Quadrangle

In the surveyor’s words

From the most serious findings on record at Quadrangle, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 16, 2025

  Based on review of facility policy, clinical record, facility documentation, and interviews with staff, it was determined the facility failed to check the temperature of the hot water provided to Resident R1 which resulted in actual harm to Resident R1, of spillage of hot water on the left upper and outer thigh, and developing a blister on the left thigh for one of six residents. (Resident R1) Findings include: Review of the facility's police title Safe holding and serving temperature for hot beverages last revised May 2, 2017, revealed the temperatures that hot beverages should be served at are governed by palatability and by the risk for a burn. Under Procedure A, it further states Serve the hot beverages between 140 and 155 degrees. […]

• No harm, potential for more than minimal, widespreadF812Apr 3, 2025

  Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served food in accordance with professional standards for food service safety. Findings include: Review of the facilities, Food Storage, Preparation and Service policy with a revision date of April 11, 2022 indicated that food storage areas included walk in and reach in refrigerators and freezers, under the counter refrigeration and freezer units, bistro and common area refrigerator and freezer units, and any dry storage area units. The policy also state that all food items are labeled, dated and rotated to maintain a system of First In First Out. […]

• No harm, potential for more than minimal, widespreadF814Apr 3, 2025

  Based on observations, it was determined that the facility failed to properly dispose of garbage and refuse. Findings Include: Observations on April 2, 2026 with the Culinary Director (Employee E23), the Director of Maintenance (Employee E24), and the Nursing Home Administrator on April 2, 2025 at 11:35 a.m. near the trash compactors (areas on the sides of , front of, back of, and underneath of the trash compactors) located near the loading dock receiving area revealed the following: Various trash items such as tops to jars, cans, sugar packets bottles and cardboard boxes were seen in the above referenced areas. The presence of fall leaves and 1 dinner plate was even also among the trash/debris. […]

• No harm, potential for more than minimal, patternF812Feb 27, 2026

  Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department was conducted on February 24, 2026, at 9:20 a.m. with Employee E4, Sous Chef, revealed the following concerns: Observation in the reach-in refrigerator revealed two shopping bags containing personal food/drink. Observation in the kitchen revealed two ice cream freezers with clear tops that were smeared with a milky-whiteish sticky substance and several of the 3-gallon ice cream containers were not covered. […]

• No harm, potential for more than minimal, patternF623Apr 3, 2025

  Based on review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that the Office of the State Long-Term Care Ombudsman was notified of facility-initiated transfers and discharges, and failed to ensure that a 30-day discharge notice included required information, for four of four residents reviewed for discharge notices (Residents R57, R16, R59 and R58). Findings include: Review of facility documentation, Admission/Discharge To/From Report revealed that Resident R16 was transferred to the hospital on January 10, 2025; that Resident R59 was transferred to the hospital on January 17, 2025; and that Resident R58 was transferred to the hospital on January 9, 2025. […]