16 Reports
Inspection Report — Jul 2, 2026
Follow-Up
Date: Jul 2, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. Deficiencies involved resident dignity and respect, medication record accuracy, and preadmission screening documentation.
Citations (3)
42c Treatment of Residents: Staff Person A called a resident 'a liar' and said 'nobody wants to work with you'. The staff member was terminated and residents will be interviewed weekly for 90 days to ensure respectful interactions.
181f Record of Medication: A resident's medication record included a discontinued medication and did not reflect current physician orders. The discontinued medication was removed and monthly audits will be conducted to ensure accuracy.
224a Preadmission Screen Form: A resident was admitted without a preadmission screening form completed within 30 days prior to admission. Staff were re-educated and procedures updated to verify screening dates before admission.
Report Facts
Residents Served: 110
Secured Dementia Care Unit Residents Served: 22
Residents Age 60 or Older: 110
Residents with Mobility Need: 54
Residents with Physical Disability: 1
Inspection Report — Jun 1, 2026
Renewal
Date: Jun 1, 2026
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including an unannounced full inspection on 06/01/2026 and 06/02/2026.
Findings
The inspection identified multiple deficiencies including failure to post the current license conspicuously, delayed incident reporting, confidentiality breaches, unsecured poisonous materials, sanitary and safety issues, medication storage and documentation problems, incomplete support plans, and resident rights education gaps. All deficiencies had accepted plans of correction implemented by 07/22/2026.
Citations (22)
The home did not post the current license inspection summary in a conspicuous and public place on 06/01/2026.
The home failed to report multiple incidents including an unwitnessed fall, a resident passing away, and a physical altercation to the Department in a timely manner.
During medication pass observation, empty blister packs with resident names were disposed of in an open trash can, breaching resident confidentiality.
Resident #5’s admission contract was not signed by the resident and lacked notation explaining the omission.
Poisonous toothpaste was unlocked and accessible to resident #3 who was not assessed as capable of safely using it.
Resident #3's bathroom toilet had a brown substance smeared on it, indicating unsanitary conditions.
An uncovered, unattended trash can was present in the main kitchen on 06/01/2026.
Resident #4’s bedroom lacked a bedside table or shelf beside the bed.
Resident #4 did not have access to a source of light that can be turned on/off at the bedside; the broken lamp was not replaced.
Unlabeled, undated ice cream was found on top of ice cream containers in the main kitchen on 06/01/2026.
Meals were delivered on styrofoam containers, which the facility discontinued using after the inspection.
Residents #6 and #7 had medical evaluations completed without selecting options indicating their needs could be safely met at the home.
Resident #8’s medical evaluation for a change in status did not include the resident's ability to self-administer medications.
Several over-the-counter medications and creams were unsecured in resident #9's bedroom, who does not self-administer medications.
Expired morphine syringes and other medications were found on the medication cart; a loose unidentified pill was also found.
Resident #11's glucometer was not calibrated and showed incorrect date and time.
Residents #3, #4, #5, #8, and #12 were not educated on their right to refuse medication if they believed there was a medication error.
Resident #12’s initial support plan was not completed within 30 days of admission.
The home’s support plan did not include all behavioral needs and lacked documentation on how needs would be met or frequency.
Residents #5 and #13 participated in support plan development but did not sign the plans.
Medical evaluation records for residents #7 and #14 had dates that were written over and illegible.
Resident #5’s medical evaluation form was not completed on the Department’s current standardized form.
Report Facts
Residents Served: 112
Secured Dementia Care Unit Residents Served: 22
Current Residents Hospice: 4
Resident with Mental Illness: 2
Resident with Mobility Need: 53
Residents Age 60 or Older: 112
Residents with Intellectual Disability: 0
Residents with Physical Disability: 0
Medication syringes expired: 19
Remaining medication count: 30
Remaining medication count: 30
Remaining medication count: 4
Inspection Report — Feb 12, 2026
Follow-Up
Date: Feb 12, 2026
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. Two deficiencies related to resident rights and support plan signatures were addressed and corrected.
Citations (2)
42o - Associate/Communicate: A resident was asked to leave another resident's room twice as instructed by the Administrator, raising concerns about residents' rights to freely associate. Both residents were evaluated and diagnosed with moderate dementia, and staff training was planned regarding resident rights and capacity to consent.
227g - Support Plan Signatures: A resident participated in support plan development but did not sign the support plans. The signature was later obtained after review.
Report Facts
Residents Served: 102
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 7
Inspection Report — Feb 2, 2026
Follow-Up
Date: Feb 2, 2026
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction for the facility.
Findings
The submitted plan of correction was found to be fully implemented. Several deficiencies related to staff contact lists, CPR/first aid training, snow removal, unobstructed egress, annual medical evaluations, menu postings, additional resident assessments, and resident record content were addressed and corrected.
Citations (8)
62 - Contact List: The administrator provided a partial contact list that did not include ancillary staff.
63a - First Aid/CPR Training: During a period when 101 residents were present, only 2 staff were certified in CPR and only 1 in first aid and obstructed airway techniques.
100b - Removal Snow/Obstructions: Approximately 3 inches of snow accumulated on several walkways and exits, blocking egress.
121a - Unobstructed Egress: Egress doors from multiple areas were blocked by 3 inches of snow and ice, preventing them from opening.
141b1 - Annual Medical Evaluation: A resident's most recent medical evaluation date was missing or incomplete.
162c - Menus Posted: The weekly menu was posted only at the front of the building and not in a conspicuous place accessible to residents in the secured dementia care unit.
225c - Additional Assessment: A resident's current and previous assessments were incomplete or missing.
252 - Record Content: A resident's record did not include a death certificate.
Report Facts
Residents present: 101
Residents served: 101
Residents served in Dementia Care Unit: 21
Current Residents in Hospice: 8
Mobility Need: 45
Inspection Report — Jan 13, 2026
Monitoring
Date: Jan 13, 2026
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was found to be fully implemented with continued compliance required. Deficiencies were identified related to food storage practices including lack of thermometer in refrigerator/freezer, unsealed opened foods, and outdated or unlabeled food items.
Citations (3)
103f Refrigerator/Freezer Temps: There was no thermometer in the refrigerator and freezer in the 1st floor activity room. The thermometer was replaced immediately and temperature logging was implemented.
103g Storing Food: Cakes, pies, whipped cream, and ice cream in refrigerators and freezers were opened and unsealed. These items were discarded and daily audits were initiated.
103i Outdated Food: An unlabeled, undated bottle of salad dressing and peanut butter were found in the secured dementia care unit freezer. These items were discarded and daily audits were initiated.
Report Facts
Residents Served: 101
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 4
Inspection Report — Nov 20, 2025
Complaint Investigation
Date: Nov 20, 2025
Visit Reason
The inspection was an unannounced complaint and incident investigation conducted on 11/20/2025 and 11/21/2025 to review compliance with regulatory requirements and the submitted plan of correction.
Complaint Details
The inspection was complaint-related, triggered by incidents including resident altercations and concerns about care and supervision. The complaint was substantiated with multiple violations found.
Findings
The facility was found to have multiple deficiencies including failure to provide required assistance with activities of daily living, incomplete and unsigned resident contracts, incidents of resident abuse and neglect, inadequate staffing hours, incomplete staff training, medication management issues, incomplete resident assessments and support plans, and failure to use standardized forms. The submitted plan of correction was accepted and fully implemented by 02/18/2026.
Citations (21)
23a - Activities of Daily Living Assistance: A resident requiring assistance with dressing was found in a hospital gown without receiving required assistance.
25b - Contract Signatures: A resident-home contract was not signed by the home as required.
42b - Abuse: Residents in the secured dementia care unit were involved in altercations resulting in injury; supervision and behavioral assessments were inadequate.
57c - 2 Hours/Day: Direct care staffing hours provided were less than the minimum required for residents with mobility needs.
57d - Waking Hours: Required personal care service hours during waking hours were not fully met on multiple dates.
62 - Contact List: The administrator did not maintain an updated staff list, including terminated and missing staff.
63a - First Aid/CPR Training: On multiple shifts, staff certified in CPR-first aid were not present despite resident counts requiring coverage.
65f - Training Topics: Several direct care staff did not receive required training on medication self-administration and resident needs during 2024.
65g - Annual Training Content: Staff did not receive required training on The Older Adult Protective Services Act and fire safety during 2024.
141b1 - Annual Medical Evaluation: Some residents' annual medical evaluations were not completed for the required years.
183d - Prescription Current: A resident had a discontinued medication present in the medication cart.
184a - Resident's Meds Labeled: A pharmacy label for a resident's medication lacked administration instructions.
185a - Implement Storage Procedures: Accountability records were not signed immediately when controlled medications were administered.
187b - Date/Time of Medication Admin.: Medication administration records lacked initials of staff administering medications at specified times.
225c - Additional Assessment: A resident's assessment did not reflect behavioral needs despite involvement in an incident.
227b - Support Plan Content: Support plans did not include behavioral needs or document how needs would be met for several residents.
227g - Support Plan Signatures: Residents participated in support plan development but did not sign the plans as required.
231c - Preadmission Screening: A resident admitted to the secured dementia care unit did not have a completed cognitive preadmission screening.
234b - Support Plan Needs Elements: A resident's support plan did not identify behavioral needs despite involvement in an altercation as aggressor.
236 - Staff Training: A direct care staff member in the secured dementia care unit had only 5 hours of required dementia care training during 2024.
251c - Standardized Forms: Some residents' medical evaluations were not completed on the Department’s current standardized form for personal care homes.
Report Facts
Residents Served: 101
Residents with Mobility Needs: 26
Direct Care Hours Required: 124
Direct Care Hours Provided: 121.5
Direct Care Hours Required During Waking Hours: 92.25
Direct Care Hours Provided During Waking Hours: 91
Direct Care Hours Required During Waking Hours: 94.5
Direct Care Hours Provided During Waking Hours: 93
Residents Present on Night Shift: 100
Residents Present on Night Shift: 98
Residents Present on Evening Shift: 100
Notice — May 27, 2025
Date: May 27, 2025
Visit Reason
The document serves to notify the facility that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted under specified conditions.
Findings
The waiver is granted with conditions including documentation of education and training to be maintained and made available upon request. The Department will review the waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Feb 27, 2025
Follow-Up
Date: 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.
Citations (4)
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
Residents Served: 86
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 — Jan 28, 2025
Follow-Up
Date: 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.
Citations (7)
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
Residents Served: 84
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 — Jul 11, 2024
Complaint Investigation
Date: Jul 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 07/11/2024.
Complaint Details
The inspection was complaint-related and the complaint was not substantiated as no deficiencies were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 141
Waking Staff: 106
Residents Served: 93
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 — Feb 28, 2023
Renewal
Date: 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.
Citations (12)
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
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 — Apr 5, 2022
Follow-Up
Date: 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.
Citations (3)
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
Residents Served: 92
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 — Sep 27, 2021
Date: 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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report — Sep 14, 2021
Renewal
Date: 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.
Citations (12)
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
Residents Served: 92
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 — Mar 8, 2021
Monitoring
Date: 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.
Citations (4)
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
Residents Served: 81
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 |
Inspection Report — Sep 17, 2020
Re-Inspection
Date: Sep 17, 2020
Visit Reason
The inspection was conducted due to a change in legal entity and as a re-inspection within 3 months of the effective date of the new license to ensure compliance with 55 Pa.Code Ch. 2600 for Personal Care Homes.
Findings
The facility was found to be in substantial compliance with regulations but had several citations including unsecured poisonous materials, unsecured knives in the secure dementia care unit, failure to submit emergency procedures annually to the local emergency management agency, and preadmission cognitive screenings completed outside the required 72-hour timeframe.
Citations (4)
82c - Locking Poisonous Materials: A tube of toothpaste with a poison warning label was found unlocked and accessible to a resident in the Secure Dementia Care Unit. Not all residents were assessed capable of safely using or avoiding poisonous materials.
95 - Furniture and Equipment: Two knives were found unsecured in an unlocked cabinet in the Secure Dementia Care Unit.
107d - Procedure Emergency Management Agency Submission: The home’s written emergency procedures had not been submitted to the municipal emergency management agency as required.
231c - Preadmission Screening: Two residents admitted to the Secure Dementia Care Unit had cognitive preadmission screenings completed outside the required 72-hour period prior to admission.
Report Facts
Residents Served: 74
Secure Dementia Care Unit Residents Served: 14
Hospice Current Residents: 8
Staff Total Daily: 124
Staff Waking: 93
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