Masonic Village at Warminster

In the surveyor’s words

From the most serious findings on record at Masonic Village at Warminster, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF755Aug 20, 2026

  Based on facility policy review, facility documentation review, and staff interview, it was determined that the facility failed to maintain complete and accurate reconciliation records to ensure the prevention of diversion of controlled substances on one of three medication carts. (East Unit) Findings include:Review of the facility policy entitled, Controlled Medication Orders, last reviewed March 17, 2026, revealed that when coming on duty, going off duty, taking over or releasing a medication cart, two licensed nurses will do a complete controlled medication count. Both nurses were to sign the controlled medication count sheet. Signatures confirmed that the count was done thoroughly and that the licensed nurse verified the count was accurate. […]

• No harm, potential for more than minimal, isolatedF607Aug 20, 2026

  Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to complete a reference check and verify a professional license/registration status prior to the start of employment for one of five newly hired employees. (Employee 2)Findings include:A review of the facility policy entitled, Abuse Prevention, dated May 3, 2026, revealed that the facility was to conduct screenings for all potential hires. This included reference checks and license/registration verification. Employee 2 (E2) had been working in the facility as a licensed practical nurse since June 10, 2026, and a reference check was not completed until July 8, 2026. […]

• No harm, potential for more than minimal, isolatedF806Dec 30, 2025

  Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to accommodate resident food allergies for one of six sampled residents. (Resident 1)Findings include:Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included dementia and depression. On October 3, 2024, it was noted in the resident's ongoing plan of care and admission documentation that she was allergic to pineapple. The Minimum Data Set assessment dated [DATE], revealed the resident had severe cognitive impairment and required set-up assistance from staff for feeding. The posted menu for December 21, 2025, listed Hawaiian Ham (ham with pineapple sauce) for the main entree. […]

• No harm, potential for more than minimal, isolatedF610Aug 25, 2022

  Based on clinical record review, facility policy review, incident report review, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 12 sampled residents. (Resident 14) Findings include: Review of the facility policy entitled, Abuse Prevention, dated June 15, 2022, revealed that procedures were in place to assure adequate review of all incidents, accidents, and suspicious bruising or injuries of unknown origin. Occurrences were reviewed for trends or patterns that might constitute abuse. An investigation was to begin immediately by interviewing the resident who was suspected of being abused and any witnesses. Clinical record review revealed that Resident 14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF758Aug 25, 2022

  Based on clinical record review, review of consultant pharmacist reports, and staff interview, it was determined that the facility failed to document the rationale for the continued use of an as needed (PRN) anti-anxiety medication for one of 12 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included anxiety. The physician ordered an anti-anxiety medication ([MEDICATION(S)]) every 12 hours PRN for anxiety January 19, 2022, through June 15, 2022, and June 15, 2022, through July 19, 2022. Review of Resident 1's medication administration record revealed that staff adminstered the PRN anti-anxiety medication on April 2 and 10, May 6 and 25, and June 29, 2022. […]