Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Masonic Village At Lafayette Hill during CMS and state inspections, most recent first.
Surveyors found that food items in storage areas were not consistently labeled, dated, or discarded according to facility policy, with multiple items in the freezer, refrigerator, and dry storage either expired, unlabeled, or uncovered. An unattended tray of produce was also observed outside the dining kitchen.
The facility did not ensure the grievance process was visibly posted or understandable to residents, and grievance forms were not readily available. Multiple alert and oriented residents were unaware of how to file a grievance, and the posted procedure lacked a contact name and was not accessible to wheelchair users. Leadership confirmed the absence of postings and forms in common areas.
A resident who was transferred to the hospital after a fall did not receive written notice of the facility's bed-hold policy or the reason for the transfer in a language and manner understood by the resident and their representative. Staff confirmed that these notifications were not provided and that no system was in place to ensure this requirement was met.
A resident and their representative were not provided with a written summary of the baseline care plan, including physician orders, dietary orders, and social service goals, within 48 hours of admission. Review of records and staff interviews confirmed the absence of documentation showing that the required information was given.
A cognitively impaired resident with a history of using razors unsupervised was found with multiple razors accessible in her room, resulting in a skin abrasion after self-shaving. Despite the resident's known cognitive deficits and prior incident, staff observed razors in her wheelchair and bathroom, and an electric razor on the counter, indicating the environment was not kept free from accident hazards.
A resident with multiple medical conditions experienced significant weight loss, and the facility did not obtain a timely re-weight to confirm the loss as required by policy. The delay in re-weighing meant that necessary interventions to address the resident's nutritional status were not implemented promptly.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
A resident receiving hemodialysis through a left arm AV fistula was not consistently monitored or assessed for complications as required by facility policy and care plan. There was no documentation of regular checks for bruit and thrill, nor was there a physician order for these assessments, as confirmed by the Infection Control Nurse.
A nurse left six medications unattended in a resident's room while retrieving the resident, with another resident present in the room. Additionally, two opened bottles of medication on a medication cart were not labeled with open dates, contrary to facility policy. Both the nurse and DON confirmed the labeling deficiency.
Dietary staff served hot soup to residents at temperatures above facility policy and safe guidelines, failing to check or allow the soup to cool before serving. Some residents, including those with cognitive and visual impairments, received the hot soup, and several alert residents reported the soup was too hot to consume immediately.
A resident with a history of falls and left-sided weakness fell after being left unassisted by a nurse and a friend while attempting to adjust a wheelchair seatbelt. The resident required hands-on assistance due to impulsivity and poor balance, which was not provided, leading to the fall.
A facility failed to store and label medications properly in a second-floor medication room. An unlocked refrigerator contained vaccines, insulin, and lorazepam, with some boxes unsecured and lacking proper labeling. Staff interviews confirmed that narcotics should be locked, but the facility did not adhere to this policy.
The facility failed to follow infection control practices during medication administration and enhanced barrier precautions. An LPN did not perform hand hygiene between administering medications to two residents. Additionally, two nursing assistants did not wear gowns while providing care to a resident under enhanced barrier precautions, despite the requirement. The facility's policies on infection prevention and control were not adhered to, leading to these deficiencies.
A facility failed to adhere to infection control practices for droplet precautions, as staff entered a resident's room without proper PPE. Despite signage and available PPE, a phlebotomist and a nurse practitioner did not follow the required protocols. The resident was on isolation due to respiratory issues, and the facility could not prove that staff were informed of the precautions, leading to a deficiency in infection control.
Failure to Properly Label, Date, and Discard Food Items
Penalty
Summary
The facility failed to ensure that food stored in the refrigerator, freezer, and dry storage areas was labeled, dated, and stored according to professional food service safety standards and the facility's own policies. During an inspection of the Food Service Department, multiple items were found in the walk-in freezer and refrigerator that were either opened and not labeled, not covered, or past their expiration dates. Specific examples included opened chicken nuggets, pureed and regular steak, beef burgers, and frozen bisques in the freezer, as well as opened cauliflower, celery, carrots, cheese, coleslaw, and chopped tomatoes in the refrigerator, many of which were not labeled or had expired. In the refrigerator for premade items, chicken salad, turkey cold cuts, ham, imitation crab meat, and defrosted turkey were found to be expired, and some baked goods were not labeled. In the dry storage area, opened rice, bowtie pasta, and dye/frosting food coloring were not labeled, while Israeli couscous, cooked apples, and sprinkles were found to be expired. Additionally, whipping cream was not labeled. An unattended rolling tray with full-sized romaine lettuce and cucumbers was also found outside the dining kitchen. These findings indicate that the facility did not follow its own policies regarding the labeling, dating, and rotation of food items, nor did it ensure that expired or potentially unsafe food was discarded in a timely manner.
Failure to Post and Provide Accessible Grievance Process and Forms
Penalty
Summary
The facility failed to ensure that the grievance process was clearly posted in a location visible and understandable to residents, and that grievance forms were readily available for residents to complete. During a Resident Council meeting, seven alert and oriented residents reported being unaware of how to file a grievance if they had a concern. One resident stated she would speak to the receptionist, indicating a lack of knowledge about the formal grievance procedure. An interview with the Administrator confirmed that they served as the grievance officer, but there was no posting in the building to communicate this to residents. Observations with facility leadership confirmed that no information related to grievance forms or a contact person for grievances was available in the areas where information is typically posted. There was also no dedicated place for residents to confidentially pick up a grievance form, and the general grievance procedure that was posted lacked a contact name and was not accessible to residents in wheelchairs.
Failure to Provide Written Bed-Hold Policy and Transfer Reason at Hospitalization
Penalty
Summary
A review of the clinical record and staff interviews revealed that the facility failed to provide a resident and their representative with written notice of the facility's bed-hold policy at the time of a facility-initiated transfer to the hospital. Specifically, after the resident experienced a fall and was transferred to the emergency room for evaluation, there was no documented evidence that the required written notice regarding the bed-hold policy—including information about the duration of the bed-hold, bed hold reserve payment, and the right to return to a bed at the facility—was given to the resident or their representative. Additionally, the clinical record lacked documentation that the resident and their representative were provided with the reason for the transfer in writing and in a language and manner they could understand. An interview with the social worker confirmed that these notifications were not provided and that there was no system in place to ensure compliance with these requirements at the time of a facility-initiated transfer.
Failure to Provide Baseline Care Plan Summary Upon Admission
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to a resident and/or the resident's representative within 48 hours of admission. Review of the clinical record showed that the resident was admitted on May 30, 2025, but there was no documented evidence that the baseline care plan, including physician orders, dietary orders, and social service goals, was given to the resident or their representative. The resident's representative confirmed in an interview that they did not receive a copy of the baseline care plan after admission. Further requests for documentation from facility staff, including the Infection Control Nurse and the Director of Nursing, did not yield any evidence that the required summary was provided.
Failure to Prevent Accident Hazards for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with multiple diagnoses, including dementia, encephalopathy, and depression, was found to have unsupervised access to razors in her room. The resident had a documented history of using her husband's razor without supervision, which resulted in a skin abrasion on her left jaw. Clinical records and nursing notes confirmed that the resident admitted to using the razor and sustained an abrasion as a result. The facility's incident report corroborated these findings. During a subsequent observation, a blue razor without a protective top was found in the resident's wheelchair, and another blue razor was discovered in the bathroom cabinet. An electric razor belonging to the resident's husband was also observed plugged in on the bathroom counter. A licensed nurse removed the razors from the room and informed the resident that she should not have them. The facility failed to ensure that the resident's environment was free from accident hazards, as required by regulations, by allowing a cognitively impaired resident unsupervised access to razors.
Delayed Re-Weight Following Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident's weights were completed in a timely manner, as required for monitoring nutritional status and care planning. A resident with multiple diagnoses, including dysphagia, cerebral infarction, hypertension, diabetes, glaucoma, and dementia, experienced a significant weight loss of 8.4 pounds, or 6.3%, over the course of one month. The initial weight loss was identified when a weight was recorded, but the facility did not obtain a re-weight promptly to confirm the loss and address any related issues. According to the facility's policy, re-weights should be obtained within 7 days of the previous weight when significant weight loss is suspected. However, in this case, the re-weight was not completed until 6 days after the initial suspected weight loss, confirming the significant loss. This delay in obtaining a timely re-weight meant that interventions or services to address the resident's nutritional status were not implemented as quickly as required by policy.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Monitor and Document Dialysis Access Site Care
Penalty
Summary
The facility failed to consistently monitor and document the care of a resident receiving hemodialysis through a left arm arteriovenous (AV) fistula. According to the facility's policy, licensed nurses are required to maintain the patency of the access area, monitor for signs of infection or complications, and check for bruit and thrill every shift, documenting these assessments in the resident's electronic health record. The care plan for the resident also specified the need to assess for bruit and thrill and monitor for symptoms such as pain, numbness, redness, swelling, warmth, exudate, and tenderness at the fistula site. However, a review of the resident's clinical and treatment administration records revealed no documented evidence that these required assessments were being performed consistently. Additionally, there was no physician order in place for staff to check bruit and thrill or to assess the AV fistula site. This was confirmed by the Infection Control Nurse, who stated that staff were expected to complete and document these checks every shift, but this was not being done for the resident in question.
Failure to Properly Label and Secure Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were properly labeled and stored according to accepted professional standards. During medication administration, a licensed nurse prepared medications for a resident and left them unattended on a tray inside the resident's room while retrieving the resident, leaving both the medications and the resident's roommate unsupervised in the room. This resulted in six medications being left unattended for approximately one minute. Additionally, inspection of the Wisteria medication cart revealed two opened bottles of medication, Fluticasone Propionate and Salmeterol, that were not labeled with the date they were opened. One bottle was marked with an arrival date that exceeded the facility's 30-day discard policy, while the other was still within the acceptable timeframe. Both the nurse and the Director of Nursing confirmed that the bottles were not labeled with open dates, as required by facility policy.
Hot Liquids Served Above Safe Temperatures
Penalty
Summary
During a lunch meal observation, dietary staff served hot pea soup to residents at temperatures exceeding the facility's policy and stated safe serving guidelines. The facility's policy required hot liquids to be served below 150°F, and the Dietary Director confirmed the preferred serving temperature was 140°F or below. However, the soup was measured at 159°F when served. Dietary aides were observed pouring and serving the soup directly to residents without allowing it to cool or checking the temperature, despite being trained to do so. One aide admitted to not checking the temperature due to being preoccupied, and another only checked after being prompted by the Dietary Director. Training on serving hot liquids had not been provided to one aide for two years. Multiple residents, including those who were not alert and oriented and one who was legally blind, received the hot soup. During a Resident Council meeting, several alert and oriented residents reported that the soup was very hot, with some needing to wait for it to cool or using ice cubes to lower the temperature. The Dietary Director later confirmed that hot liquids were not served at the preferred temperatures, in violation of facility policy and state regulations.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance, resulting in a fall for Resident R16, who was at risk for falls due to a cerebrovascular accident with left-sided weakness and a history of falls. The resident's care plan included the use of a seatbelt on the wheelchair due to poor trunk control and spasticity. On the day of the incident, a licensed nurse, Employee E9, noticed that the resident's seatbelt was not fastened and asked the resident to stand up to adjust it. The resident stood up with the aid of a stand-up walker but was left unassisted when the nurse and the resident's friend attempted to retrieve the stuck seatbelt, leading to the resident falling sideways and hitting his head on the wall. Interviews with facility staff confirmed that Resident R16 was not safe to stand unassisted, as the resident was impulsive and required hands-on contact guard assistance. The Director of Therapy, Employee E10, confirmed the resident's need for assistance, while the Director of Nursing, Employee E2, stated that having the resident's friend assist was inappropriate as the friend was not trained by the facility. This lack of proper supervision and assistance directly contributed to the resident's fall.
Failure to Secure and Label Medications Properly
Penalty
Summary
The facility failed to store and label drugs according to professional standards of practice in the medication room on the second floor. During an observation, it was found that the medication refrigerator, which was supposed to be locked at all times, was unlocked. This refrigerator contained vaccines, insulin, and other medications requiring low temperatures, including four boxes of lorazepam. One box was labeled with a resident's name and dosage information, while another was in a see-through locked box without a resident name or prescription. Two unopened boxes of lorazepam were found unsecured on a shelf, accessible to anyone in the medication room. Interviews with staff revealed that the box with the resident's name was recorded in the narcotic book on the medication cart, while the other boxes were considered pharmacy extras. According to the licensed nurse, all narcotics in the medication refrigerator should be in a locked box, with access to the key controlled through the pyxis system by a supervisor. The Director of Nursing confirmed that the lorazepam boxes should have been secured in a locked box, indicating a failure to adhere to the facility's medication storage policy.
Infection Control Deficiencies in Medication Administration and Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration and while implementing enhanced barrier precautions. During an observation, a licensed nurse, Employee E8, was seen administering medication to two residents in the hallway without performing hand hygiene between the residents. Despite the presence of a hand sanitizer on the wall, Employee E8 did not use it and later denied the observation when questioned by the Director of Nursing. Additionally, the facility did not follow enhanced barrier precautions for a resident under such precautions. Resident R5, who had a urinary catheter and required maximal assistance for activities of daily living, was observed receiving care from two nursing assistants, Employees E6 and E5, who wore gloves but did not don gowns as required. The sign indicating enhanced barrier precautions was mistakenly left on the door, according to Employee E5, but the Infection Preventionist confirmed that the resident was indeed under these precautions. The facility's policies on infection prevention and control, hand hygiene, and infection transmission prevention were not followed, leading to these deficiencies. The failure to perform hand hygiene and to use appropriate personal protective equipment during care activities for residents under enhanced barrier precautions were the main issues identified during the survey.
Inadequate Infection Control Practices for Droplet Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices, specifically regarding droplet precautions, for a resident identified as R1. The facility's policy on infection transmission prevention and interventions was not adequately followed, as evidenced by observations of staff entering Resident R1's room without appropriate personal protective equipment (PPE). Despite signage indicating droplet precautions and the availability of PPE outside the resident's room, a contracted phlebotomist and a nurse practitioner entered the room without wearing the necessary protective gear. Resident R1, who was admitted with multiple diagnoses including acute respiratory failure and cognitive communication deficit, was placed on isolation and droplet precautions due to wheezing and the possibility of infection. During the observations, it was noted that the phlebotomist initially entered the room with only a mask and later had to search for additional PPE. The nurse practitioner entered the room without any PPE, citing unawareness of the droplet precautions. These actions were contrary to the facility's infection control policy, which mandates the use of masks, face shields, and gloves for staff entering rooms under droplet precautions. Interviews with the Director of Nursing and other staff confirmed that all personnel should adhere to PPE protocols when entering rooms with droplet precautions. However, the facility could not provide evidence that the nurse practitioner and phlebotomist were informed of Resident R1's precautionary status before their contact with the resident. This oversight contributed to the deficiency in maintaining a safe and sanitary environment to prevent the transmission of communicable diseases.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Nursing homes near Lafayette Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowview Rehabilitation And Nursing Center | 0.1 mi | ★★★★★ | 11 | 0 |
| Cathedral Village | 1.1 mi | ★★★★★ | 4 | 0 |
| Health Center At The Hill At Whitemarsh, The | 1.6 mi | ★★★★★ | 0 | 0 |
| Saint Joseph Villa | 2.1 mi | ★★★★★ | 0 | 0 |
| Fairview Rehab And Care Center | 2.1 mi | ★★★★★ | 35 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.