4 Reports
Inspection Report — Dec 3, 2025
Annual Inspection CMS
Date: Dec 3, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards in multiple areas including resident dignity, food safety, and facility environment.
Findings
The facility was found deficient in respecting resident dignity by failing to ensure a resident was properly covered. Food preparation and storage areas were unsanitary with buildup of debris and sticky substances. The facility environment had damaged ceiling tiles and a kitchen floor in poor condition, posing safety and cleanliness risks.
Deficiencies (3)
F 0550: The facility failed to honor a resident's right to dignity by allowing a resident to sit with her legs exposed and visible to staff and visitors despite her dependency on staff for lower body dressing.
F 0812: The facility failed to procure food from approved sources and maintain sanitary conditions in the kitchen, including dust and food debris on equipment and containers.
F 0921: The facility failed to maintain a safe, clean, and homelike environment, with damaged ceiling tiles and a kitchen floor with food debris creating safety and cleanliness risks.
Report Facts
Residents sampled: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) N | Commented on resident's ability to cover legs | |
| Administrative Nurse D | Stated expectation for staff to ensure residents were covered appropriately | |
| Dietary Staff BB | Confirmed kitchen sanitation concerns and poor kitchen floor condition | |
| Maintenance U | Monitored and replaced damaged ceiling tiles | |
| Administrative Staff A | Stated expectations for facility cleanliness and maintenance |
Inspection Report — Dec 3, 2025
Routine CMS
Date: Dec 3, 2025
Visit Reason
Routine inspection of Quaker Hill Manor to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate notification of hospital transfers, incomplete care plan revisions, insufficient assistance with activities of daily living, failure to monitor and treat skin issues and constipation, unsafe environment hazards, improper medication administration, inadequate infection control practices, and failure to maintain sanitary food preparation areas.
Deficiencies (11)
F 0550: The facility failed to honor a resident's right to dignity by allowing a resident to be exposed with bare legs visible to others.
F 0628: The facility failed to provide written notification to residents or their representatives explaining the purpose of hospital transfers.
F 0657: The facility failed to revise a resident's care plan to include interventions addressing a diagnosis of cancer and related wounds.
F 0677: The facility failed to provide oral care assistance to a resident dependent on staff for oral hygiene.
F 0684: The facility failed to monitor skin issues and failed to administer and assess for constipation as ordered for residents.
F 0689: The facility failed to ensure call light accessibility for a resident and failed to use wheelchair pedals when propelling another resident.
F 0732: The facility failed to post nurse staffing information including actual nursing hours worked.
F 0757: The facility failed to hold blood pressure medication when resident's systolic blood pressure was below ordered parameters.
F 0812: The facility failed to maintain sanitary conditions in the kitchen, including dust and food debris on equipment and surfaces.
F 0880: The facility failed to implement adequate infection prevention and control practices, including proper hand hygiene during resident care.
F 0921: The facility failed to maintain a safe, clean, and homelike environment, including damaged ceiling tiles and poor kitchen floor conditions.
Report Facts
Residents sampled: 12
Medication administrations out of parameters: 7
Skin tear measurements: 1
Skin tear measurements: 0.1
Skin tear measurements: 4
Skin tear measurements: 1.5
Wound size: 6.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including dignity, care plan revisions, medication administration, infection control, and wheelchair pedal use |
| Certified Nurse Aide N | Certified Nurse Aide | Mentioned in dignity and oral care deficiencies |
| Certified Medication Aide R | Certified Medication Aide | Named in medication administration finding |
| Licensed Nurse G | Licensed Nurse | Named in infection control and wheelchair pedal use findings |
| Social Services X | Social Services | Mentioned in hospital transfer notification deficiency |
| Consultant HH | Consultant | Mentioned in hospital transfer notification deficiency |
| Dietary Staff BB | Dietary Staff | Named in kitchen sanitation and environment findings |
Inspection Report — Feb 15, 2024
Routine CMS
Date: Feb 15, 2024
Visit Reason
Routine inspection of Quaker Hill Manor to assess compliance with regulatory standards related to resident care, medication management, sanitation, and facility environment.
Findings
The facility failed to provide bathing opportunities as per resident preferences, failed to develop comprehensive care plans for medication use, failed to provide adequate oral care for a dependent resident, and failed to maintain sanitary conditions in food preparation and kitchen areas. The environment was found to be unsafe and unsanitary in the kitchen.
Deficiencies (6)
F 0561: The facility failed to ensure bathing opportunities per resident preferences for two residents, resulting in less frequent bathing than requested.
F 0656: The facility failed to develop a comprehensive care plan for one resident's use of Estrace for inappropriate sexual behaviors.
F 0677: The facility failed to provide adequate oral care for one dependent resident, resulting in buildup of food debris on the resident's teeth and lips.
F 0757: The facility failed to clarify diagnoses for a medication prescribed to one resident and lacked a care plan for inappropriate sexual behavior.
F 0812: The facility failed to prepare and serve food under sanitary conditions, with multiple areas of food debris, undated and unlabeled food items, and unclean kitchen equipment observed.
F 0921: The facility failed to maintain a safe, functional, sanitary, and comfortable environment, with kitchen floors having heavy buildup of dirt and grime and lacking a cleaning policy.
Report Facts
Residents affected: 44
Residents selected for review: 14
Bathing frequency: 2
Medication dosage: 0.5
BIMS score: 15
BIMS score: 12
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Confirmed bathing expectations and care plan issues for residents R30 and R36; confirmed lack of care plan for Resident R26; stated oral care expectations. |
| Administrative Nurse F | Administrative Nurse | Confirmed care plan included black box warning for Estrace and lack of diagnosis for Resident R26. |
| Licensed Nurse I | Licensed Nurse | Provided oral care to Resident R35 and confirmed oral hygiene issues. |
| Certified Nurse Aide N | Certified Nurse Aide | Provided bathing to residents and explained bath aide coverage. |
| Certified Nurse Aide M | Certified Nurse Aide | Provided bathing opportunities five days a week and made up missed baths. |
| Certified Nurse Aide P | Certified Nurse Aide | Observed oral hygiene issues with Resident R35. |
| Certified Nurse Aide Q | Certified Nurse Aide | Confirmed oral care expectations for Resident R35. |
| Dietary Staff BB | Dietary Staff | Acknowledged lack of knowledge about cookie sheets being put away wet. |
| Dietary Staff CC | Dietary Staff | Confirmed food labeling and cleaning issues in kitchen and kitchenette. |
Inspection Report — Jun 16, 2022
Annual Inspection CMS
Date: Jun 16, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements, including resident care plans and accident prevention.
Findings
The facility failed to honor a resident's bathing preference on Saturdays and failed to review and revise care plans for two residents regarding bathing preferences and fall interventions. Additionally, the facility failed to implement appropriate fall prevention interventions for a resident with multiple falls.
Deficiencies (3)
F 0561: The facility failed to honor Resident R17's bathing preference for Saturdays, missing two of six scheduled baths, impacting her ability to prepare for church on Sundays.
F 0657: The facility failed to review and revise care plans for Residents R17 and R21 to include bathing preferences and post-fall interventions respectively.
F 0689: The facility failed to follow planned fall interventions and implement new interventions to prevent additional falls for Resident R21 with multiple falls.
Report Facts
Residents selected for review: 13
Missed baths: 2
Falls: 3
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