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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment
for residents on two of two nursing units. (South Wing and North Wing)
Findings include:
Observation from February 4, 2025, between 9:45 a.m. and 1:35 p.m., February 5, 2025, between 8:20
a.m. and 9:00 a.m., and 12:15 p.m. and 2:21 p.m., and February 7, 2025, between 9:10 a.m. and 9:30 a.m.
revealed the following:
In room [ROOM NUMBER], the walls were heavily marred.
In room [ROOM NUMBER], the walls were marred and the closet was missing both doors.
In room [ROOM NUMBER], the closet was missing both doors.
In room [ROOM NUMBER] bed H, the fan had a heavy accumulation of dust and dirt.
In room [ROOM NUMBER]'s bathroom, there was a broken floor tile in front of the toilet and a water-stained
ceiling tile.
In room [ROOM NUMBER], the walls were heavily marred.
In room [ROOM NUMBER], the walls were heavily marred. In the bathroom, there was a large hole in the
drywall on the right side of the wall. There was a water-stained ceiling tile.
In room [ROOM NUMBER], the windowsill was covered with dirt and debris. The wallpaper was peeling
behind bed W.
In room [ROOM NUMBER] bed W, the dresser drawer handle was broken.
In room [ROOM NUMBER], the ptac unit (ductless air conditioning unit that heats and cools small areas)
contained debris and dirt. In the bathroom, the floor was buckled on the left and right sides of the toilet
In room [ROOM NUMBER] bed W, there was a solid black thick substance splattered on the floor.
(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
02/07/2025
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 0584
Level of Harm - Minimal harm
or potential for actual harm
In room [ROOM NUMBER]'s bathroom, there was a brown stain along the bottom molding on the wall by
the toilet and under the sink. There was a floor tile behind the toilet that was stained with a black substance.
In room [ROOM NUMBER], there was an accumulation of dust in the top corner of the window as well as
on the curtain.
Residents Affected - Some
In room [ROOM NUMBER], a layer of floor material in the entry way was lifted away from the base.
28 Pa. Code 201.18(b)(3) Management.
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
02/07/2025
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**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 ensure that the
Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of one of 26
sampled residents. (Resident 7)
Residents Affected - Few
Findings include:
Clinical record review revealed that Resident 7 had diagnoses that included bipolar disorder and heart
failure. On May 17, 2024, the resident weighed 152.4 pounds. On November 1, 2024, the resident weighed
173.6 pounds, which reflected a significant weight gain of 13.9% in the last six months. Review of the
physician's orders revealed that Resident 7 had been receiving an antipsychotic medication, olanzapine (a
medication that affected brain activities) since May 17, 2024. Review of the November 2024 medication
administration record revealed that Resident 7 received olanzapine during the MDS review period. The
MDS assessment dated [DATE], incorrectly indicated in section K that Resident 7's weight was 146 pounds,
which was not a weight reflected in the resident's clinical record, and that the resident had no significant
weight gain in the last six months. Further review of the MDS assessment revealed that section N
incorrectly indicated that the resident did not receive an antipsychotic medication in the review period.
In an interview on February 7, 2025, at 1:00 p.m., the Director of Nursing confirmed that Resident 7's MDS
assessment areas were inaccurate.
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
02/07/2025
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.
**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 develop a
comprehensive care plan that addressed individual resident needs as identified in the comprehensive
assessment for two of 26 sampled residents. (Residents 112, 115)
Findings include:
Clinical record review revealed that Resident 112 was admitted to the facility on [DATE], and had diagnoses
that included chronic kidney failure. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary
dated August 24, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan.
The quarterly MDS summary dated November 7, 2024, indicated the resident was frequently incontinent of
urine. There was no evidence that interventions to address Resident 112's urinary incontinence were
included in the current care plan.
Clinical record review revealed that Resident 115 was admitted to the facility on [DATE], and had diagnoses
that included epilepsy (a brain disorder that causes seizures) and rheumatoid arthritis. The MDS CAA
summary dated September 14, 2024, noted that the resident's urinary incontinence was to be addressed in
the care plan. The quarterly MDS summary dated November 27, 2024, indicated that the resident was
frequently incontinent of urine. There was no evidence that interventions to address Resident 115's urinary
incontinence were included in the current care plan.
In an interview on February 7, 2025, at 12:36 p.m., the Director of Nursing confirmed there was no
documented evidence that the care areas were addressed in the residents' current care plans.
CFR 483.21(b)(1) Comprehensive Care Plans
Previously cited 3/8/2024
28 Pa. Code 211.12(d)(1)(3)(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
02/07/2025
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 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility
failed to provide person-centered pain management consistent with professional standards of practice for
one of 26 sampled residents. (Resident 20)
Residents Affected - Few
Findings include:
Review of the facility policy entitled, Pain Management Policy, last reviewed October 15, 2024, revealed that
the physician ordered PRN (as needed) pain medications were to have defined parameters for use.
Clinical record review revealed that Resident 20 had diagnoses that included chronic venous insufficiency
(a condition in which the veins have problems sending blood from the legs back to the heart), lymphedema
(tissue swelling caused by an accumulation of protein-rich fluid drained through the lymphatic system), and
Parkinson's disease. There were physician's orders dated November 27, 2024, for the resident to receive
the narcotic pain medication tramadol every eight hours as needed for pain (failed to identify pain
parameters), ibuprofen every eight hours as needed for pain (failed to identify pain parameters), and
acetaminophen every four hours as needed for mild pain. Review of Medication Administration Records
revealed that the resident received the as needed narcotic (tramadol) for mild or moderate pain on 35
occasions in December 2024, 23 in January 2025, and six in February 2025. The resident did not receive
any doses of the as needed acetaminophen for mild pain or ibuprofen in December 2024, January 2025, or
February 2025.
In an interview on February 7, 2025, at 12:58 p.m., the Director of Nursing confirmed that parameters had
not been ordered for the administration of the prn (as needed) pain medication.
28 Pa. Code 211.9(a)(1) Pharmacy services.
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
02/07/2025
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility
failed to provide ongoing assessment and monitoring for one of one sampled residents receiving dialysis
(process of removing excess toxins and water from the blood). (Resident 70)
Residents Affected - Few
Findings include:
A review of a facility policy entitled, Dialysis: Hemodialysis- Communication and Documentation, last
reviewed October 15, 2024, revealed that staff were to complete the pre-dialysis portion of the
Hemodialysis Communication Record that provided information regarding the resident's ongoing status to
send with the resident to dialysis.
Clinical record review revealed that Resident 70 had diagnoses that included end-stage renal (kidney)
disease and dependence on renal dialysis and had a physician's order for the facility to provide dialysis
three days per week. There was a lack of evidence to support that the pre-dialysis portion of the resident's
dialysis communication forms were completed and that the resident was assessed before dialysis on five of
14 occasions from January 4, 2025, through February 4, 2025.
In an interview on February 7, 2025, at 9:35 a.m., the Director of Nursing confirmed that communication
forms were to be completed before dialysis to assess residents and that the forms were not completed.
28 Pa. Code 211.12(1)(3)(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
02/07/2025
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 and staff interview, it was determined that the facility failed to ensure
psychotropic medications (medications that affect brain activities) were prescribed for a specific diagnosis
for two of seven sampled residents who were prescribed psychotropic medications. (Residents 82, 116)
Findings include:
Clinical record review revealed that resident 82 had diagnoses that included Alzheimer's disease, anxiety,
and stroke. A physician's order dated January 18, 2024, directed staff to administer an antipsychotic
medication, Seroquel, at bedtime for agitation. There was a lack of evidence to support that the medication
was used to treat a specific diagnosis.
Clinical record review revealed that resident 116 had diagnoses that included post traumatic stress disorder
(PTSD) and depression. Physician's orders dated January 25, 2025, directed staff to administer
antipsychotic medications, haloperidol, every six hours for psychosis and quetiapine, twice daily for
psychosis. There was a lack of evidence to support that the medication was used to treat a specific
diagnosis.
In an interview on February 7, 2025, at 1:11 p.m., the Director of Nursing confirmed that the antipsychotic
medication orders should have included specific diagnoses.
CFR 483.45(e)(1) Pharmacy Services
Previously cited 3/8/2024
28 Pa. Code 211.12(d)(1)(3)(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.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
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.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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 February 7, 2025 survey of QUAKERTOWN CENTER?
This was a inspection survey of QUAKERTOWN CENTER on February 7, 2025. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at QUAKERTOWN CENTER on February 7, 2025?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
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.