Cycle 1
Health 2025-07-17 · Fire 2025-07-17
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Lafayette Hill, PA
Masonic Village At Lafayette Hill
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
801 Ridge Pike, Lafayette Hill, PA
(610) 825-6100
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
49
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.11
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.91
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.92
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.35
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.16
CMS adjusted RN staffing hours
Adjusted total hours
5.16
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,086
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9994
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.41
Baseline 18.80% · Performance 20.32% · Measure score 2.41 · Achievement 2.41 · Improvement 0
Healthcare-associated infections
5.01
Baseline 6.92% · Performance 6.34% · Measure score 5.01 · Achievement 5.01 · Improvement 2.52
Total nurse turnover
6.41
Baseline 34.92% · Performance 37.50% · Measure score 6.41 · Achievement 6.41 · Improvement 0
Adjusted total nurse staffing
4.62
Baseline 4 hours · Performance 4.39 hours · Measure score 4.62 · Achievement 4.62 · Improvement 1.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.45% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 5.17% · Lower 95% interval 6.49% |
| Discharge to community | 34.33% |
50.57%
16.2 pts worse
|
Worse than the National Rate · Eligible stays 49 · Observed rate 22.45% · Lower 95% interval 22.61% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 87.8% |
95.27%
7.5 pts worse
|
Numerator 36 · Denominator 41 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 41 |
| Discharge self-care score | 28.57% |
53.69%
25.1 pts worse
|
Numerator 10 · Denominator 35 |
| Discharge mobility score | 25.71% |
50.94%
25.2 pts worse
|
Numerator 9 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 4.88% |
2.29%
2.6 pts worse
|
Numerator 2 · Denominator 41 · Adjusted rate 3.91% |
| Healthcare-associated infections requiring hospitalization | 6.34% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 3.23% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 0.69% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 145 |
| Staff flu vaccination coverage | 93.48% |
42%
51.5 pts better
|
Numerator 129 · Denominator 138 |
| Discharge function score | 37.14% |
56.45%
19.3 pts worse
|
Numerator 13 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 12 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 5.6 |
1.7
3.9 pts worse
|
1.9
3.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.6 · Observed 6.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
86.9%
9.7 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 91.7% · Q3 100.0% · Q4 100.0% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.2%
2.1 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
6.5%
5.9 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
6.5%
3.5 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 3.3% · Q4 2.7% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
19.9%
About the same
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 18.4% · Q3 18.2% · Q4 21.6% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
18.7%
4.9 pts better
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 14.3% · Q3 9.4% · Q4 20.0% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 50.4% |
19.6%
30.8 pts worse
|
16.3%
34.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 57.1% · 4Q avg 50.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.5% |
18.3%
10.2 pts worse
|
14.9%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 30.3% · Q3 20.7% · Q4 26.5% · 4Q avg 28.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.1% |
1.7%
5.4 pts worse
|
1.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 11.4% · Q3 0.0% · Q4 9.1% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
26.4%
2.7 pts better
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.7% · Q2 15.3% · Q3 27.0% · Q4 22.8% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.3%
0.9 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 7.8% · Q3 2.3% · Q4 5.2% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.2% |
68.9%
7.7 pts worse
|
81.7%
20.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 66.7% · Q4 72.0% · 4Q avg 61.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
9.8%
2.3 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
23.1%
3.1 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 24.4% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-20 · Fire 2024-09-20
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-11-17 · Fire 2023-11-17
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-07-17
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-07-17
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-07-17
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-07-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-07-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-07-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-07-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-07-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-07-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-19
E · Potential for more than minimal harm
2024-09-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-09-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-01
E · Potential for more than minimal harm
2024-09-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-01
E · Potential for more than minimal harm
2024-09-20
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-12-01
F · Potential for more than minimal harm
2023-11-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-11-17
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-11-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-11-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-11-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-11-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-11-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-29
D · Potential for more than minimal harm
2024-09-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-10
Penalties and ownership
What sits behind the stars
Ownership
Masonic Villages Of The Grand Lodge Of Pennsylvania
5% Or Greater Direct Ownership Interest · Organization
Bahney, Thomas
Corporate Director · Individual
Baker, Lynn
Corporate Director · Individual
Brink, Robert
Corporate Director · Individual
Cepielik, Robert
Corporate Director · Individual
Downs, Eric
Corporate Director · Individual
Formica, Pamela
Operational/Managerial Control · Individual
Formica, Pamela
Corporate Officer · Individual
Heese, Adam
Corporate Director · Individual
Hirsch, Michael
Operational/Managerial Control · Individual
Jones, Denise
Operational/Managerial Control · Individual
Kingsbury, William
Corporate Officer · Individual
Kraus, Peter
Corporate Director · Individual
Miller, Glenn
Corporate Director · Individual
Ockovic, Todd
Corporate Director · Individual
Roup, Paul
Corporate Director · Individual
Saylor, Stanley
Corporate Director · Individual
Snyder, Robert
Corporate Director · Individual
Spence, Brenda
Corporate Director · Individual
Wheeler, Frederic
Corporate Director · Individual
Nearby options
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#3
Health Center At The Hill At Whitemarsh, The
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5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
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