Pennsylvania Department of Health
QUADRANGLE, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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QUADRANGLE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to a complaint, completed on February 27, 2026, it was determined that The Quadrangle, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations: Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department was conducted on February 24, 2026, at 9:20 a.m. with Employee E4, Sous Chef, revealed the following concerns: Observation in the reach-in refrigerator revealed two shopping bags containing personal food/drink. Observation in the kitchen revealed two ice cream freezers with clear tops that were smeared with a milky-whiteish sticky substance and several of the 3-gallon ice cream containers were not covered. Observation in the walk-in refrigerator revealed a shelving unit with a broken bottom shelf with a container of food hanging off. The floor in the cooler was dirty and had debris. Observation in the walk-in freezer revealed a rack with fruit pies that were not covered. Observation of the convection ovens revealed heavy build-up of black baked-on food particles on the inside surface of the ovens, especially the top two ovens. Observation of other cooking equipment revealed the outside surfaces, especially the legs were spattered with dirt and debris. Observation in the dry storage area revealed no designated location for dented cans. Observation in the second floor pantry revealed a hole in the wall behind the dish sink adjacent to the dish machine. Interview with the Sous Chef on February 24, 2026, at 9:20 a.m. confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 04/03/2026

Personal items were immediately discarded by executive sous chef from the reach-in refrigerator on 2/24/26.

Ice cream freezer was immediately cleaned and containers were covered by executive sous chef on 2/24/26.

Shelving unit with broken shelf was fixed by maintenance on 2/25/26.

Fruit pies in walk-in freezer were immediately covered by executive sous chef on 2/24/26.

Ovens were immediately cleaned to remove heavy build-up of baked-on food particles including top two ovens by executive sous chef on 2/24/26.

All surfaces and tables cleaned by executive sous chef on 2/24/26.

Dry storage area has an area
for dented cans- immediately
labeled by executive sous chef on 2/24/26 and confirmed that all staff are aware of location

Second floor pantry- hole in the
wall was immediately repaired by maintenance on 2/26/26.

The Registered Dietitian (RD) reviewed residents and internal process for food preparation and distribution, and sanitary practices. It was determined that no residents were at risk or adversely effected as related to the deficient practice.

RD educated dietary staff on 2/27/26-3/20/26 on the policy and procedures for maintaining cleanliness of kitchen.

RD or designee will audit main kitchen
weekly x4 weeks followed by monthly for 2 additional months.

The Dietary Manager will review findings from the audit/rounds during monthly QA meeting. The Administrator will be responsible for confirming the implementation and compliance of this POC and will address and resolve any variations that may occur.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Plan of Correction - To be completed: 04/03/2026

DNS recieved orders for arm circumference and external catheter length immediately and updated for residents R9 and R46 on 2/26/26.

An audit was completed by DNS on 2/26/26 and indicated that Residents R9 and R46 were the only residents in the facility at that time with a PICC line.

Nursing staff trained and educated on 3/18/26-3/20/26 on PICC lines and the procedure for documenting length of PICC, arm circumference, and date PICC was inserted. Newly hired nursing staff will be educated upon hire of the expectations for documenting PICC line orders, arm circumference, and measurements of external cath.

Moving forward, any residents with
a PICC line on admission will have
orders for the date PICC line was
inserted, baseline measurement
of upper arm circumference,
and length of the external catheter.

Additional documentation of weekly
measurements of arm circumference
and external length of PICC while PICC
line is in place. Admissions director will provide DNS with a copy of PICC line placement procedure note to upload into EMR upon admission.

This will be audited by ADNS weekly x4 weeks, then monthly for two additional months.

The DNS will review findings from the audit during monthly QAPI meeting. The Administrator will be responsible for confirming the implementation and compliance of this POC and will address and resolve any variations that may occur.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations: Based on observation, record review, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice of two of 18 residents reviewed (Residents R53, and R72). Findings include: Review facility policy title Oxygen, revealed that a nasal cannula (small tube that gives oxygen through the nose to help someone breathe easier), should labeled with date and your initials. Review of Resident R72's clinical record revealed the resident was admitted on February 23, 2026, ,with diagnoses including hypo-osmolality (low salt level in the blood), other nonspecific abnormal finding of lung field, and hypertensive heart disease without heart failure (heart problems caused by high blood pressure without heart failure). Review revealed a January 18, 2026, physician's order revealed an order for oxygen at 2 liters per minute via nasal cannula. Observations conducted in Resident R72's room on February 24, 2026, at 9:52 a.m. revealed an oxygen concentrator (a machine that takes in room air and provides extra oxygen to help a person breathe easier) in use. The machine was set to deliver oxygen at 2 liters per minute through tubing connected to a nasal cannula, (a small soft tube placed in the resident's nostrils), The oxygen tubing was not labeled with the date or initial as indicated in the facility policy. Interview conducted on February 26, 2026, at 9:54 a.m. with Registered Nurse, Employee E17 confirmed that Resident R72's oxygen tubing and concentrator was not labeled per facility policy., Observations in Resident R53's room 121 on February 24, 2026, at 10:50 a.m. revealed a CPAP machine (continuous positive airway pressure, machine is one of the most common treatments for sleep apnea. It keeps airways open while you sleep so you can receive the oxygen you need) on the nightstand and two oxygen concentrators next to the nightstand. Interview with Resident R53 revealed that (she/he) was using the CPAP machine every night along with oxygen while sleeping and that the staff would make sure that (she/he) has fresh distilled water and put the mask on before going to sleep. Review of Resident R53's clinical record revealed an admission date of January 18, 2026, with diagnoses including obstructive sleep apnea (a common sleep disorder where the airway repeatedly becomes blocked during sleep, causing pauses in breathing and disrupted sleep). Further review revealed a January18, 2026, physician's order for oxygen at 2 lpm via nasal cannula at hour of sleep every evening and night shift. Exhaustive review of R53's physician orders revealed no order for CPAP. Interview with the Registered nurse, Employee E10 on February 26, 2026, at 1:28 p.m. confirmed that Resident R53 was using the CPAP machine at night with the oxygen, and that there was not order for the CPAP machine. Interview with the Director of Nursing on February 26, 2026, at 2:15 p.m. confirmed that there was no order for the CPAP machine for Resident R53. 28 Pa. code 211.12(d)(1)(2) Nursing Services

Plan of Correction - To be completed: 04/03/2026

DNS immediately changed, labeled, and dated o2 tubing for residents R53 and R72 on 2/26/26.

A review was completed by DNS on 2/26/26
for the residents in facility on o2 and confirmed that each resident had tubing that was changed weekly, labeled, and dated.

ADNS and DNS educated nursing staff on 3/18/26-3/20/26 about changing o2 tubing weekly and labeling/dating the tubing. New hires will be educated on the policy and procedures of changing o2 tubing, labeling, and dating.

Moving forward, DNS/ADNS will audit any new o2 orders for weekly changes, labeling, and dating. This will occur weekly x4 weeks and then monthly for two additional months.

The DNS will review findings from the audit/rounds during monthly QA meeting. The Administrator will be responsible for confirming the implementation and compliance of this POC and will address and resolve any variations that may occur.

Orders for CPAP and settings were immediately entered and updated for resident R53.

A review for residents with CPAP/BiPAP were evaluated on 2/27/26,
all care plans and orders were accurate and up to date. Nursing staff educated on 3/18/26-3/20/26 about procedure for orders of CPAP/BiPAPs.

Moving forward, ADNS/DNS will complete
weekly audit x4 weeks for residents with CPAPs and BiPAP's in facility, then monthly for two additional months.

The DNS will review findings from the audit/rounds during monthly QA meeting. The Administrator will be responsible for confirming the implementation and compliance of this POC and will address and resolve any variations that may occur.

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations: Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services. Findings include: An interview on February 24, 2026, at 9:20 a.m. with Employee E3, Sous Chef, revealed that the department had no Food Service Director (FSD) since the beginning of January, 2026, when the FSD left employment. Further the Executive Chef had quit without notice just before Christmas 2025. The Sous Chef (Employee E 4) indicated that he and the other Sous Chef were running the kitchen together at this time, splitting the duties of food orders, production schedules and managing the staff. He indicated that he was not a Certified Dietary Manager (CDM), and that the CDM for the healthcare side was on her way into the facility. Interview with Employee E8, listed on the facility phone list as Dietary Manager/CDM, on February 26, 2026, revealed that she is in charge on the nursing home side. She was asked to provide a copy of her CDM Certificate. Interview with the Administrator on February 27, 2026, at 11:45 a.m. confirmed that Employee E8 was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; and that she had not received frequently scheduled consultations from a qualified dietitian. The Administrator further confirmed that the building has not had a CDM since the FSD retired in early January 2026. 28 Pa. Code 211.6(c)(d) Dietary services 28 Pa Code 201.18(e)(1)(6) Management

Plan of Correction - To be completed: 04/03/2026

The facility employs a full time
Registered Dietitian (RD). The RD provides oversight and supervision for the Dietary Manager.

The Registered Dietitian reviewed residents and internal process for food preparation and distribution, and sanitary practices. It was determined that no residents were at risk as related to the deficient practice.

The Dietary Manager is in the process
of scheduling Certification exam for Certified Dietary Manager (CDM). Dietary manager has requested transcripts from the university and awaiting approval to take exam.

RD will complete weekly audit x4 weeks and monthly for two additional months to confirm proper food preparation, distribution and sanitary practices.

Administrator will continue to work with dietary manager to confirm date that exam is scheduled. Once completed, Administrator will review at QAPI meeting.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

§483.60(i)(4)- Dispose of garbage and refuse properly.

Observations: Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Findings include: An initial tour of the Food Service Department was conducted on February 24, 2026, at 9:20 a.m. with Employee E4, Sous Chef, which revealed the following: Observation in the outdoor receiving area revealed 5 wooden pallets piled near the wall to the left of the door, and another was standing on edge to the right of the door with two old chairs. Further observation in the receiving area revealed a trash compactor with a broken latch on the gate and the trash pit with bags of garbage exposed and the ram and cover in the open position. When the compactor was activated the ram compacted the garbage and the cover closed and when the process was complete the door opened again revealing the exposed trash in the pit. Interview with the Sous Chef (Employee E4) at 9:30 a.m. on February 24, 2026, confirmed the above findings and that he thought that the reason you could still see the trash was that maybe the compactor was full, and that the chairs were supposed to be discarded. Interview with the Facilities Manager, Employee E7 on February 27, 2026, at 11:00 a.m. confirmed that the latch on the gate was broken and that the compactor was in the open position with trash exposed. 28 PA Code: 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Plan of Correction - To be completed: 04/03/2026

Loading dock area immediately cleaned by Director of Facilities on 2/24/26. Broken chairs were thrown out on 2/24/26.

Lock on dumpster was fixed by Director of Facilities on 2/25/26.

6 wooden pallets were removed
from loading dock area on 2/24/26.

Director of Facilities consulted
with dumpster company on 2/27/26. It was confirmed that dumpster closes and trash is covered.

There was no adverse effects or impact on residents due to the trash being located outside of the dumpster.

Director of Facilities in-serviced
staff on 3/18/26-3/20/26 that the dumpster closes and to not trash exposed.

Weekly audits of dumpster/loading
dock area will be conducted by housekeeping and maintenance to ensure
cleanliness and organization. This will occur weekly x4 weeks then monthly for two additional months.

The Director of Facilities will review findings from the audit/rounds during monthly QA meeting. The Administrator will be responsible for confirming the implementation and compliance of this POC and will address and resolve any variations that may occur.

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