Quarryville Presbyterian Retirement Community

In the surveyor’s words

From the most serious findings on record at Quarryville Presbyterian Retirement Community, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF565Aug 30, 2025

  Based on review of Resident Council meeting minutes and information provided to residents, as well as resident and staff interviews, it was determined that the facility failed to act promptly upon the grievances of the Resident Council. Findings Include: Resident Council meeting minutes for June 30, July 28 and August 25, 2025, revealed that residents brought up repeat concerns regarding food temperatures and flies in the dining room. During each meeting the residents were reminded that any dining concerns with food temperatures were to be brought to their attention immediately so they could make necessary adjustments at the time of the complaint. […]

• No harm, potential for more than minimal, patternF605Aug 30, 2025

  Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for four of 39 residents reviewed (Residents 3, 28, 36 and 78).Findings Include: A facility policy for psychotropic medication management dated March 31, 2025, indicated that the facility will minimize the use of psychotropic medications, avoid unnecessary drug use, and promote the use of non-pharmacological interventions whenever possible. […]

• No harm, potential for more than minimal, patternF812Aug 30, 2025

  Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that ice was made and stored in sanitary ice machines for one of two ice machines (main kitchen). Findings include: The facility's policy for ice machines, dated March 31, 2025, revealed that every month the ice machines were to have the ice removed, the inside of the machine washed with sanitizing solution and a clean cloth, allowed to dry, and then refilled with ice. A third party vendor would come in quarterly and as needed to service the ice machine. A Service log, dated March 3, 2025, revealed that preventative maintenance was performed by a contracted service. […]

• No harm, potential for more than minimal, isolatedF552Aug 30, 2025

  Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident or resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the person's mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for two of 39 residents reviewed (Residents 3 and 36).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 26, 2025, indicated that the resident was admitted to the facility on [DATE], was cognitively impaired, was rarely or never understood, had physical, verbal and other behaviors not directed towards… […]

• No harm, potential for more than minimal, isolatedF607Aug 30, 2025

  Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete nurse aide registry verification for one of three new nurse aides reviewed (Nurse Aide XX) and failed to ensure that the status of nursing licenses were checked with the State Board of Nursing for one of one newly hired nurses reviewed (Registered Nurse XX).Findings include:The facility's policy regarding abuse prohibition, dated March 31, 2025, indicated that the prior to the first day of employment, the facility would verify with the Pennsylvania Department of Health Nurse Aid Registry the standing/certification of all applicants offered employment as a nurse aide. […]