Inspection·July 7, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility documents, clinical record review, and staff interview it was determined that the facility failed to revise a care plan to accurately reflect the current status for one of three residents (Resident R1). Findings include: Review of facility policy Care Plan and Interdisciplinary Care Conferences dated 11/8/24, indicated that the purpose of a care plan is to structure and guide therapeutic interventions to meet resident's needs and achieve expected outcomes. The care plan is formally reviewed and completed within 21 days after admission at the Interdisciplinary Care Plan Conference and communicated to appropriate staff. The care plan may be specifically reviewed and updated as the resident's condition changes- for example, but not limited to: medications are added or discontinued Resident returns from the hospital Change in resident's mood, behavior, activities of daily living Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident 1's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/20/25, indicated diagnoses of high blood pressure, muscle weakness, and malnutrition (lack of proper nutrition). Review of Resident R1's clinical record revealed a progress note dated 5/20/25, that stated Resident is A+O x 3 (alert and oriented times three- a person is alert and oriented to person, place, and time). Resident is able to make needs known. Resident uses call light appropriately. Resident does go off the unit to Vista (a Personal Care unit that is attached to the facility via a connecting Dining Room) to visit wife throughout the day. Review of documentation provided by the facility dated 5/27/25, indicated that on 5/25/25, Nursing staff were notified that Resident R1 was not found in the skilled facility. It is noted that Resident is known to go visit his wife who is located on the Vista (Personal care) side of the facility. Staff went to the Vista area where they found Resident to be with his wife in the Dining hall eating his meal. No injuries noted due to this incident. Order obtained from provider that Resident may go (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 2 Event ID: 395118 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 395118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Chicora 160 Medical Center Road Chicora, PA 16025 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)