Masonic Village At Lafayette Hill

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; do not sell products in the retail area or place them on patient trays/resident plates past the date on the product. Food past the 'use-by,' 'sell-by,' 'best-by,' or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. However, there was no posting in the building available to communicate to the residents of this. Grievance forms were not available on the nursing unit nor in the building for residents to file a grievance. Observation of the wall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number 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)Findings include:Review of nursing note for Resident R54, dated May 3, 2025, revealed that Resident R54 was transferred to hospital emergency room for evaluation after a fall.Review of Resident R54's clinical record revealed that there was no documented evidence that the resident and his representative were provided with a written notice of the facility bed-hold policy at the time of Resident R54's facility-initiated transfer to the hospital.Further review of Resident R54's clinical record revealed that there was no documented evidence that the resident and his representative were provided the reason for the move in writing and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number 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).Findings include:Review of Resident R3's clinical record revealed that the resident was admitted to facility on May 30, 2025.Interview with Resident R3's representative on July 14, 2025, stated the facility did not provide a copy of the baseline care plan after the admission.Review of the clinical record revealed no documented evidence that resident and/or the resident's representative received a written summary of the baseline care plan including physician orders, dietary orders and social service goals.Further review of the care plan revealed no documented evidence that the resident representative received a written summary of the baseline care plan.A request was made to the Infection Control Nurse on July 17, 2025, for the evidence that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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). Findings include: Review of the July 2024 physician orders for the resident included the following diagnosis: arthritis (inflammation of the joints); dependence on wheelchair; chronic obstruction pulmonary disorder (COPD-a term for a group of progressive lung and airway diseases that cause breathing difficulties); dementia (a general term for a decline in cognitive function that affects daily life, including memory, reasoning and language skills); encephalopathy (a broad term for any disease or disorder that affects the brain function or structure); cognitive communication deficit (difficulties in communication that arise from impaired cognitive functions such as attention, memory, reasoning and problem solving); depression (a mood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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).Findings include:Review of the undated policy, Monitoring Resident Weight Change, indicated that accurate weight measurements are essential for assessing nutritional status, calculating doses of drugs, indicating fluid status, accurate minimum data set documentation (MDS- a periodic assessment of a resident's needs), and care planning. Review of the July 2025 physician orders for Resident R4 included the following diagnosis: dysphagia (difficulty swallowing); cerebral infarction (a stroke); hypertension (high blood pressure); diabetes (a group of diseases that affect how the body uses blood sugars); glaucoma (a group of eye diseases that cause vision, loss and blindness), and dementia (a general term for a decline in cognitive function that affects daily life, including memory, reasoning and language skills).Review of a note from the clinical dietician (Employee E9) dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number 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).Findings include:Review of an undated facility policy Pain Assessment & Management Record Procedure, revealed that Integrative Pain Care and Alternative Interventions - To be used and documented in conjunction with oral medications. The following integrative pain interventions may be documented in the electronic chatting system and on the eMAR (electronic Medication Administration Record) with PRN (as needed) Medication Administration. Alternate interventions will also be documented in the IDPN (interdisciplinary progress notes) as needed.1. Positioning/rest2. Compassionate touch/massage3. Cold4. Heat5. Distraction/humor/activity6. Music7. Aromatherapy8. Spirituality/prayer9. Healing touch10. One on one11. Quiet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number 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).Findings include:Review of an undated facility policy Managing Residents Receiving Hemodialysis, revealed, Masonic Village licensed nurses will provide clinical monitoring and care for theresident which includes:1. Maintaining patency of and caring for the access areaa. Fistula or graft(1) Wash the antibacterial soap each day, and always before dialysis. Discourage the resident from scratching at skin or picking scabs that may form.(2) Monitor for redness, a feeling of excess warmth, or the beginning of a pustule on the access area.(3) Check bruit and thrill every shift and document in the resident's EHR.(4) Do not use arm with dialysis access…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. A total of six medications were left unattended from 9:53 a.m. to 9:54 a.m. Resident R55 had a roommate, Resident R34 who was awake and sitting in a wheelchair near the closet inside the room.Observation of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Dietary Aide, Employee E6, was observed pouring pea soup into three different bowls and directly taking them to three residents (R19, R25, R46) without allowing them to cool off.The surveyor asked, What is the serving temperature for hot liquids? It was revealed by the Dietary Director, Employee E5,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Review of Resident R16's comprehensive care plan dated February 7, 2024, revealed the resident was at risks for falls related to Cerebrovascular Accident (CVA - an obstruction or bleed from a blood vessel of the brain causing brain damage) with left-sided weakness, ataxia (a condition that affects muscle coordination and can cause clumsy movements and balance problems)/spastic movements and history…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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) Findings include: Review of facility policy provided, titled Medication Storage from the Department of Health and Human Services, Centers for Medicare, and Medicaid Services, revealed medications and biologicals that are stored in medication rooms, carts, boxes, and refrigerators will be maintained within secured locks and accessible only to designated staff. A sufficient detailed record of receipt and disposition of controlled medications are to be maintained to enable an accurate reconciliation. Review of the medication Lorazepam's insert revealed risks of use with opioids including Lorazapam may result in profound sedation, respiratory depression, coma, and death. Lorazepam has a potential for abuse and may lead to dependence. Observation of the only medication room shared within three nursing units on the facility second floor on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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) Findings include: Review of facility policy titled Infection Prevention and Control revealed that in accordance with state and federal guidance the facility has established and will maintain, and 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 this policy defines our overarching infection prevention and control program. Further review of this policy revealed hand hygiene a general term that applies to washing hands with water or thoroughly applying an alcohol-based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. These precautions protect staff, visitors, and other residents from droplets that are expelled during coughing, sneezing, or talking. 2. Masks are to be worn when working in close proximity to the resident. 3. Specific guidelines may be needed during the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.