administrator | Named in facility header |
| Sabrina Freeman | Department Representative | Conducted inspection on May 21 and May 23, 2018 |
Inspection Report — Sep 19, 2017
Renewal
Date: Sep 19, 2017
Visit Reason
The document is a renewal license issued in response to the facility's renewal application to operate a Personal Care Home. The Department advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal certificate and notification letter confirming the issuance of a regular license.
Report Facts
Inspection Report — Nov 9, 2016
Renewal
Date: Nov 9, 2016
Visit Reason
The inspection was conducted as part of the annual licensing renewal of the Masonic Village of Lafayette Hill Personal Care Home.
Findings
Violations related to fire safety evacuation times, medication management, and adherence to prescriber directions were identified. Plans of correction were submitted to address these issues with ongoing monitoring and re-education.
Citations (3)
Regulation 2600.132(d) requires residents to be evacuated within the fire safety expert's specified time. The home's fire drill evacuation time exceeded the suggested 8 minutes on 08/25/16.
Regulation 2600.183(d) restricts only current prescriptions, OTC, sample, and CAM medications in the home. A discontinued medication was found in the medication cart during the 11/09/16 inspection.
Regulation 2600.187(d) requires the home to follow prescriber directions. Accu-checks were performed outside prescriber orders on 05/10/16, 11/06/16, and 11/08/16.
Report Facts
Number of Residents Served: 39
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Weaver | Assistant Executive Director | Signed as Legal Entity Representative on all Plan of Correction pages. |
| Donna Hartnell | Administrator | Named as Administrator in facility header on page 2. |
Notice — Sep 21, 2016
Date: Sep 21, 2016
Visit Reason
The document is a renewal notification letter confirming receipt of the renewal application and informing the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and outlines the Department's inspection requirements.
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