F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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
observations, facility policy, and staff interview, it was determined that the facility failed to ensure
comfortable air temperature levels were provided for one of 34 resident rooms (room [ROOM NUMBER])
and two of three resident areas (Millers Common Room and Dining Room).Findings Include:Review of the
facility policy Extreme Weather dated 12/1/25, indicated excessive cold for lengthy periods of time can
negatively impact center operations. Excessive cold poses a severe potential harm to confused exit-seeking
residents. Geriatric residents have a greater risk of suffering hypothermia because their bodies do no
effectively regulate internal temperatures.During an interview on 1/28/26, at 9:30 a.m. the Nursing Home
Administrator (NHA) revealed that on 1/25/26, the boiler (form of heat source) needed reset.Observations
conducted on 1/28/26, from 12:15 p.m. to 12:45 p.m. with the Maintenance Director, Employee E2 revealed
the following air temperatures:[NAME] Lane Nursing Floor-room [ROOM NUMBER]-68 of degrees
FahrenheitMiller Common Room-Common Room - 67.3 degrees Fahrenheit-[NAME] Dining Room - 70.5
degrees FahrenheitDuring an interview on 1/28/26, at 3:00 p.m. the Nursing Home Administrator confirmed
the facility failed to ensure comfortable air temperature levels were provided for one of 34 resident rooms
(room [ROOM NUMBER]) and two of three resident areas (Millers Common Room and Dining Room).28
Pa. Code: 201.18(b)(3) Management
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
01/28/2026
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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 documents, facility policy, clinical records, observation, and staff interviews, it was
determined that the facility failed to make certain each resident received adequate supervision that resulted
in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for
one of 17 residents (Resident R1). Findings include:Based on facility policy Elopement Prevention dated
12/1/25, indicated the facility will properly assess residents and plan their care to prevent accidents related
to wandering behavior or elopement. Upon admission, readmission, quarterly and as necessary, nurses will
complete a Wandering Risk Assessment. Should the resident's behavior warrant elopement prevention
measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff
observations will be noted during the residents' stay and modifications will be made to the care plan and
prevention techniques.Review of the clinical record indicated Resident R1 was admitted to the facility on
[DATE].Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated
11/9/25, indicated diagnoses of depression, dementia (a group of symptoms that affect memory, thinking
and interferes with daily life), and anxiety.A review of the Resident Assessment Instrument 3.0 User's
Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test
that aides in detecting cognitive impairment). The BIMS total score suggests the following
distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairmentReview of Resident
R1's MDS assessment dated [DATE], Section C0100 screening indicated a score of 0 revealing that
Resident R1 is rarely/never understood and the BIMS screening test was not completed. Review of
Resident R1's care plan dated 5/22/24, indicated Resident R1 was an elopement risk/wanderer as
evidence by a history of attempts to leave home unattended prior to admission. Care plan included
identifying any patterns of wandering that I exhibit: purposeful wandering, aimless, or attempting to escape.
Monitor my frequent location.Review of documentation provided by facility dated 1/22/26, at 1:40 p.m.
revealed, Resident R1 was observed ambulating outside of the locked memory lane unit, on another
resident hallway. Resident R1 was observed in the hallway next to memory lane unit and approximately 36
feet away from memory lane unit.Review of an interview conducted by NHA on 1/23/26, at 2:00 p.m.
revealed that Resident R1's husband had visited on 1/22/26, and felt that the resident was far enough from
locked door when he exited and left the unit. Residents' husband was in a hurry to get to the pharmacy and
failed to look behind him upon leaving the unit.Review of witness statement dated 1/23/26, at 4:15 p.m.
revealed that Licensed Practical Nurse Employee E1 indicated the Resident R1 followed her husband out of
the unit and staff noticed resident in the hallway and returned resident to locked memory unit.During a
review of progress notes dated 6/1/2025, through 1/28/26, revealed that Resident R1 had documented
behaviors but none were exit seeking.During an interview on 1/28/26, at 2:08 p.m. the Director of Nursing
(DON) stated that when she worked in the locked memory unit that Resident R1's husband would come
and go since he knew the code to the doors.During an interview on 1/28/26, at 2:45 p.m. the Nursing Home
Administrator (NHA) and DON confirmed that the facility failed to make certain each resident received
adequate supervision that resulted in an elopement for one of 17 residents (Resident R1).28 Pa. Code
201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code
211.12(d)(1)(3)(5) Nursing services.
Event ID:
Facility ID:
395118
If continuation sheet
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