Inspection Report
Follow-Up
Census: 86
Capacity: 143
Deficiencies: 4
Feb 27, 2025
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted on 02/27/2025 to review the submitted plan of correction related to prior deficiencies.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. The facility addressed issues related to resident dignity and respect, staffing adequacy, direct care staff training, and annual training topics. Continued compliance and ongoing monitoring were emphasized.
Deficiencies (4)
| Description |
|---|
| Staff member A treated a resident without dignity by refusing to properly make the bed and displaying disrespectful behavior. |
| The facility lacked a policy or procedure defining reasonable response times to call bells, indicating inadequate staffing. |
| Direct care staff member A provided unsupervised ADL services without completing required Department-approved training and competency testing. |
| Direct care staff member A did not receive required annual training in medication self-administration, resident needs, safe management techniques, and care for residents with mental illness or intellectual disabilities during 2024. |
Report Facts
License Capacity: 143
Residents Served: 86
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 9
Residents Age 60 or Older: 86
Residents with Mental Illness: 1
Residents with Physical Disability: 1
Residents with Mobility Need: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in multiple findings related to resident dignity, training deficiencies, and provision of unsupervised ADL services |
Inspection Report
Follow-Up
Census: 84
Capacity: 143
Deficiencies: 7
Jan 28, 2025
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing issues such as timely reporting of suspected resident abuse, staff qualifications, training deficiencies, and accuracy of resident support plans. Continued compliance is required.
Deficiencies (7)
| Description |
|---|
| Failure to immediately report suspected verbal abuse of a resident to the local area agency on aging. |
| Failure to report incidents to the Department’s personal care home regional office within 24 hours. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff persons B and C did not receive required training in medication self-administration, resident needs, and safe management techniques during training year 2024. |
| Direct care staff person B did not receive training in resident rights during training year 2024. |
| Resident Individual Service Plan contained inaccuracies regarding assistive devices, bathing assistance, and turning and positioning. |
| Direct care staff persons B and C working in the Secure Dementia Care Unit had insufficient dementia care training hours during 2024 training year. |
Report Facts
License Capacity: 143
Residents Served: 84
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 23
Current Hospice Residents: 7
Residents Age 60 or Older: 84
Residents with Mobility Need: 29
Residents with Physical Disability: 1
Total Daily Staff: 113
Waking Staff: 85
Direct Care Staff B Dementia Training Hours: 2.5
Direct Care Staff C Dementia Training Hours: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Administrator | Met with resident family members regarding verbal abuse allegation and involved in incident reporting. |
| Staff person B | Direct Care Staff | Did not have required qualifications or training; removed from schedule and no longer employed. |
| Staff person C | Direct Care Staff | Did not receive required training and no longer works for the community. |
| Resident Care Director | Conducted re-education and training on abuse reporting and staff training requirements; responsible for monitoring compliance. | |
| Executive Director | Reported suspected abuse to local agency; provided re-education and responsible for confirming plan of correction implementation. | |
| Human Resources Manager | Conducted audits on staff qualifications and training compliance. |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 143
Deficiencies: 0
Jul 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 07/11/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and the complaint was not substantiated as no deficiencies were found.
Report Facts
Total Daily Staff: 141
Waking Staff: 106
Residents Served: 93
License Capacity: 143
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 21
Residents Age 60 or Older: 93
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 48
Residents with Physical Disability: 1
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Inspection Report
Renewal
Census: 63
Capacity: 143
Deficiencies: 12
Feb 28, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including sanitary conditions, emergency telephone postings, maintenance issues, food safety violations, fire drill record deficiencies, and medication management concerns. All deficiencies had plans of correction accepted and were implemented by April 10, 2023, with ongoing monitoring planned.
Deficiencies (12)
| Description |
|---|
| Shower seat in bathroom of room #8141 was unclean and unsanitary with a brown smear. |
| No emergency telephone numbers posted on or by telephones in rooms 8141, 8219, 8253. |
| Rugs in bedroom were lifting and buckling creating a trip hazard. |
| Food temperature of a plate being served was 118°F, below required 135°F; failure to use plate covers. |
| No thermometer in freezer or refrigerator on 2nd floor kitchen and memory care kitchenette. |
| 5 gallon tub of ice cream in freezer was opened and unsealed. |
| Accumulation of lint debris under lint tray of dryer on 2nd floor. |
| Fire drill records for 12/6/22 and 1/20/23 did not include specific exit route used. |
| Alternate exit routes not specified in fire drill records; only generic location noted. |
| Resident #1 required assistance with medication self-administration but assistance was not provided, resulting in medication error. |
| Resident #1 had several unlocked, unattended medications stored in a shoebox in bedroom; sample medications lacked prescriber instructions. |
| Resident #1 and #2 had prescribed as-needed medications not available in the home at times. |
Report Facts
Residents Served: 63
License Capacity: 143
Residents Served in Secured Dementia Care Unit: 23
Current Hospice Residents: 8
Residents Age 60 or Older: 87
Residents with Mobility Need: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Associate Executive Director (AED) | Conducted training on cleaning bathrooms and fire prevention policy; involved in monitoring plan of correction | |
| Reminiscence Coordinator (RC) | Conducted room rounds, audits, and training related to sanitary conditions and medication assessments | |
| Personal Care Coordinator (PCC) | Conducted audits and training related to telephone postings and room conditions | |
| Dining Services Coordinator (DSC) | Ensured food safety compliance and refrigerator temperature monitoring | |
| Maintenance Coordinator (MC) | Conducted audits and training related to fire drills, lint removal, and maintenance issues | |
| Resident Care Director (RCD) | Conducted medication assessments and training related to medication management deficiencies |
Inspection Report
Follow-Up
Census: 92
Capacity: 143
Deficiencies: 3
Apr 5, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident, conducted off-site on multiple dates to review compliance and plan of correction submissions.
Findings
The inspection identified deficiencies related to staff orientation on fire safety and emergency preparedness, and medication administration errors where medications were given to the wrong resident. The facility submitted an acceptable plan of correction addressing these issues.
Deficiencies (3)
| Description |
|---|
| Staff person A did not receive orientation on general fire safety and emergency preparedness topics prior to or during the first day of work. |
| Staff A did not identify the correct resident and administered resident #1's medications to resident #2. |
| Resident #2 was administered prescription medications prescribed for resident #1. |
Report Facts
License Capacity: 143
Residents Served: 92
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 22
Total Daily Staff: 140
Waking Staff: 105
Residents with Mobility Need: 48
Residents 60 Years or Older: 92
Residents Diagnosed with Mental Illness: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiency for lack of fire safety orientation and medication administration error | |
| Associate Executive Director (AED) | Associate Executive Director | Responsible for reviewing and confirming implementation of plan of correction and ongoing compliance |
| RCD | Initiated refresher training on medication administration and responsible for conducting medication pass observations |
Notice
Capacity: 143
Deficiencies: 0
Sep 27, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for The Quadrangle Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative license renewal notice and certificate of compliance.
Report Facts
Maximum capacity: 143
Secure Dementia Care Unit capacity: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 92
Capacity: 143
Deficiencies: 12
Sep 14, 2021
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Quadrangle Personal Care.
Findings
The inspection identified multiple deficiencies including late incident reporting, unsecured poisonous materials, improper refrigerator temperatures, outdated food, lint accumulation in dryers, smoking policy violations, medication storage and labeling issues, and incomplete support plan signatures. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (12)
| Description |
|---|
| Late reporting of incidents involving resident injuries to the Department. |
| Poisonous materials (toothpaste and mouthwash) were found unlocked and accessible in a resident's bathroom. |
| Refrigerator temperatures in multiple locations exceeded the required 40°F, risking food safety. |
| Outdated food items (Teriyaki sauce and scallions) found in walk-in refrigerator past expiration date. |
| Full accumulation of lint in lint traps of clothes dryers, posing fire hazard. |
| Cigarette butts found outside near trash compactor despite no smoking policy and signage. |
| Resident medications stored unlocked in resident's room. |
| Expired eye drops found on medication cart. |
| Medication label instructions did not match prescribed directions. |
| Over-the-counter medication without resident label found in reminiscence medication cart. |
| Incorrect documentation of glucometer readings in Medication Administration Record. |
| Resident support plans were not signed, refused to sign, or marked unable to sign without proper notation. |
Report Facts
License Capacity: 143
Residents Served: 92
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 22
Hospice Residents: 7
Total Daily Staff: 137
Waking Staff: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Named in multiple medication-related findings and plans of correction. |
| Associate Executive Director | Associate Executive Director (AED) | Reviewed incidents, provided education, and monitored plans of correction. |
| Reminiscence Coordinator | Reminiscence Coordinator (RC) | Involved in securing poisonous materials and refrigerator temperature corrections. |
| Maintenance Coordinator | Maintenance Coordinator (MC) | Addressed lint removal and smoking area violations. |
| Dining Services Coordinator | Dining Services Coordinator (DSC) | Managed food safety issues including outdated food and refrigerator audits. |
| Personal Care Coordinator | Personal Care Coordinator (PCC) | Involved in medication storage and support plan signature corrections. |
Inspection Report
Monitoring
Census: 81
Capacity: 143
Deficiencies: 4
Mar 8, 2021
Visit Reason
The inspection was a full, unannounced monitoring visit conducted on March 8, 2021 to review compliance with licensing requirements.
Findings
The inspection identified several deficiencies including failure to post the current license inspection summary, uncovered trash receptacles in the kitchen, lack of operable bedside lighting for a resident, and discrepancies in glucometer readings versus medication administration records. Plans of correction were submitted and fully implemented by July 28, 2022.
Deficiencies (4)
| Description |
|---|
| The home's current license inspection summary dated 10/16/20 was not posted in a conspicuous and public place. |
| Two full, uncovered, unattended trash cans were found in the kitchen. |
| Resident #1 did not have access to a source of light that can be turned on/off at bedside. |
| The glucometer reading for resident #2 was 282, but the medication administration record was recorded as 269. |
Report Facts
License Capacity: 143
Residents Served: 81
Secured Dementia Care Unit Capacity: 25
Residents Served in Secured Dementia Care Unit: 17
Hospice Residents: 9
Residents Age 60 or Older: 81
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Human Services Licensing Supervisor | Signed letter confirming plan of correction implementation |
| Resident Care Director | Named in glucometer calibration deficiency and plan of correction | |
| Dining Services Coordinator | Named in trash receptacle deficiency and plan of correction | |
| PC Administrator | Responsible for placing reports in survey binder and reviewing plans of correction |
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