Inspection visit
Inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0552
Ensure that residents are fully informed and understand their health status, care and treatments.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 others, took antipsychotic medications (medications used
to treat psychosis and other mental and emotional conditions), antianxiety and antidepressant medications
(psychotic medications), and had diagnoses that included Alzheimer's dementia, depression, and
anxiety.Physician's orders for Resident 3, dated May 13, 2025, May 30, 2025, and August 1, 2025, revealed
that the resident was to receive 1 milligram (mg) of transdermal (application of a medicine through the skin)
Ativan (a psychotropic medication) gel twice daily as needed for agitation. A psychiatry note for Resident 3,
dated May 23, 2025, revealed that as needed Ativan gel was recently added May 15, 2025, by the
resident's primary care physician.Review of Resident 3's Medication Administration Record (MAR) for May
2025 through August 2025, revealed that the resident received 1 mg of transdermal Ativan on June 2 at
5:04 p.m., June 24 at 3:54 p.m., June 29 at 5:29 p.m., June 30 at 4:45 a.m., July 7 at 3:35 a.m., August 16
at 8:00 p.m. and August 25 at 3:26 a.m.Review of Resident 3's clinical record revealed no documented
evidence that an informed consent was obtained from the resident representative prior to initiating the
administration of the as needed transdermal Ativan.An admission MDS assessment for Resident 36, dated
August 25, 2025, revealed that the resident was cognitively impaired, was rarely/never, took antipsychotic
and antianxiety medications, and had diagnoses that included Alzheimer's dementia and
anxiety.Physician's orders for Resident 36, dated August 23, 2025, revealed that the resident was to receive
0.25 mg of Ativan three times daily as needed for anxiety and agitation.Review of Resident 36's MAR for
August 2025, revealed that the resident received 0.25 mg of Ativan on August 23 at 1:17 p.m., August 25 at
3:32 p.m., and August 27 at 8:39 p.m.Physician's orders for Resident 36, dated August 25, 2025, revealed
that the resident was to receive 0.25 mg of transdermal Lorazepam (Ativan) gel twice daily as needed for
anxiety/agitation.Review of Resident 36's MAR for August 2025, revealed that the resident received 0.25
mg of transdermal Lorazepam (Ativan) on August 26 at 4:16 p.m., August 27 at 10:39 a.m., and August 29
at 12:30 p.m.Review of Resident 36's clinical record revealed no documented evidence that an informed
consent was obtained from the resident representative prior to initiating the administration of the as needed
Ativan.Interview with the Director of Nursing on August 29, 2025, at 2:02 p.m., revealed that the facility was
completing informed consents for use of antipsychotic medications, but not
Residents Affected - Few
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 14
Event ID:
395336
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0552
for any other psychotropic medications.28 Pa. Code 201.29(a)(j) Resident Rights.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 2 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm
or potential for actual harm
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:
Residents Affected - Some
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. The residents were also reminded that there was regularly scheduled pest control visits and
multiple remedies in place to control the flies as best as possible. At June's meeting they were to notify the
pest control company.
An interview with a group of residents on August 28, 2025, at 11:30 a.m. revealed that the food was not hot
and they brought flies up three times and the facility didn't do anything about it.
Pest control records for June 20, July 18, and August 15, 2025 revealed there was no treatment for flies
There was no documented evidence provided to show that prompt efforts were made to resolve the
Resident Council's concerns, regarding food temperatures and flies, when they were expressed during the
meetings on June 30, July 28 and August 25, 2025.
Interview with the Assistant Nursing Home Administrator on August 29, 2025 at 3:02 p.m. revealed that a fly
catcher was purchased in June; however there were no new interventions put into place in July and August.
Interview with the Nursing Home Administrator on August 30, 2025, at 11:08 a.m. revealed that tray audits
were done on June 15 and July 16, 2025 and that the President of Resident Council complains at every
meeting.
28 Pa. Code 201.29(i) Resident rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 3 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0605
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's
ability to function.
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. Psychotropic medications include antipsychotics
(class of drugs used to treat mental health conditions), antianxiety medications, antidepressants, and
hypnotics (induce sleep and sedation).
Physician’s orders for Resident 3, dated May 30, 2025, revealed that the resident was to receive 1
milligram (mg) of transdermal (application of a medicine through the skin) Ativan gel twice daily as needed
for agitation.
Review of Resident 3’s Medication Administration Record (MAR) for May 2025 through July 2025,
revealed that the resident received 1 mg of transdermal Ativan on June 2 at 5:04 p.m., June 24 at 3:54
p.m., June 29 at 5:29 p.m., June 30 at 4:45 a.m., and July 7 at 3:35 a.m. Resident 3’s Ativan was
ordered on May 30, 2025, and extended through August 1, 2025. There was no documented evidence that
a physician provided a rationale to extend the medication past 14 days.
An Interview with the Director of Nursing on August 28, 2025, at 3:18 p.m. confirmed that the facility failed
to ensure that Resident 3’s as needed psychotropic medication was limited to 14 days or had a
clinical rationale for continuing beyond 14 days.
Physician’s orders for Resident 3, dated May 30, 2025, revealed that the resident was to receive 1
milligram (mg) of transdermal (application of a medicine through the skin) Ativan gel twice daily as needed
for agitation. A care plan for the resident, dated March 24, 2025, revealed that the resident was taking
psychotropic medications and staff were to offer non-pharmacological interventions prior to medication
administration.
Review of Resident 3’s MAR for May 2025 through August 2025, revealed that the resident received
1 mg of transdermal Ativan on June 2 at 5:04 p.m., July 7 at 3:35 a.m., and August 16 at 8:00 p.m. Review
of Resident 3’s clinical record, including documentation on the MAR and in the progress notes,
revealed no documented evidence that non-pharmacological interventions were attempted prior to
administering the as needed Ativan on the above-mentioned dated and times.
Interview with the Director of Nursing on August 29, 2025, at 2:48 p.m. confirmed that there was no
documented evidence that non-pharmacological interventions were attempted prior to administering as
needed Ativan to Resident 3 on the above-mentioned dates/times.
A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's
abilities and care needs) for Resident 28 dated June 6, 2025, indicated that the resident was cognitively
impaired, required assistance from staff for daily care needs, and had diagnosis that included dementia.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 4 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0605
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Physician’s orders for Resident 28 dated August 4, 2025, included for the resident to receive 0.25
milligrams (mg) of Ativan (an antianxiety medication) every six hours as needed for anxiety. There was no
documented evidence that a physician provided a rationale to extend the medication past 14 days.
Review of the Medication Administration Record (MAR) for Resident 28 dated August 2025, revealed that
the resident was administered 0.25 mg of Ativan on August 24, 2025, at 3:58 p.m.
An Interview with the Director of Nursing on August 28, 2025, at 3:18 p.m. confirmed that the facility failed
to ensure that Resident 28’s as needed psychotropic medication was limited to 14 days or had a
clinical rationale for continuing beyond 14 days.
An admission MDS assessment for Resident 36, dated August 25, 2025, revealed that the resident was
cognitively impaired, was rarely/never, took antipsychotic and antianxiety medications, and had diagnoses
that included Alzheimer’s dementia and anxiety. A care plan for the resident, dated August 18, 2025,
revealed that the resident was taking psychotropic medications and staff were to offer non-pharmacological
interventions prior to medication administration.
Physician’s orders for Resident 36, dated August 23, 2025, revealed that the resident was to receive
0.25 mg of Ativan three times daily as needed for anxiety and agitation.
Review of Resident 36’s MAR for August 2025, revealed that the resident received 0.25 mg of
Ativan on August 23 at 1:17 p.m., August 25 at 3:32 p.m., and August 27 at 8:39 p.m. Review of Resident
36’s clinical record, including documentation on the MAR and in the progress notes, revealed no
documented evidence that non-pharmacological interventions were attempted prior to administering the as
needed Ativan on the above-mentioned dated and times.
Physician’s orders for Resident 36, dated August 25, 2025, revealed that the resident was to receive
0.25 mg of transdermal Lorazepam (Ativan) gel twice daily as needed for anxiety/agitation.
Review of Resident 36’s MAR for August 2025, revealed that the resident received 0.25 mg of
transdermal Lorazepam (Ativan) on August 26 at 4:16 p.m., August 27 at 10:39 a.m., and August 29 at
12:30 p.m. Review of Resident 36’s clinical record, including documentation on the MAR and in the
progress notes, revealed no documented evidence that non-pharmacological interventions were attempted
prior to administering the as needed Ativan on the above-mentioned dated and times.
Interview with the Director of Nursing on August 29, 2025, at 4:02 p.m. confirmed that there was no
documented evidence that non-pharmacological interventions were attempted prior to administering as
needed Ativan to Resident 36 on the above-mentioned dates/times.
An annual MDS assessment for Resident 78, dated June 25, 2025, revealed that the resident was
cognitively impaired, was sometime understood, could sometimes understand, took antipsychotic and
antianxiety medications, and had diagnoses that included Alzheimer’s dementia, depression, and
anxiety
A psychiatry consult dated March 14, 2025, for Resident 78 indicated that the facility and their staff were to
utilize non pharmacological interventions, supportive care, and redirection.
Physician’s orders for Resident 78, dated May 12, 2025 and August 18, 2025, revealed that the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 5 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0605
resident was to receive 0.5 mg of Ativan every eight hours as needed for anxiety.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 78’s MAR for July and August 2025, revealed that the resident received 0.25 mg
of Ativan on July 26 at 9:32 p.m., August 21 at 9:53 p.m., and August 21at 11:29 p.m. Review of Resident
78’s clinical record, including documentation on the MAR and in the progress notes, revealed no
documented evidence that non-pharmacological interventions were attempted prior to administering the as
needed Ativan on the above-mentioned dated and times.
Residents Affected - Some
Interview with the Director of Nursing on August 29, 2025, at 2:48 p.m. confirmed that there was no
documented evidence that non-pharmacological interventions were attempted prior to administering as
needed Ativan to Resident 78 on the above-mentioned dates/times.
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 cognitively impaired, was
rarely or never understood, had physical, verbal and other behaviors not directed towards others, took
antipsychotic (medications used to treat psychosis and other mental and emotional conditions), antianxiety
and antidepressant medications, and had diagnoses that included Alzheimer’s dementia,
depression, and anxiety.
28 Pa. Code 211.2(d)(3) Medical director
28 Pa. Code: 211.9(a)(1) Pharmacy services.
28 Pa. Code: 211.12 (d)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 6 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
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. The facility would not employ
individuals who had a finding entered in the nurse aide registry or who had a disciplinary action in effect
against their professional license by a state licensure body as a result of a finding of abuse, neglect,
exploitation, misappropriation of their property or mistreatment of residentsThe personnel file for Nurse
Aide E3 revealed that she was hired as a nurse aide on May 11, 2025, and there was no documented
evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified prior to hire.
The personnel file for Registered Nurse E4 revealed she was hired as a registered nurse on June 1, 2025.
There was no documented evidence that her licensure status was checked with the State Board
(Texas).Interview with the Director of Human Resources on August 27, 2025, at 1:19 p.m. and 2:09 p.m.
confirmed that Nurse Aide E3's standing on the Pennsylvania Nurse Aide Registry was not verified prior to
her hire and Registered Nurse E4's licensure status was not checked prior to hire.28 Pa. Code 201.14(a)
Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 7 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to
ensure that a resident's baseline care plan included information regarding the resident's immediate care
needs for one of 39 residents reviewed (Residents 101). Findings include: An admission note for Resident
101, dated August 21, 2025, at 12:16 p.m., revealed that the resident arrived at the facility and had sinusitis
(an inflammation of the sinuses) and was going to receive medication for three more days. A current care
plan for the resident, dated August 21, 2025, indicated that the resident had an infection diagnosed as
sinusitis. A progress note for Resident 101, dated August 22, 2025, at 3:01 p.m. revealed that the resident
was positive for COVID and was in respiratory isolation. Observations during the facility tour on August 27,
2025, at 11:34 a.m. revealed a stop sign on Resident 101's door. Interview with staff during the tour
indicated that the resident was placed on droplet precautions due to testing positive for covid on admission.
There was no documented evidence in the resident's clinical record that a baseline care plan was
implemented related to the resident's positive COVID diagnosis and his need for droplet precautions.
Interview with the Assistant Director of Nursing on August 30, 2025, at 1:08 p.m. confirmed that a baseline
care plan was not implemented for Resident 101 related to his positive COVID diagnosis after admission.
She indicated that he had a diagnosis of sinusitis on admission, and the care plan was not revised to reflect
that he had COVID and was on droplet precautions. 28 Pa. Code 211.12(d)(1) Nursing Services
Event ID:
Facility ID:
395336
If continuation sheet
Page 8 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that
the facility failed to develop an individualized care plan for two of 39 residents reviewed (Residents 10 and
88). Findings include:
A facility policy for Comprehensive Care Plans dated March 31, 2025, indicated that it is the facility’s
policy that each resident receives individualized, comprehensive, and coordinated care through the
development, implementation and ongoing evaluation of an interdisciplinary care plan. The development of
a comprehensive care plan should occur by the interdisciplinary team following the initial Minimum Data Set
(MDS) assessment (a mandated assessment of a resident's abilities and care needs).
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 10, dated July 17, 2025, revealed that the resident was cognitively impaired, was
usually understood and was able to sometimes understand others, required assistance with care needs,
took an anticoagulant medication (used to prevent or treat blood clots).
Physician’s orders for Resident 10, dated August 25, 2025, included an order for the resident to
receive 2 milligrams (mg) of warfarin (an anticoagulant) every other day for atrial fibrillation (irregular heart
rhythm). There was no documented evidence that the facility implemented a care plan related to the
resident’s need for anticoagulant therapy.
An interview with the Director of Nursing on August 30, 2025, at 2:37 p.m. confirmed that there was no
documented evidence that the facility implemented a care plan related to Resident 10’s need for
anticoagulant therapy.
A quarterly MDS) assessment for Resident 88, dated July 11, 2025, indicated that the resident was
cognitively intact, required assistance from staff for daily care needs, had diagnoses that included heart
failure and was receiving anticoagulant medication (used to prevent or treat blood clots).
Physician’s orders for Resident 88 dated August 27, 2025, included for the resident to receive 3
milligrams (mg) of warfarin (an anticoagulant) daily.
An interview with the Assistant Director of Nursing on August 30, 2025, at 1:11 p.m. confirmed that
Resident 88's care plan did not include care and treatment needs related to the resident’s
anticoagulant medication use.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 9 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that
the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific
care needs for two of 39 residents reviewed (Residents 7 and 9). Findings include:
A facility policy for Comprehensive Care Plans dated March 31, 2025, indicated that the resident’s
plan of care should be updated as necessary on an on-going basis. Changes will be communicated to team
members as needed or indicated.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs
and abilities) for Resident 7 dated August 4, 2025, indicated that the resident was cognitively intact, was
understood, could understand, required assistance with daily care needs, and had diagnoses that included
a stroke.
Interview with Resident 7 on August 28, 2025, at 1:43 p.m. indicated that he currently had an indwelling
catheter, and no other to have straight catheterization (single-use tube inserted into the bladder to drain
urine).
Physician’s order for Resident 7 dated August 11, 2025, indicated he had a indwelling foley catheter
(a thin, flexible tube inserted into the urethra that carries urine from the bladder to the outside of the body to
drain urine) size 16 French (Fr) with a 15 cubic centimeter (cc) balloon for urinary retention.
The care plan for Resident 7 dated July 28, 2025, indicated that the resident was continent and incontinent
of bladder. He has urinary retention with the need for intermittent catheterization. Resident 7 has a
intervention that he requires straight catheterization.
An interview with the Assistant Director of Nursing on August 28, 2025, confirmed that Resident 7 care plan
was not revised to reflect that he has an indwelling catheter and should have been.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs
and abilities) for Resident 9 dated June 25, 2025, indicated that the resident was cognitively intact, required
assistance with daily care needs, and had diagnoses that included a hip fracture.
The Care plan for Resident 9 dated June 24, 2025, indicated that the resident had anticoagulant (used to
prevent and treat blood clots) medication ordered that included Lovenox (an anticoagulant), and that the
resident had diabetes and staff were to administer insulin as ordered.
Review of the Medication Administration Record (MAR) for Resident 9 dated August 2025 and September
2025, revealed no documented evidence that the resident received Lovenox or insulin.
An interview with the Director of Nursing on August 30, 2025, confirmed that Resident 9 was no longer
receiving Lovenox or insulin and her care plan should have been revised to indicate that.
28 Pa. Code 211.12(d)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 10 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policies and clinical records, as well as staff interviews, it was determined that the facility
failed to complete safety assessments for one of 39 residents reviewed who used a electric lifting recliner
chair (Resident 6) and failed to ensure that assistance devices to prevent accidents or injury were in place
for one of 39 residents reviewed (Resident 15).Findings Include:
A facility policy for wheelchair leg rests dated March 31, 2025, indicated that the facility would ensure and
promoted safe and appropriate use of wheelchairs leg rests when transporting residents short or long
distances. Wheelchair leg rests should be used when transporting residents over klong distances or when a
resident is unable to lift their leg rests while the chair is in motion. Wheelchair leg rests should also be used
when resident cannot or will not [NAME] their legs for short transports.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 6, dated June 10, 2025, indicated that the resident was cognitively intact, required
assistance from staff for daily care needs, and had diagnoses that included chronic kidney disease
(condition where the kidneys gradually lose their ability to function properly over time).
A nurse’s note for Resident 6 dated August 7, 2025, at 4:41 a.m. revealed that the resident was
observed on his knees facing his recliner with his upper body resting on the recliner. The resident reported
at the time that he was getting up to ring his call bell.
An occupational therapy note for Resident 6 dated August 13, 2025, indicated that the resident was able to
operate his recliner to sit upright and elevated with supervision.
Observation in Resident 6’s room on August 27, 2025, revealed the resident sitting in his wheelchair
with a electric lifting recliner chair in his room in the up position.
Review of a fall investigation provided by the facility dated August 7, 2025, indicated that the Resident 6
was in his recliner because he was vomiting earlier in the night and that he has poor safety awareness with
impulsive actions and behaviors.
An interview with the Director of Nursing on August 29, 2025, at 2:02 p.m. revealed that the facility did not
have an electric lifting recliner chair safety assessment completed on Residents 6 who used electric lifting
recliner chair at the time of the survey.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and
abilities) for Resident 15 dated July 31, 2025, indicated that the resident was severely cognitively impaired,
was usually understood, could usually understand, required assistance with daily care needs, used a
wheelchair for mobility, and had diagnoses that included a rheumatoid (Joint pain, stiffness and swelling)
and osteoarthritis Joint pain, stiffness, creaking or grinding sounds in the joints, and limited range of
motion)
Observations on August 27, 2025 at 11:46 a.m. revealed that Hospitality Aide E5 pushed Resident 15 from
the her room to in the dining room through the hall past both nursing stations while her feet, which had
shoes were crossed at the ankles, with one foot dragging on the floor.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 11 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview with Hospitality Aide E5 on August 27, 2025 at 11:31 a.m. revealed that she pushed the resident
to the dining room for lunch. She stated that Resident 15 was able to self-propel and that is why she did not
have leg rests on her chair. She further stated that she didn't think that she had foot petals for her
wheelchair.
Interview with Director of Nursing on August 28, 2025, at 9:44 a.m. confirmed that Resident 15 should have
had leg rests on her wheelchair while being transported if she was unable to lift her feet off the floor. She
said that they will use them for long distances when outside of the facility.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 12 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on review of facility policies and clinical records, as well as staff and resident interviews, it was
determined that the facility failed to ensure that a toileting program was followed to maintain a resident's
continence for one of 39 residents reviewed (Resident 24). Findings include: A facility policy related to
restorative nursing programs, dated March 31, 2025, indicated that facility provides individualized
restorative nursing interventions in accordance with resident needs, care plans, and regulatory
requirements to promote and maintain the highest level of physical, mental and psychosocial functioning for
residents. Restorative interventions may include bowel and bladder programs that consist of training and
toileting schedules. Restorative programs will be carried out by trained restorative nursing assistants, nurse
aides, or licensed staff as delegated. Restorative interventions, frequency, and outcomes will be
documented in the medical record per facility policy. A quarterly Minimum Data Set (MDS) assessment (a
mandated assessment of a resident's abilities and care needs) for Resident 24, dated August 12, 2025,
revealed that the resident was mildly cognitively impaired, was clearly understood and able to clearly
understand others, was dependent on staff for toileting transfers and hygiene, was on a toileting program,
was frequently incontinent of urine, and had a diagnosis of Parkinsonism (a neurological disorder causing
slowed movements, stiffness and tremors) and dementia. A care plan for the resident, dated September 6,
2024, indicated that the resident was on a scheduled toilet plan for bladder. Interventions included to offer
assistance/encourage toileting at least every two hours during awake time and at bed checks. Offer toileting
upon rising, within one hour before meals, within one hour after meals, at bedtime and whenever the
resident requests. In addition to routine toileting, toilet at scheduled times as follows: have the resident sit
on the toilet to void at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., 8:00 p.m., and
10:00 p.m. if still awake. An interview with Resident 24 on August 27, 2025, at 10:47 a.m. revealed that she
cannot use bathroom any sooner than every two hours and if she says she has to go, they don't always
take her indicating that it is not her scheduled time to go. Interview with the resident's husband at the time
of the resident interview indicated that they do not toilet her when needed. Review of Resident 24's clinical
documentation from April 18, 2025, through August 22, 2025, including review of progress notes and review
of the toileting program documentation, revealed that there was no documented evidence that the resident's
toileting program was completed as scheduled and as per the resident's care plan. Interview with the
Director of Nursing on August 30, 2025, at 12:50 p.m. confirmed that there was no documented evidence
that Resident 24's toileting program was completed as scheduled and as per the resident's care plan. 28
Pa. Code 211.12(d)(5) Nursing Services.
Event ID:
Facility ID:
395336
If continuation sheet
Page 13 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quarryville Presbyterian Retirement Community
625 Robert Fulton Highway
Quarryville, PA 17566
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
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. There was no documented evidence that the ice machine was cleaned on a monthly
basis.
Observations on August 27, 2025, at 9:02 a.m. revealed that inside the ice machine there was a build up of
a pink substance on the right hand corner of the white plastic piece and a build up of a black substance on
the entire length of the strip at the top of the ice machine. The chest was full of ice.
Interview with Dietary Manager at that time confirmed that the ice machine needed cleaned. 28 Pa. Code
211.6(f) Dietary services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395336
If continuation sheet
Page 14 of 14
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the August 30, 2025 survey of QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY?
This was a inspection survey of QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY on August 30, 2025. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY on August 30, 2025?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep aisles, corridors, and exits free of obstruction in case of emergency."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.