Masonic Village at Lafayette Hill

Inspectors wroteBased on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure safety interventions for falls were in place for one of three residents reviewed (Resident R21).

Inspectors wroteBased on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food stored in the refrigerator and freezer was stored by professional standards for food service safety. Findings Include:The facility policy titled Production, Purchasing, Storage - Food and Supply Storage Procedure, last revised in January 2024, states: All food, non-food items, and supplies used in food preparation shall be stored in such a manner as to prevent contamination and to maintain the safety and wholesomeness of the food for human consumption. Under the procedures section, it further specifies: Most, but not all, products contain an expiration date. The words 'sell-by,' 'best-by,' 'enjoy-by,' or 'use-by' should precede the date. The 'sell-by' date is the last date that food can be sold or consumed; [...]

Inspectors wroteBased on the Resident Council meeting and interviews with residents and staff, it was determined that the facility failed to ensure the grievance process was posted in a location visible and understandable to residents, grievance forms were not readily available for residents to complete for 7 out of 7 residents reviewed (Residents R26, R18, R39, R30, R42, R14 and R23). During the Resident Council meeting held on July 15, 2025, at 1:30 PM, seven alert and oriented residents (R26, R18, R39, R30, R42, R14, and R23) indicated that they were unaware of how to file a grievance if they had a concern. When Resident R26 was asked if she knew the grievance procedure, she responded that she would talk to the receptionist. An interview with Employee E1, the Administrator, on July 17, 2025, at 10:03 AM, confirmed that E1 serves as the facility's grievance officer. [...]

Inspectors wroteNumber of residents sampled:13Number of residents cited:1 Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of a facility-initiated transfer and the reason for the move in writing and in a language and manner they understand for one of 13 residents reviewed for hospitalization. (Resident R54)

Inspectors wroteNumber of residents sampled:13Number of residents cited:1Based on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for one of 13 residents reviewed (Residents R3).

Inspectors wroteBased on observations, interviews and review of clinical records, it was determined that the facility failed to ensure that the resident's environment was free of accidents and hazards for a cognitively impaired resident with a history of utilizing razors unsupervised and resulting in a skin abrasion for 1 out of 13 residents reviewed (Resident R8).

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to ensure that a resident's weights, were completed in a timely manner for 1 out of 13 residents (Resident R4).

Inspectors wroteNumber of residents sampled:13Number of residents cited:1Based on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to provide pain management in accordance with professional standards for one of 13 residents reviewed (Resident R7).

Inspectors wroteNumber of residents sampled:1Number of residents cited:1Facility did provide dialysis site was assessed accord to PSP. Based on clinical record review, observations, policy review and staff interview, it was determined the facility failed to monitor residents' dialysis (hemodialysis/ a process of removing waste products and excess water from the body) site for a resident receiving hemodialysis for one of one resident on dialysis (Residents 40).

Inspectors wroteBased observations and staff interviews, it was determined that facility did not ensure that opened medications were properly labeled and stored with the date that the medication was opened for one of three medication carts reviewed and two of two medication room reviewed. (Wisteria medication cart on the Healthcare unit). Findings Include:Observation of medication administration conducted by Licensed Nurse, Employee E10, on July 16, 2025, at 9:53 a.m. revealed that Resident R55 was waiting to receive her medication by the Wisteria medication cart on the nursing care unit. Employee E10 finished preparing the medication and entered Resident R55's room, leaving the resident sitting in the hallway by the medication cart. Employee E10 placed all of Resident R55's medications on a tray located by the window inside the resident's room and then left the room to get the resident. [...]

Inspectors wroteBased on review of facility documents, resident interviews, meal tray observations and staff interviews, it was determined that the facility failed to provide a safe temperature meal during lunch for one of one meal observation. Findings Include:The facility policy titled, MV [NAME] Hill Hot Liquids/lids Procedures- for dining rooms (dietary) staff last revised January 2024, stated temperatures for all Hot liquids coming from the kitchen must be below (150 degrees)served all hot liquids with lids on cups. On July 15, 2025, at 12:10 p.m., observations were conducted in the main dining room, where approximately 15 residents were eating lunch and dietary aides were serving lunch to them, starting with pouring pea soup. [...]

Inspectors wroteBased on review of facility documentation, review of clinical record, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance resulting in a fall for one of two residents reviewed for falls (Resident R16). Findings Include: Review of Resident R16's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 7, 2024, revealed the resident was cognitively intact had diagnoses of hemiplegia or hemiparesis and muscle weakness. Continued review of Resident R16's MDS Section GG - Functional Abilities and Goals revealed the resident had impairment on one side of the upper and lower extremity. [...]

Inspectors wroteBased on observation, facility documentation, facility policy review and staff interview, it was determined that the facility failed to store and label drug according to professional standards of practice on one of one medication room. (Second Floor)

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to ensure proper infection control practices were followed during medication pass between two resident and by implementing proper use of personal protective equipment (PPE) when practicing enhanced barrier precautions during care for three of 12 residents reviewed. (Resident R32, R42 and R5)

Inspectors wroteBased on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to maintain proper infection control practices to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents reviewed. (Resident R1) Findings Include: Review of the facility policy titled, Infection Transmission Prevention and Interventions undated states The facility has established and will maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. iii. Droplet precautions 1. [...]