Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Quakertown Center during CMS and state inspections, most recent first.
Food Storage and Labeling Deficiencies: Surveyors observed unsanitary food storage in the dietary area and on the North unit, including dust and debris on equipment, food stored on the floor or in contact with crates and shelves, expired and undated items, and unlabeled resident foods in the pantry. The pantry also had sticky spills, food debris, ants on the counter and pitchers, and dried food debris inside the microwave; the DON confirmed several items should have been dated and removed.
Unsanitary and Damaged Resident Environment: Surveyors observed torn and stained lobby chairs, chipped and marked walls, missing floor tiles, stained hallway walls and baseboards, and multiple room issues on the North Nursing Unit, including stained floors, stained privacy curtains, holes under a bathroom sink, stained bed linens, peeling paint, debris, dust on fall mats, and a curtain missing hooks. The Administrator confirmed the environmental issues were present.
The facility failed to follow physician medication orders for two residents. One resident with hypotension received midodrine without documented BP checks before administration, and another resident with diabetes and end stage kidney disease received insulin glargine when BG was below the ordered parameter. The DON confirmed the documentation was missing and that the insulin was given outside the physician's order.
Failure to post current nurse staffing information. During a facility tour, surveyors observed that the lobby staffing sheet was outdated and dated several weeks earlier than the day of the observation.
A resident with a history of toe infection had a physician order for staff to clean both great toes and apply bacitracin ointment. On one occasion, the resident reported that the nurse did not perform this ordered treatment, and review of the Treatment Administration Record showed no documentation that the cleaning and ointment application were completed as prescribed, indicating a failure to follow physician orders for skin care.
The facility did not ensure that hot food was served at required temperatures on one nursing unit, contrary to its “Food Prep” policy that mandates hot foods be above 135°F and cold foods at or below 41°F. Several residents reported that their meals were often served cold. A test tray audit conducted after the last meal trays were delivered on the affected unit found that crunchy buttermilk chicken measured 126.5°F and green beans measured 132°F, and both items were cool to taste. The Dietary Manager acknowledged that hot foods should have been at least 135°F at the time of service, confirming noncompliance with facility policy and state regulatory requirements.
Surveyors found that the facility did not follow its own “Food Prep” policy requiring food temperatures to be recorded at the time of service and monitored during meal service. Review of the kitchen temperature logs showed no documented holding temperatures for breakfast and lunch to verify that food was maintained at safe internal temperatures. The Dietary Manager acknowledged that temperatures should have been recorded for these meals at the time of service but were not.
A resident and their representative were not provided with a reconciliation of all pre- and post-discharge medications at the time of a planned discharge. Despite a request from the representative for this information, the facility did not supply the required documentation, as confirmed by the Administrator.
The facility failed to maintain its fire alarm system components in operable condition. A fire alarm report noted that the FACP had broken acknowledge, silence, and reset buttons, and recommended a new panel. Verification of repair was not available during the survey, as confirmed in an exit interview with the Administrator and Maintenance Director.
The facility did not conduct the required annual 90-minute test for emergency lighting, as they could not provide documentation for the past 12 months. This deficiency was confirmed during an interview with the Administrator and Maintenance Director.
The facility did not maintain a hazardous area enclosure in the laundry room, affecting one of the five smoke compartments. Both doors were propped open with wedges, preventing them from closing and latching. This was confirmed during an exit interview with the Administrator and Maintenance Director.
A deficiency was identified in the facility's corridor door maintenance, specifically in the Ice Machine Room, where the door failed to latch properly, compromising its ability to resist smoke passage. This issue was confirmed by the Administrator and Maintenance Director during an exit conference.
The facility failed to ensure that smoke barrier doors were maintained to resist smoke passage in two of five smoke compartments. Observations revealed that the smoke doors outside the medical records area and outside a resident room did not close smoke tight when tested. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain a safe, clean, and comfortable environment, with deficiencies observed in multiple rooms. Issues included marred walls, missing closet doors, dust accumulation, broken tiles, and stained surfaces. These conditions were found across both the South Wing and North Wing, affecting the overall living conditions for residents.
A resident with bipolar disorder and heart failure experienced a significant weight gain and was on olanzapine, an antipsychotic medication. However, the MDS assessment inaccurately recorded the resident's weight and failed to acknowledge both the weight gain and the administration of the antipsychotic medication.
The facility failed to develop comprehensive care plans for two residents, as required by federal regulations. One resident with chronic kidney failure and another with epilepsy and rheumatoid arthritis had care area assessments indicating the need to address urinary incontinence. However, the quarterly MDS summaries showed frequent incontinence without any interventions documented in their care plans. The DON confirmed the absence of documented interventions for these care areas.
A facility failed to provide person-centered pain management for a resident with chronic conditions, as PRN pain medications lacked defined parameters for use. Despite orders for tramadol, ibuprofen, and acetaminophen, only tramadol was administered frequently without specific guidelines, while the other medications were not used. The DON confirmed the absence of necessary parameters, indicating a deviation from the facility's pain management policy.
A facility failed to complete pre-dialysis assessments for a resident with end-stage renal disease, as required by their policy. The resident, who had a physician's order for dialysis three times a week, did not have the necessary pre-dialysis communication forms completed on multiple occasions. This deficiency was confirmed by the DON.
The facility failed to ensure psychotropic medications were prescribed for specific diagnoses for two residents. One resident with Alzheimer's, anxiety, and stroke was given Seroquel for agitation without a documented diagnosis. Another resident with PTSD and depression was prescribed haloperidol and quetiapine for psychosis without evidence of a specific diagnosis. The DON confirmed the orders should have included specific diagnoses.
The facility failed to meet the required NA to resident ratios on several occasions. The day shift ratio of one NA per ten residents was not met, the evening shift ratio of one NA per eleven residents was not adhered to, and the night shift ratio of one NA per fifteen residents was also not maintained. These deficiencies were identified through a review of nursing schedules over a 21-day period.
The facility did not meet the required LPN to resident ratios on three occasions. On one day, the day and evening shifts were understaffed, lacking the mandated one LPN per 25 and 30 residents, respectively. Additionally, on another day, the night shift did not meet the required one LPN per 40 residents. These deficiencies were identified through a review of nursing schedules.
The facility did not meet the required minimum of 3.2 hours of direct resident care per day on three occasions, providing only 2.97 and 2.90 hours on specific days. This shortfall was identified during a review of nursing schedules over a 21-day period.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner in the dietary department and on the North unit. During the kitchen tour, surveyors observed a thick layer of dust and debris on top of the dish machine, cooked diced chicken stored on milk crates with the bottom box in contact with the crates and showing a red stain, raw chicken fillets touching the floor, an opened butter package with a brown substance on the bottom in contact with the shelf, and multiple food items past their use-by dates, including sweet and sour sauce, sour cream, cranberry juice, prune juice, and whipped topping. Other items were observed without dates, including an opened half gallon of ice cream, shelled eggs, poured glasses of orange juice, and glasses of tea. Dry storage also contained bananas and onions on the floor, a box of prune juice with food debris, food debris and condiment packets on the floor, and an unsealed box of chocolate chips. The Dietary Director confirmed that the undated and expired items should have been dated and removed. On the North unit resident pantry, surveyors observed a piece of brownie and pie on a plate and a bottle of soda in the freezer without a resident name or date, along with yogurt dated use by February 9, 2026, and other food items in the refrigerator that were not labeled or dated, including a plastic bag with a container of food, an orange, milk, and a container of two slices of cheesecake. There was also pink, dried, sticky liquid spilled along the bottom shelf and onto the floor in front of the refrigerator. On the counter, a banana and two pitchers of fruit punch were present, and four ants were seen crawling on the counter and pitchers. The counter had sticky food debris along its length, dried food debris was inside the microwave, and NA 1 stated that the microwave and pantry were used for residents only.
Unsanitary and Damaged Resident Environment
Penalty
Summary
The facility failed to maintain the resident environment in a sanitary and homelike manner in the main lobby and on the North Nursing Unit. Observations showed two lobby chairs with torn cushions, one with a dark liquid stain, chipped paint and black marks on the wall adjacent to the reception desk, black marks on the wall across from the reception desk, and missing floor tiles in front of resident laundry. On the North Nursing Unit, hallway walls between resident rooms were stained with brown streaks under the chair rail molding, and red stains were present on the baseboard between resident rooms 101 and 103. In resident rooms, surveyors observed a yellow stain on the floor, a privacy curtain stained with brown streaks, holes in the concrete under the bathroom sink with the rubber baseboard pulling away, a brown stain on a bed sheet, paper debris and peeling paint behind a bed, dust and debris on and under fall mats, and a privacy curtain missing hooks and marred with light brown stains. The Administrator confirmed the environmental issues were present.
Failure to Follow Medication Orders
Penalty
Summary
The facility failed to ensure physicians' orders were implemented for two residents. One resident had diagnoses including hypotension, and a physician ordered midodrine once daily with instructions not to administer it if systolic blood pressure was greater than 130 mm/Hg. Review of the March 2026 MAR showed the medication was administered 16 times without evidence that blood pressure was assessed before the medication was given or withheld. A second resident had diagnoses including diabetes and end stage kidney disease, and a physician ordered 43 units of insulin glargine subcutaneous solution twice daily with instructions not to administer it if blood sugar was less than 150 mg/dL. Review of the February and March 2026 MARs showed the insulin glargine was administered one time in February and one time in March when blood sugar was below 150 mg/dL. The DON confirmed there was no documented evidence that blood pressure was obtained before the medication administration for the first resident and that the insulin was administered outside the parameters of the physician's order for the second resident.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information every day. During a tour of the facility on March 15, 2026, at 9:15 a.m., surveyors observed that the staffing information posted in the lobby was dated February 20, 2026.
Failure to Perform Ordered Toe Skin Treatment and Document Care
Penalty
Summary
The facility failed to provide ordered skin treatment for a resident with a history of toe infection. Clinical record review showed that since November 4, 2025, the physician had ordered staff to clean both great toes and apply an antibacterial ointment (bacitracin). During an interview on January 30, 2026, the resident reported that on January 27, 2026, the nurse did not perform this ordered toe treatment. Review of the Treatment Administration Records for that date revealed no documented evidence that nursing staff completed the prescribed cleaning and bacitracin application to both great toes as ordered by the physician. This deficiency was cited under 28 Pa. Code 211.12(d)(5) related to nursing services.
Failure to Serve Hot Food at Required Temperatures on One Nursing Unit
Penalty
Summary
The facility failed to provide food at an appetizing and policy-compliant temperature on one of two nursing units (North Unit). Facility policy titled “Food Prep,” dated December 18, 2025, required that hot foods be served at temperatures greater than 135°F and cold foods at temperatures no greater than 41°F. During interviews conducted on January 10, 2026, between 11:40 a.m. and 12:00 p.m., three residents (Residents 1, 2, and 3) reported that their food was often served cold. A test tray audit performed on January 10, 2026, at 12:33 p.m., after the last resident meal tray had been served from the dining cart on the North Unit, showed that the crunchy buttermilk chicken was at 126.5°F and the green beans were at 132°F, and both items were cool to taste. During this observation, the Dietary Manager confirmed that hot food should have reached at least 135°F at the time of service, indicating that the food served did not meet the facility’s temperature standards, in violation of 28 Pa. Code 201.14(a) and 201.18(b)(3).
Failure to Record Food Holding Temperatures During Meal Service
Penalty
Summary
The facility failed to record food temperatures at the time of service in the main kitchen as required by its own policy and regulatory standards. The facility’s policy titled “Food Prep,” dated December 18, 2025, stated that food temperatures would be recorded at the time of service and monitored periodically during meal service. On review of the facility’s food temperature log on January 10, 2026, at 12:15 p.m., there was no documented evidence that holding food temperatures were obtained at the time of or during service for breakfast and lunch to ensure that food maintained safe internal temperatures. During this review period, the Dietary Manager confirmed in an interview that food temperatures should have been recorded for breakfast and lunch at the time of service, but they were not.
Failure to Provide Medication Reconciliation at Discharge
Penalty
Summary
The facility failed to provide a resident and/or the resident's representative with a reconciliation of all pre- and post-discharge medications at the time of a planned discharge. Clinical record review showed that the resident was discharged without documented evidence that this medication reconciliation was given. Additionally, the resident's representative specifically requested the medication reconciliation after the discharge, but it was not provided at that time. The Administrator confirmed in an interview that the required reconciliation was not given to the resident or their representative at discharge.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system components in operable condition, affecting the entire facility. During a document review on February 10, 2025, it was discovered that a fire alarm report dated January 15, 2025, included an inspector's comment noting that the Fire Alarm Control Panel (FACP) had broken acknowledge, silence, and reset buttons, and recommended a new panel. During an exit interview with the Administrator and the Maintenance Director, it was confirmed that verification of the repair was not available at the time of the survey.
Plan Of Correction
1) The facility will contact vendors for quotes on repairs to the panel. 2) A time limited waiver was submitted for repairs to the panel. 3) The facility will make repairs to the panel.
Failure to Conduct Annual Emergency Lighting Test
Penalty
Summary
The facility failed to ensure that emergency lighting was tested annually, as required by NFPA 101 standards. During a document review on February 10, 2025, it was found that the facility could not provide documentation of a 90-minute annual test for their emergency lighting over the past 12 months. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1) Maintenance was able to find paperwork after the audit was completed. 2) Maintenance was educated on how to find Emergency Lighting documentation. 3) Maintenance will audit the online monitoring system weekly to monitor regulatory tasks three times a week for 8 weeks, then monthly x2. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
Failure to Maintain Hazardous Area Enclosure in Laundry Room
Penalty
Summary
The facility failed to maintain a hazardous area enclosure, specifically in the laundry room, which affected one of the five smoke compartments in the facility. During an observation on February 10, 2025, at 11:00 a.m., it was noted that both doors of the laundry room were propped open with door wedges, preventing them from closing and latching as required. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 1:15 p.m.
Plan Of Correction
1) Laundry doors were closed and door wedges were removed. 2) Staff were educated that door wedges are not to be used in the facility. 3) Laundry rooms will be audited three times a week for 8 weeks, then monthly for two months. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
Corridor Door Latching Deficiency
Penalty
Summary
The facility was found to have a deficiency related to the maintenance of corridor doors, specifically in one of its five smoke compartments. During an observation conducted on February 10, 2025, at 11:45 a.m., it was noted that the door to the Ice Machine Room failed to latch properly. This failure to latch compromises the door's ability to resist the passage of smoke, which is a requirement for corridor doors in such facilities. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director on the same day at 1:15 p.m. The inability of the door to latch was acknowledged by the facility's representatives, indicating a lapse in maintaining the required safety standards for corridor doors. This issue affects the facility's compliance with regulations designed to ensure the safety and protection of residents and staff from smoke in the event of a fire.
Plan Of Correction
1) Parts were ordered for the door latch in the Ice Machine Room. 2) Maintenance will replace the latch when the part is received. 3) The maintenance director or designee will perform random weekly audits for 8 weeks, then monthly for two months, as part of a preventive maintenance plan to ensure corridor doors do not have problems closing. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
Smoke Barrier Doors Failed to Close Smoke Tight
Penalty
Summary
The facility failed to maintain doors in smoke barrier walls to resist the passage of smoke in two of five smoke compartments. During an observation on February 10, 2025, it was noted that the smoke doors outside the medical records area and outside resident room 147 did not close smoke tight when tested. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1) The facility contacted an outside vendor for repair quotes on fire doors. 2) The facility will have outside vendor make repairs and a timed limited waiver was submitted for repairs to the panel. 3) The maintenance director or designee will perform weekly audits for 8 weeks, then monthly for two months, as part of a preventive maintenance plan to ensure corridor doors do not have problems closing. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents on both the South Wing and North Wing. Observations revealed multiple deficiencies across various rooms. In room 120, the walls were heavily marred, while room 121 had marred walls and a closet missing both doors. Room 123 also had a closet missing both doors. In room 125 bed H, a fan was found with a heavy accumulation of dust and dirt. Room 127's bathroom had a broken floor tile in front of the toilet and a water-stained ceiling tile. Room 129 and room 131 had heavily marred walls, with room 131 also having a large hole in the drywall and a water-stained ceiling tile in the bathroom. Additional issues were noted in other rooms: room 133 had a windowsill covered with dirt and debris, and the wallpaper was peeling behind bed W. Room 134 bed W had a broken dresser drawer handle. Room 135's ptac unit contained debris and dirt, and the bathroom floor was buckled. In room 137 bed W, a solid black thick substance was splattered on the floor. Room 98's bathroom had a brown stain along the bottom molding and a black-stained floor tile. Room 116 had an accumulation of dust in the window corner and on the curtain. Lastly, room 109 had a layer of floor material lifted away from the base in the entryway.
Plan Of Correction
1. The fan in room 125, bed H, has been cleaned and dusted by the housekeeping staff. Housekeeping staff also cleaned the windowsill in room 133, the PTAC unit (ductless air conditioning unit) in room 135, the solid black substance in room 137, bed W, and the dust on the window and curtain in room 116. Room 123 had the closet doors replaced. Room 134 bed W the dresser drawer handle was repaired. Room 127 had the tile repaired and the ceiling tile replaced. Room 131 had the ceiling tile replaced. Room 133 had the wallpaper reglued to the wall. Rooms 120, 121, 129, and 131 will have marred walls repaired. Room 131 will have the hole repaired. Room 135 will have the bathroom floor redone. Room 98's bathroom wall and floor will be repaired. Room 109's floor will be replaced in the area that was lifted away from the base. 2. The maintenance director and housekeeping director will conduct a building wide audit of walls, closet doors, floors and furniture for areas of repair needed. 3. The housekeeping director will reeducate housekeeping staff on maintaining standards of cleanliness of the building. 4. Maintenance director and Housekeeping director will conduct weekly audits of walls, closet doors, floors, and furniture in resident rooms for areas that need repaired x 8 weeks, then monthly x2. Audits will be reviewed at the QAPI meeting for review or recommendations.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident diagnosed with bipolar disorder and heart failure. The resident experienced a significant weight gain of 13.9% over six months, increasing from 152.4 pounds to 173.6 pounds. Despite this, the MDS assessment dated November 8, 2024, inaccurately recorded the resident's weight as 146 pounds and failed to acknowledge the significant weight gain. Additionally, the assessment incorrectly indicated that the resident did not receive antipsychotic medication during the review period, despite records showing the resident had been receiving olanzapine since May 17, 2024.
Plan Of Correction
1. The MDS of Resident 7 was modified. 2. A house wide audit was conducted by CRC for residents with completed MDS for the past 30 days to verify accuracy of coding of antipsychotic medications and weights. 3. NPE or designee will re-educate the CRC on accurate coding of antipsychotic medications and weights on the MDS. Residents scheduled for MDS completion will be reviewed during clinical meeting to verify antipsychotic and weight accuracy. 4. CRC and/or designee will conduct weekly audits of MDS completed weekly x 8, then monthly x 2 to verify accuracy antipsychotic medications and weight documentation. Audits will be reviewed at the QAPI meeting for review or recommendations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as required by federal regulations. Resident 112, admitted with chronic kidney failure, had a care area assessment indicating the need to address urinary incontinence in the care plan. However, the quarterly MDS summary showed frequent urinary incontinence without any interventions documented in the care plan. Similarly, Resident 115, diagnosed with epilepsy and rheumatoid arthritis, also had a care area assessment noting the need to address urinary incontinence. The quarterly MDS summary confirmed frequent incontinence, yet no interventions were included in the care plan. In an interview, the Director of Nursing confirmed the absence of documented interventions for the identified care areas in the residents' care plans. This deficiency was previously cited in March 2024, indicating a recurring issue with the facility's compliance in developing and implementing comprehensive care plans that address individual resident needs as identified in their comprehensive assessments.
Plan Of Correction
1. The care plans of Residents 112 and 115 were updated to reflect urinary incontinence. 2. Current residents identified with incontinence on the most recent MDS have been reviewed to verify incontinence needs are addressed in the care plan. 3. NPE or designee will reinservice licensed nursing staff on the process for developing care plans that address the individual resident needs as it relates to incontinence. 4. DON and/or designee will conduct weekly audits x 8, then monthly x 2 of residents identified with urinary incontinence to verify a care plan is in place. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
Failure in Person-Centered Pain Management
Penalty
Summary
The facility failed to provide person-centered pain management consistent with professional standards of practice for a resident with chronic venous insufficiency, lymphedema, and Parkinson's disease. The facility's policy required that PRN (as needed) pain medications have defined parameters for use, but this was not adhered to. The resident had physician's orders for tramadol, ibuprofen, and acetaminophen, all as needed for pain, but the orders for tramadol and ibuprofen lacked specific parameters for administration. Despite this, the resident received tramadol for mild or moderate pain on numerous occasions over a three-month period, while no doses of acetaminophen or ibuprofen were administered during this time. The Director of Nursing confirmed that the necessary parameters for the administration of PRN pain medication were not ordered, which is a deviation from the facility's pain management policy. This oversight was identified during a review of the clinical records and an interview with the Director of Nursing, highlighting a failure in the facility's pain management practices for the resident in question.
Plan Of Correction
1. The PRN pain medication orders for Resident 20 were updated to include parameters of usage. 2. Current residents with orders for PRN pain medications have been reviewed to verify defined parameters are ordered. 3. NPE or designee will re-inservice licensed nurses on ensuring that PRN medications have proper defined parameters for administration. Residents with new orders for PRN pain medications will be reviewed during clinical meeting to verify pain parameters are ordered. 4. DON and/or designee will conduct random audits weekly x 8, then monthly x 2 for all residents with PRN pain medications to ensure defined parameters are stated. Audits will be reviewed with the QAPI committee for any further actions or recommendations that may be necessary.
Failure to Complete Pre-Dialysis Assessment for Resident
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident receiving dialysis, as required by professional standards of practice and the resident's care plan. The facility's policy, titled "Dialysis: Hemodialysis- Communication and Documentation," mandates that staff complete the pre-dialysis portion of the Hemodialysis Communication Record to assess the resident's status before sending them to dialysis. However, a review of clinical records revealed that for one resident with end-stage renal disease and a physician's order for dialysis three times a week, the pre-dialysis communication forms were not completed on five out of 14 occasions over a one-month period. This deficiency was confirmed by the Director of Nursing during an interview.
Plan Of Correction
1. The facility is unable to correct the cited deficient practice for Resident 70 due to documentation was for an appointment that happened in the past. 2. Current residents receiving dialysis have been reviewed to verify completion of the pre-dialysis portion of the Hemodialysis Communication form. 3. NPE or designee will re-educate licensed nursing staff on completion of dialysis communication forms. Residents receiving dialysis will be reviewed during clinical meeting to verify completion of the hemodialysis communication forms. 4. DON and/or designee will conduct audits weekly x 8, then monthly x 2 for residents on dialysis to ensure communication forms are being completed. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
Failure to Document Specific Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were prescribed for specific diagnoses for two residents. Resident 82, who had diagnoses including Alzheimer's disease, anxiety, and stroke, was prescribed the antipsychotic medication Seroquel for agitation without evidence supporting its use for a specific diagnosis. This lack of documentation indicates a failure to comply with the requirement that psychotropic drugs be used only when necessary to treat a specific condition as diagnosed and documented in the clinical record. Similarly, Resident 116, with diagnoses of PTSD and depression, was prescribed antipsychotic medications haloperidol and quetiapine for psychosis. However, there was no evidence to support that these medications were used to treat a specific diagnosis. The Director of Nursing confirmed that the antipsychotic medication orders should have included specific diagnoses, highlighting a deficiency in the facility's adherence to regulatory requirements for psychotropic drug prescriptions.
Plan Of Correction
1. The psychotropic medication orders for Residents 82 and 116 were reviewed by the provider for proper diagnosis. 2. Current residents receiving antipsychotic medications was conducted to verify the medications were prescribed for a specific diagnosis. Residents with new orders for anti-psychotic medications will be reviewed during clinical meeting to verify that the medication was prescribed for a specific diagnosis. 3. NPE or designee will re-inservice licensed nursing staff on ensuring that psychotropic medications have specific diagnosis for administration and usage. 4. DON and/or designee will conduct audits weekly x 8, then monthly x 2 for residents with antipsychotic medications to verify a proper diagnosis has been ordered. Results of the audits will be presented at the QAPI committee for review and/or recommendations.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on multiple occasions over a 21-day period. Specifically, the facility did not maintain the minimum ratio of one NA per ten residents during the day shift on February 2, 2025. Additionally, the evening shift ratio of one NA per eleven residents was not met on December 24 and 25, 2024. Furthermore, the night shift ratio of one NA per fifteen residents was not adhered to on December 25, 2024, January 5, 6, 7, and 11, 2025, and February 1 and 2, 2025. These deficiencies were identified through a review of nursing schedules, indicating a pattern of non-compliance with staffing regulations.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on three separate occasions. On February 2, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not have the mandated one LPN per 25 residents. Additionally, on the same day during the evening shift from 3:00 p.m. to 11:00 p.m., the facility did not meet the required one LPN per 30 residents. Furthermore, on December 22, 2024, during the night shift from 11:00 p.m. to 7:00 a.m., the facility failed to maintain the minimum ratio of one LPN per 40 residents. These deficiencies were identified through a review of nursing schedules over a 21-day period.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Deficiency in Meeting Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules over a 21-day period. Specifically, on December 25, 2024, February 1, 2025, and February 2, 2025, the facility provided only 2.97, 2.97, and 2.90 care hours per resident, respectively. These findings indicate that the facility did not consistently meet the mandated staffing levels on these days, resulting in a shortfall in the required direct care hours for residents.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 709 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Quakertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belle Terrace | 0.6 mi | ★★★★★ | 15 | 0 |
| Lifequest Nursing Center | 2.4 mi | ★★★★★ | 5 | 0 |
| Phoebe Richland Hcc | 3 mi | ★★★★★ | 6 | 0 |
| Community At Rockhill, The | 6.2 mi | ★★★★★ | 1 | 0 |
| Valley Manor Rehabilitation And Healthcare Center | 6.7 mi | ★★★★★ | 7 | 0 |
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