Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Quarryville Presbyterian Retirement Community during CMS and state inspections, most recent first.
Residents repeatedly raised concerns about cold food and flies in the dining room during Resident Council meetings, but the facility did not provide evidence of prompt or effective action to resolve these issues. Pest control records showed no fly treatments, and interviews confirmed that residents felt their complaints were not addressed.
The facility did not ensure that as-needed psychotropic medications were limited to 14 days or had documented physician rationale for continued use, and failed to document non-pharmacological interventions prior to administering these medications for several residents with cognitive impairment and behavioral symptoms. The DON confirmed the lack of required documentation for both medication extension and non-pharmacological interventions.
A deficiency was identified when an ice machine in the main kitchen was found with visible build-up of pink and black substances, and no documentation was available to show that required monthly cleaning had been performed. The Dietary Manager confirmed the need for cleaning, and facility policy required monthly sanitation and quarterly servicing by a third-party vendor.
Two residents with cognitive impairment and diagnoses such as Alzheimer's dementia, depression, and anxiety were given Ativan, a psychotropic medication, without documented informed consent from their representatives. The facility's practice was to obtain consent only for antipsychotic medications, not for other psychotropics, as confirmed by the DON.
The facility did not verify the nurse aide registry status for a newly hired aide or check the nursing license status for a newly hired RN before employment, as required by policy. These omissions were confirmed through personnel file review and staff interviews.
A resident admitted with sinusitis was later diagnosed with COVID-19 and placed on droplet precautions, but the baseline care plan was not updated to reflect the new diagnosis or required precautions, as confirmed by staff and documentation review.
Two residents receiving warfarin for conditions such as atrial fibrillation and heart failure did not have individualized care plans addressing their anticoagulant therapy, as confirmed by facility leadership and review of clinical records.
The facility did not update care plans for two residents to reflect changes in their medical treatments. One resident's care plan listed intermittent catheterization despite having an indwelling Foley catheter, while another resident's care plan included anticoagulant and insulin administration that were no longer being provided. Nursing leadership confirmed that the care plans were not revised as required.
The facility failed to complete a safety assessment for a resident using an electric lifting recliner chair, despite the resident's poor safety awareness and impulsive actions. Additionally, another resident with severe cognitive impairment was transported in a wheelchair without leg rests, causing her foot to drag on the floor, as the staff member did not ensure the use of appropriate assistance devices.
A resident with mild cognitive impairment, Parkinsonism, and dementia, who was dependent on staff for toileting, did not receive assistance according to her individualized scheduled toileting program. Interviews indicated staff did not always respond to her requests outside of scheduled times, and there was no documentation that the toileting program was completed as outlined in her care plan.
A facility failed to complete a physician's discharge summary for a resident prior to or at the time of discharge. The resident was discharged without the necessary documentation, and this oversight was confirmed by the Nursing Home Administrator during an interview.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage 4 Pressure Ulcer, as required by their policy. The absence of EBP signage and communication in the resident's room was observed, and interviews with the DON, Nursing Home Administrator, and Wound Nurse confirmed the lapse. This deficiency was noted under several Pennsylvania Code regulations.
Failure to Promptly Address Resident Council Grievances on Food Temperature and Flies
Penalty
Summary
The facility failed to promptly address grievances raised by the Resident Council regarding food temperatures and the presence of flies in the dining room. Resident Council meeting minutes from three consecutive months documented repeated concerns about these issues. During each meeting, residents were told to report food temperature concerns immediately and were reminded of ongoing pest control efforts, but no evidence was provided to show that the facility took prompt or effective action in response to the Council's repeated complaints. Interviews with residents confirmed that their concerns about cold food and flies were brought up multiple times without resolution. Pest control records showed no treatments for flies during the relevant months, and there was no documentation of new interventions after the initial purchase of a fly catcher. Facility leadership acknowledged the ongoing complaints but did not implement additional measures to address the issues, and tray audits were only conducted prior to the reported concerns.
Failure to Limit and Document Use of PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications and that non-pharmacological interventions were attempted prior to administering as-needed (PRN) psychotropic medications. Facility policy required minimizing the use of psychotropic medications, avoiding unnecessary drug use, and promoting non-pharmacological interventions. However, for four residents reviewed, there was no documented evidence that these requirements were met. For multiple residents with cognitive impairment and diagnoses such as dementia, depression, and anxiety, physician orders prescribed PRN Ativan for agitation or anxiety. In several cases, the medication was administered beyond the 14-day limit without documented physician rationale for continuation, as required. Additionally, review of Medication Administration Records and clinical documentation revealed that staff did not document attempts at non-pharmacological interventions prior to administering PRN Ativan, despite care plans and psychiatric consults specifying this requirement. Interviews with the Director of Nursing confirmed the lack of documentation for both the required physician rationale for extended PRN psychotropic use and the use of non-pharmacological interventions prior to medication administration. These findings were observed for four residents over multiple months, indicating a pattern of non-compliance with facility policy and regulatory requirements regarding psychotropic medication management.
Failure to Maintain Sanitary Ice Machine in Kitchen
Penalty
Summary
The facility failed to ensure that ice was made and stored in sanitary conditions in one of its two ice machines located in the main kitchen. According to the facility's policy, ice machines were to be cleaned monthly by removing the ice, washing the interior with a sanitizing solution, and allowing it to dry before refilling. Additionally, a third-party vendor was contracted to service the machine quarterly. However, review of the service log showed no documented evidence of monthly cleaning. During an observation, a build-up of a pink substance was noted on the right-hand corner of a white plastic piece inside the ice machine, and a black substance was observed along the entire length of a strip at the top of the machine, while the chest was full of ice. The Dietary Manager confirmed at the time that the ice machine needed cleaning.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to inform residents or their representatives in advance about the risks, benefits, and treatment alternatives associated with the use of psychotropic medications prior to administration. Specifically, two residents with cognitive impairments and diagnoses including Alzheimer's dementia, depression, and anxiety were administered Ativan (lorazepam), an antianxiety and antipsychotic medication, without documented evidence of informed consent. For one resident, physician orders indicated the use of transdermal Ativan gel as needed for agitation, and the medication was administered multiple times over several months. However, there was no documentation that the resident's representative was informed or provided consent prior to the initiation of this medication. Similarly, another resident with cognitive impairment and diagnoses of Alzheimer's dementia and anxiety received both oral and transdermal Ativan for anxiety and agitation, as ordered by the physician. The medication administration records confirmed multiple doses were given, but again, there was no evidence in the clinical record that informed consent was obtained from the resident's representative before starting the medication. An interview with the DON confirmed that the facility was only obtaining informed consent for antipsychotic medications, not for other psychotropic medications.
Failure to Verify Nurse Aide Registry and RN Licensure Prior to Hire
Penalty
Summary
The facility failed to follow its own abuse prohibition policy by not verifying the standing of a newly hired nurse aide on the Pennsylvania Nurse Aide Registry prior to employment, as required. Additionally, the facility did not check the licensure status of a newly hired registered nurse with the State Board of Nursing before the nurse began work. These deficiencies were identified through a review of personnel files and confirmed in interviews with the Director of Human Resources, who acknowledged that the required verifications were not completed prior to the respective hires.
Failure to Update Baseline Care Plan for Resident with New COVID-19 Diagnosis
Penalty
Summary
The facility failed to ensure that a baseline care plan was implemented to address a resident's immediate needs following admission. Upon admission, the resident was diagnosed with sinusitis and was to receive medication for three days, which was reflected in the initial care plan. However, the following day, the resident tested positive for COVID-19 and was placed in respiratory isolation with droplet precautions, as observed by signage on the resident's door and confirmed by staff interviews. Despite these developments, there was no documented evidence in the clinical record that the baseline care plan was updated to include the resident's new diagnosis of COVID-19 and the need for droplet precautions. The Assistant Director of Nursing confirmed that the care plan was not revised to reflect these changes.
Failure to Develop Individualized Care Plans for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop individualized care plans addressing anticoagulant therapy for two residents. For one resident, the quarterly MDS assessment indicated cognitive impairment and the need for assistance with care, as well as an active order for warfarin to treat atrial fibrillation. Despite these needs, there was no documented evidence of a care plan related to anticoagulant therapy for this resident, as confirmed by the Director of Nursing. Similarly, another resident, who was cognitively intact and required staff assistance for daily care, had diagnoses including heart failure and was also receiving warfarin per physician's orders. The Assistant Director of Nursing confirmed that this resident's care plan did not address care and treatment needs related to anticoagulant medication use. These findings were based on a review of facility policy, clinical records, and staff interviews.
Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to accurately reflect the current care needs of two residents. For one resident with a history of stroke who was cognitively intact and required assistance with daily care, the care plan indicated the need for intermittent straight catheterization, despite a physician's order for an indwelling Foley catheter for urinary retention. The resident confirmed the presence of an indwelling catheter, and the Assistant Director of Nursing acknowledged that the care plan had not been revised to reflect this change. For another resident with a history of hip fracture and diabetes, the care plan included interventions for anticoagulant therapy with Lovenox and insulin administration. However, a review of the Medication Administration Record for two consecutive months showed no evidence that the resident received either medication. The Director of Nursing confirmed that the resident was no longer receiving Lovenox or insulin and that the care plan should have been updated to reflect this change.
Failure to Complete Safety Assessments and Ensure Use of Assistance Devices
Penalty
Summary
The facility failed to complete a safety assessment for a resident who used an electric lifting recliner chair. This resident, who was cognitively intact but required staff assistance for daily care and had chronic kidney disease, was found on his knees facing his recliner with his upper body resting on it after attempting to get up to ring his call bell. Documentation indicated that the resident had poor safety awareness and impulsive behaviors, yet no safety assessment specific to the use of the electric lifting recliner chair was completed for him. Additionally, the facility did not ensure that appropriate assistance devices were in place for another resident who was severely cognitively impaired, required assistance with daily care, and used a wheelchair for mobility. This resident was observed being transported by a hospitality aide without leg rests on her wheelchair, resulting in one foot dragging on the floor. The aide stated that she did not use leg rests because the resident could self-propel and was unsure if foot petals were available. The DON confirmed that leg rests should have been used during transport if the resident could not lift her feet off the floor.
Failure to Follow Scheduled Toileting Program for Dependent Resident
Penalty
Summary
The facility failed to ensure that a scheduled toileting program was followed for a resident with mild cognitive impairment, Parkinsonism, and dementia, who was dependent on staff for toileting and hygiene. The resident's care plan specified a detailed toileting schedule, including assistance at least every two hours during awake times, at bed checks, upon rising, before and after meals, at bedtime, and whenever requested. However, interviews with the resident and her husband revealed that staff did not always provide toileting assistance when the resident requested it, instead adhering strictly to the scheduled times. Review of the resident's clinical documentation and toileting program records over several months showed no documented evidence that the scheduled toileting program was completed as outlined in the care plan. The Director of Nursing confirmed the lack of documentation supporting completion of the toileting program as scheduled. This deficiency was identified through review of facility policies, clinical records, and staff and resident interviews.
Failure to Complete Physician's Discharge Summary
Penalty
Summary
The facility failed to ensure that a physician's discharge summary was completed prior to or at the time of discharge for a resident. The clinical record review revealed that the resident was discharged on July 2, 2024, but there was no evidence of a completed discharge summary by the physician at that time. This deficiency was confirmed during an interview with the Nursing Home Administrator on July 10, 2024, who acknowledged that the discharge summary was not completed as required.
Failure to Implement Enhanced Barrier Precautions for Resident
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who required them, leading to a deficiency in infection prevention and control. The facility's policy on EBP, dated March 2024, mandates the use of gowns and gloves during high-contact care activities for residents at higher risk of colonization or infection with multi-drug resistant organisms (MDROs). This includes residents with chronic wounds or indwelling medical devices. However, during an observation, it was found that there was no EBP signage or communication in the room of a resident with a Stage 4 Pressure Ulcer to the coccyx, indicating a lapse in following the EBP process. Interviews with the Director of Nursing, Nursing Home Administrator, and Wound Nurse confirmed that the EBP process was not adhered to for the resident in question. This oversight was identified during a survey, and it was determined that the facility did not ensure the necessary precautions were in place to prevent the transmission of MDROs. The deficiency was cited under several Pennsylvania Code regulations, highlighting the importance of management, clinical records, and nursing services in maintaining infection control standards.
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What surveyors actually found near you
We read the 142 citations issued within 25 miles in the last 12 months — including the 2 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Quarryville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside At Willow Valley | 8.9 mi | ★★★★★ | 0 | 0 |
| Glen At Willow Valley | 10.1 mi | ★★★★★ | 3 | 0 |
| Newport Meadows Health And Rehabilitation Center | 10.3 mi | ★★★★★ | 10 | 0 |
| Oxford Health Center | 11.9 mi | ★★★★★ | 3 | 0 |
| Lancaster Nursing And Rehabilitation Center | 12.4 mi | ★★★★★ | 7 | 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.