Quarryville Presbyterian Retirement Community

Based on review of Resident Council meeting minutes and information provided to residents, as well as resident and staff interviews, it was determined that the facility failed to act promptly upon the grievances of the Resident Council. Findings Include: Resident Council meeting minutes for June 30, July 28 and August 25, 2025, revealed that residents brought up repeat concerns regarding food temperatures and flies in the dining room. During each meeting the residents were reminded that any dining concerns with food temperatures were to be brought to their attention immediately so they could make necessary adjustments at the time of the complaint. The residents were also reminded that there was regularly scheduled pest control visits and multiple remedies in place to control the flies as best as possible. At June's meeting they were to notify the pest control company. An interview with a group of residents on August 28, 2025, at 11:30 a.m. revealed that the food was not hot and they brought flies up three times and the facility didn't do anything about it. Pest control records for…

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 a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for four of 39 residents reviewed (Residents 3, 28, 36 and 78).Findings Include: A facility policy for psychotropic medication management dated March 31, 2025, indicated that the facility will minimize the use of psychotropic medications, avoid unnecessary drug use, and promote the use of non-pharmacological interventions whenever possible. Psychotropic medications include antipsychotics (class of drugs used to treat mental health conditions), antianxiety medications, antidepressants, and hypnotics (induce sleep and sedation). Physician’s orders for Resident 3, dated May 30, 2025, revealed that the resident was to receive 1 milligram (mg) of transdermal (application of a medicine through the skin) Ativan gel twice daily as needed for agitation. Review of Resident 3’s Medication Administration…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that ice was made and stored in sanitary ice machines for one of two ice machines (main kitchen). Findings include: The facility's policy for ice machines, dated March 31, 2025, revealed that every month the ice machines were to have the ice removed, the inside of the machine washed with sanitizing solution and a clean cloth, allowed to dry, and then refilled with ice. A third party vendor would come in quarterly and as needed to service the ice machine. A Service log, dated March 3, 2025, revealed that preventative maintenance was performed by a contracted service. There was no documented evidence that the ice machine was cleaned on a monthly basis. Observations on August 27, 2025, at 9:02 a.m. revealed that inside the ice machine there was a build up of a pink substance on the right hand corner of the white plastic piece and a build up of a black substance on the entire length of the strip at the top of the ice machine. The chest was full of ice.…

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 clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident or resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the person's mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for two of 39 residents reviewed (Residents 3 and 36).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 26, 2025, indicated that the resident was admitted to the facility on [DATE], was cognitively impaired, was rarely or never understood, had physical, verbal and other behaviors not directed towards others, took antipsychotic medications (medications used to treat psychosis and other mental and emotional conditions), antianxiety and antidepressant medications (psychotic medications), and had diagnoses that included Alzheimer's…

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 policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete nurse aide registry verification for one of three new nurse aides reviewed (Nurse Aide XX) and failed to ensure that the status of nursing licenses were checked with the State Board of Nursing for one of one newly hired nurses reviewed (Registered Nurse XX).Findings include:The facility's policy regarding abuse prohibition, dated March 31, 2025, indicated that the prior to the first day of employment, the facility would verify with the Pennsylvania Department of Health Nurse Aid Registry the standing/certification of all applicants offered employment as a nurse aide. The facility would not employ individuals who had a finding entered in the nurse aide registry or who had a disciplinary action in effect against their professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, misappropriation of their property or mistreatment of residentsThe personnel file for Nurse Aide E3 revealed that she was hired as a…

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 a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 39 residents reviewed (Residents 101). Findings include: An admission note for Resident 101, dated August 21, 2025, at 12:16 p.m., revealed that the resident arrived at the facility and had sinusitis (an inflammation of the sinuses) and was going to receive medication for three more days. A current care plan for the resident, dated August 21, 2025, indicated that the resident had an infection diagnosed as sinusitis. A progress note for Resident 101, dated August 22, 2025, at 3:01 p.m. revealed that the resident was positive for COVID and was in respiratory isolation. Observations during the facility tour on August 27, 2025, at 11:34 a.m. revealed a stop sign on Resident 101's door. Interview with staff during the tour indicated that the resident was placed on droplet precautions due to testing positive for covid on admission. There was no documented…

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 a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan for two of 39 residents reviewed (Residents 10 and 88). Findings include: A facility policy for Comprehensive Care Plans dated March 31, 2025, indicated that it is the facility’s policy that each resident receives individualized, comprehensive, and coordinated care through the development, implementation and ongoing evaluation of an interdisciplinary care plan. The development of a comprehensive care plan should occur by the interdisciplinary team following the initial Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated July 17, 2025, revealed that the resident was cognitively impaired, was usually understood and was able to sometimes understand others, required assistance with care needs, took an anticoagulant medication (used to…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 39 residents reviewed (Residents 7 and 9). Findings include: A facility policy for Comprehensive Care Plans dated March 31, 2025, indicated that the resident’s plan of care should be updated as necessary on an on-going basis. Changes will be communicated to team members as needed or indicated. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 7 dated August 4, 2025, indicated that the resident was cognitively intact, was understood, could understand, required assistance with daily care needs, and had diagnoses that included a stroke. Interview with Resident 7 on August 28, 2025, at 1:43 p.m. indicated that he currently had an indwelling catheter, and no other to have straight catheterization (single-use tube inserted into the bladder to drain urine). Physician’s order…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete safety assessments for one of 39 residents reviewed who used a electric lifting recliner chair (Resident 6) and failed to ensure that assistance devices to prevent accidents or injury were in place for one of 39 residents reviewed (Resident 15).Findings Include: A facility policy for wheelchair leg rests dated March 31, 2025, indicated that the facility would ensure and promoted safe and appropriate use of wheelchairs leg rests when transporting residents short or long distances. Wheelchair leg rests should be used when transporting residents over klong distances or when a resident is unable to lift their leg rests while the chair is in motion. Wheelchair leg rests should also be used when resident cannot or will not [NAME] their legs for short transports. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for…

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 policies and clinical records, as well as staff and resident interviews, it was determined that the facility failed to ensure that a toileting program was followed to maintain a resident's continence for one of 39 residents reviewed (Resident 24). Findings include: A facility policy related to restorative nursing programs, dated March 31, 2025, indicated that facility provides individualized restorative nursing interventions in accordance with resident needs, care plans, and regulatory requirements to promote and maintain the highest level of physical, mental and psychosocial functioning for residents. Restorative interventions may include bowel and bladder programs that consist of training and toileting schedules. Restorative programs will be carried out by trained restorative nursing assistants, nurse aides, or licensed staff as delegated. Restorative interventions, frequency, and outcomes will be documented in the medical record per facility policy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care…

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 a review of clinical records and interview with staff, it was determined that the facility failed to ensure a physician's discharge summary was completed prior to or at the time of discharge for one of two closed records (Resident 83). Findings include: Review of Resident 83's clinical record revealed that the resident was discharged from the facility on July 2, 2024. Further review of Resident 83's clinical record failed to reveal evidence that the discharge summary was completed by the physician prior to or at the time of discharge. Interview with the Nursing Home Administrator on July 10, 2024 at 10:00 a.m. confirmed that the discharge summary was not completed. 28 Pa Code 211.5(d) Clinical record

Based on observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for one of four residents reviewed (Residents 2). Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP) dated March 2024, revealed EBP will be used in the care of any residents who are at higher risk of colonization or infection with multi-drug resistant organisms (MDROs). Use of Enhanced Barrier Precautions is a strategy for improved success for infection control and to expand on standard precautions. Enhanced Barrier Precautions are designed to reduce the risk of transmission and/or colonization of MDROs from both recognized and unrecognized sources. Enhanced Barrier Precautions require gowns and gloves to be worn during any high-contact resident care…

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.