Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview, it was determined that the facility failed to notify the resident's
representative(s) of transfer/discharge and the reasons for the move in writing for eight of 26 sampled
residents. (Residents 12, 29, 45, 49, 83, 101, 119, 126)
Findings include:
Clinical record review revealed that Resident 12 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no evidence that the resident and resident's representative were
provided with written information regarding the resident's transfer to the hospital.
Clinical record review revealed that Resident 29 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no evidence that the resident and resident's representative were
provided with written information regarding the resident's transfer to the hospital.
Clinical record review revealed that Resident 45 was transferred and admitted to the hospital on [DATE],
and December 30, 2023, after changes in condition. There was no evidence that the resident and resident's
representative were provided with written information regarding the resident's transfer to the hospital.
Clinical record review revealed that Resident 49 was transferred and admitted to the hospital on [DATE],
and February 16, 2024 after changes in condition. There was no evidence that the resident and resident's
representative were provided with written information regarding the resident's transfer to the hospital.
Clinical record review revealed that Resident 83 was transferred and admitted to the hospital on [DATE],
August 8, 2023, October 4, 2023, and January 19, 2024, after changes in condition. There was no evidence
that the resident and resident's representative were provided with written information regarding the
resident's transfers to the hospital.
Clinical record review revealed that Resident 101 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no evidence that the resident and resident's representative were
provided with written information regarding the resident's transfer to the hospital.
Clinical record review revealed that Resident 119 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no evidence that the resident and resident's representative were
provided with written information regarding the resident's transfer to the hospital.
(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 7
Event ID:
395405
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
395405
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quakertown Center
1020 South Main Street
Quakertown, PA 18951
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 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Clinical record review revealed that Resident 126 was discharged from the facility on December 27, 2023,
for an increase in behaviors. There was no evidence that the resident and resident's representative were
provided with written information regarding the discharge.
In an interview on March 8, 2024, at 12:12 p.m., the Administrator confirmed that written transfer or
discharge information, including the reasons for the move, were not provided to the residents and residents'
representative.
28 Pa. Code 201.29(c.3)(2)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395405
If continuation sheet
Page 2 of 7
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
395405
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quakertown Center
1020 South Main Street
Quakertown, PA 18951
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 0625
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview, it was determined that the facility failed to provide a written notice
of the facility's bed-hold policy to the resident, family member, or legal representative at the time of transfer
for two of 12 sampled residents who were transferred to the hospital. (Residents 45, 101)
Findings include:
Clinical record review revealed that Resident 45 was transferred and admitted to the hospital on [DATE],
and December 30, 2023, after changes in condition. There was no documented evidence that the resident,
resident's responsible party, or legal representatives were provided written information about the facility's
bed-hold policy at the time of transfer.
Clinical record review revealed that Resident 101 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no documented evidence that the resident, resident's responsible
party, or legal representatives were provided written information about the facility's bed-hold policy at the
time of transfer.
In an interview on March 8, 2024, at 11:20 a.m., the Director of Nursing confirmed that no written notice of
the bed-hold policy was given to the resident or residents' representative upon transfer out of the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395405
If continuation sheet
Page 3 of 7
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
395405
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quakertown Center
1020 South Main Street
Quakertown, PA 18951
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 clinical record review and staff interview, it was determined that the facility failed to develop a
comprehensive care plan that addressed individual resident needs as identified in the comprehensive
assessment for one of 26 sampled residents. (Resident 119)
Findings include:
Clinical record review revealed that Resident 119 had a Minimum Data Set assessment completed on
February 13, 2024. According to the assessment, the resident received nutrition from a feeding tube.
According to the Care Area Assessment summary from that assessment, the facility identified that nutrition
and a feeding tube were problem areas for the resident and should have been included on the
comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to
address these care areas.
In an interview on March 8, 2024, at 10:10 a.m., the Director of Nursing confirmed that Resident 119's care
plan did not include the areas of potential concern identified in the comprehensive assessment.
28 Pa. Code 211.12(d)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395405
If continuation sheet
Page 4 of 7
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
395405
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quakertown Center
1020 South Main Street
Quakertown, PA 18951
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, observation, and staff interview, it was determined that the facility failed to implement
interventions to prevent further decline and/or improve range of motion for one of seven sampled residents.
(Resident 49)
Findings include:
Clinical record review revealed that Resident 49 had diagnoses that included multiple sclerosis,
quadriplegia, and Parkinson's Disease. The Minimum Data Set assessment dated [DATE], indicated that
the resident had memory impairment and required extensive assistance from staff for personal hygiene and
dressing. Review of the care plan revealed that staff was to apply bilateral hand carrots (orthotic devices)
for four hours to prevent contractures and maintain skin integrity. Review of the current physician's orders
revealed that staff was to apply bilateral hand carrots four hours daily, on at 10 a.m. and off at 2 p.m.
Observation on March 5, 2024, revealed the resident in bed at 11:34 a.m., 12:15 p.m., and 1:10 p.m.,
without the bilateral hand carrots in place. On March 6, 2024, the resident was in bed at 12:45 p.m., and
1:50 p.m., without the bilateral hand carrots in place. On March 7, 2024, the resident was again in bed at
10:55 a.m. and 1:07 p.m., without the bilateral hand carrots in place.
In an interview on March 8, 2024, at 10:45 a.m., the Director of Nursing confirmed that the staff was to
apply bilateral hand carrots as ordered by the physician.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395405
If continuation sheet
Page 5 of 7
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
395405
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quakertown Center
1020 South Main Street
Quakertown, PA 18951
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
facility policy review, clinical record review, observation, and resident and staff interview, it was determined
that the facility failed to assess and implement safety measures related to smoking for two of two sampled
residents. (Resident 6, 83)
Findings include:
Review of the facility policy entitled, Smoking, last reviewed August 7, 2023, revealed that smoking would
be permitted in designated areas, that residents would be assessed on admission, quarterly, and with
change in condition for the ability to smoke safely and, if necessary, would be supervised. The policy also
required that smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid,
batteries, refill cartridges, etc.) would be labeled with the resident 's name, room number, and bed number,
maintained by staff, and stored in a suitable cabinet kept at the nursing station.
Clinical record review revealed that Resident 6 had diagnoses that included Post Traumatic Stress Disorder,
sacroiliitis, blindness in the left eye, personal history of pulmonary embolism and thrombosis, personal
history of hip replacements. According to the Minimum Data Set assessment (MDS), dated [DATE], the
resident had no cognitive impairment. Observations on March 5, 2024, at 11:42 a.m., and March 6, 2024, at
10:42 a.m., revealed Resident 6 smoking outside the front of the building. In an interview on March 6, 2024,
at 10:42 a.m., Resident 6 reported smoking on a regular basis. There was no documented evidence that
the facility completed smoking assessments for Resident 6 after July 8, 2023.
Clinical record review revealed that Resident 83 had diagnoses that included Diabetes with polyneuropathy,
chronic kidney disease, and paralytic syndrome following a cerebral infarction. According to the MDS, dated
[DATE], the resident had no cognitive impairment. In an interview on March 7, 2024, at 12:05 p.m.,
Resident 83 reported smoking on a regular basis. There was no documented evidence that the facility
completed smoking assessments for Resident 83 after October 1, 2023.
In an interview on March 7, 2024, at 1:40 p.m., the Director of Nursing and Administrator confirmed that
Residents 6 and 83 had been permitted to smoke and that quarterly smoking assessments had not been
completed.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395405
If continuation sheet
Page 6 of 7
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
395405
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quakertown Center
1020 South Main Street
Quakertown, PA 18951
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on clinical record review, facility policy review, and staff interview, it was determined that the facility
failed to ensure that a PRN (as needed) psychotropic medication was limited to 14 days unless the
physician documented in the clinical record the rationale for the PRN to be extended beyond 14 days for
two of 26 sampled residents. (Residents 43, 67)
Findings include:
Review of the facility policy entitled, Psychotropic Medication Use, last reviewed October 26, 2023, PRN
psychotropic medication should not be ordered for more that 14 days. Residents who were taking PRN
psychotropic medications were to have their prescription reviewed by the physician every 14 days.
Clinical record review revealed that Resident 43 had diagnoses that included dementia and depression. On
February 8, 2024, a physician ordered that staff administer a psychotropic medication (risperidone) every
day as needed for anxiety. The order for the risperidone failed to include a time frame for the continued use
of the medication. There was no physician documentation that it was appropriate for the order to be
extended beyond 14 days.
Clinical record review revealed that Resident 67 had diagnoses that included dementia and anxiety. On
December 29, 2023, a physician ordered that staff administer a psychotropic medication (lorazepam) every
24 hours as needed for agitation. Review of the Medication Administration Record for March 2024, revealed
that staff had administered the prn lorazepam three times and the physician's order was still current. The
order for the lorazepam failed to include a time frame for the continued use of the medication. There was no
physician documentation that it was appropriate for the order to be extended beyond 14 days.
In an interview on March 8, 2024, at 10:10 a.m., the Director of Nursing confirmed that the there was no
evidence the physician documented a rationale for continuing the medications beyond 14 days.
28 Pa. code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395405
If continuation sheet
Page 7 of 7
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Back to topCitations
6 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.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
FAQ · About this visit
Common questions about this visit
What happened during the March 8, 2024 survey of QUAKERTOWN CENTER?
This was a inspection survey of QUAKERTOWN CENTER on March 8, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at QUAKERTOWN CENTER on March 8, 2024?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
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.