Health inspection·August 6, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R1's progress notes dated 7/14/24, at 9:21 p.m. indicated Resident R1 was ramming his wheelchair into the baseboard heater repeatedly and refused to stop when asked. Review of Resident R1's progress notes dated 7/15/24, at 6:44 a.m. indicated Resident R1 woke at 3:30 a.m. and has been wandering. Found in another resident's room, went off to Personal Care unit twice, finding his wife and woke her up. [NAME] around threatening to burn the place down. He was given Ativan (anxiety medication) 1 mg (milligram). Review of Resident R1's progress notes dated 7/21/24, at 1:31 p.m. indicated Resident R1 was talking about how he's in the military and he wants to escape here and steal a car but if he goes outside, he's going to get shot. Proceeded to say it's easy to steal a car wander guard on and functioning. Registered Nurse (RN) Supervisor notified. Review of Resident R1's progress notes dated 7/22/24, at 3:11 a.m. indicated physician on call called for an order of intramuscular injection (IM) Haldol (antipsychotic medication) due to resident becoming violent after waking up agitated while looking for his wife and children. Resident was reminded his wife was sleeping and his children were at home. He was asked to go back to his room then he began threatening staff and attempting to punch nursing staff. Review of Resident R1's progress notes dated 7/22/24, at 11:46 a.m. indicated social services spoke with family regarding Dementia Unit placement. Review of Resident R1's progress notes dated 7/22/24, at 9:06 p.m. indicated resident opened front doors, wanderguard alarm sounding. Redirected. Then went up ramp in Personal Care, alarm sounding again, made it all the way up the ramp and opened fire tower doors as staff was approaching. Resident was walking without walker or wheelchair. When asked what he was looking for he stated, I'm sorry. Review of Resident R1's Psychiatric Provider note dated 7/23/24 at 1:00 a.m. indicated short term memory poor, concentration/attention poor- distracted. Insight - poor, lack of insight concerning matters of self. Judgement poor, lacks judgement regarding everyday activities. The patient misses his wife, and he often wanders through the facility looking for her. He is easily agitated and can be hard to redirect. Becomes anxious when told that this wife and truck are not here. Often awake at night. Review of Resident R1's progress notes dated 7/24/24, at 3:30 p.m. indicated resident up in his wheelchair self-propelling looking for the place that you eat - dining area and at 8:09 p.m. nurse aide reported observing Resident R1 urinating in the shower stall of shower room. Review of Resident R1's progress notes dated 7/25/24, at 6:03 a.m. indicated resident was exit seeking and opened the front doors, activating the wanderguard alarm. He was walking without a walker or wheelchair. Every 15-minute checks were ordered. Review of Resident R1's progress notes dated 7/26/24, at 12:56 a.m. Indicated resident was verbally aggressive and yelling at staff. Staff were able to calm resident, get him to his room and into bed. Review of Resident R1's progress notes dated 7/27/24, at 1:28 p.m. indicated staff notified the family and physician about the elopement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395534 If continuation sheet Page 2 of 6 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 395534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sarver 126 Iron Bridge Road Sarver, PA 16055 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R1's progress notes dated 7/27/24, at 1:57 p.m. Staff heard the wanderguard alarm going off. Noted it was for the [NAME] Hall and went down to the Personal Care to investigate. I found the Personal Care Aide who stated she didn't see anyone, and I could not locate anyone. When I went back upstairs, I saw Resident R1 upstairs eating lunch. Staff informed me somehow, he got downstairs. Review of Resident R1's care plan failed to include new interventions or revisions aftre each behavior displayed above to prevent elopement despite multiple behaviors of exit seeking, confusion, agitation, and wandering. Interview on 8/5/24, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to update the care plan for one of four residents reviewed to accurately reflect the current status of the resident. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code: 201.29(b)(d)(j) Resident rights. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395534 If continuation sheet Page 3 of 6 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 395534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sarver 126 Iron Bridge Road Sarver, PA 16055 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 review of facility policy, clinical records, observations, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R1). Findings include: Review of the facility's policy Elopement Prevention dated 12/1/23, indicated the receptionist will maintain the list of all residents at risk for elopement, including name and room number. This list will be distributed to the management team of the care community with staff members who may be in contact with those residents. Departments include nursing, therapeutic recreation, housekeeping, and maintenance. Review of the facility's policy Accidents and Incidents dated 12/1/23, indicated the purpose of the policy is to promote a safe environment for all residents. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/8/24, indicated the diagnoses of Non-Alzheimer ' s Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), high blood pressure, and anxiety. Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) as a three - severe cognitive impairment. Review of Resident R1's physician order dated 4/1/24, indicated safety device - Wanderguard (right wrist a bracelet that alarms when resident goes beyond supervised area) check placement and function every shift. Review of Resident R1's care plan dated 4/1/24, indicated distract me from wandering by offering me pleasant diversions, structured activities, food, conversation, television, books etc. Further review of Resident R1's care plan dated 4/3/24, indicated I enjoy one on one visitation with my wife in PC (personal care - the PC wife's room is the last room in the skilled nursing hallway) I ambulate independently to her personal care home. Review of Resident R1's Nursing Review short form dated 4/1/24, indicated Elopement - resident is at risk and requires a wanderguard bracelet. Review of Resident R1's progress notes dated 7/14/24, at 9:21 p.m. indicated Resident R1 was ramming his wheelchair into the baseboard heater repeatedly and refused to stop when asked. Review of Resident R1's progress notes dated 7/15/24, at 6:44 a.m. indicated Resident R1 woke at 3:30 a.m. and has been wandering. Found in another resident's room, went off to Personal Care unit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395534 If continuation sheet Page 4 of 6 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 395534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sarver 126 Iron Bridge Road Sarver, PA 16055 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 twice, finding his wife and woke her up. [NAME] around threatening to burn the place down. He was given Ativan (anxiety medication) 1 mg (milligram). Review of Resident R1's progress notes dated 7/21/24, at 1:31 p.m. indicated Resident R1 was talking about how he's in the military and he wants to escape here and steal a car but if he goes outside, he's going to get shot. Proceeded to say it's easy to steal a car wander guard on and functioning. Registered Nurse (RN) supervisor notified. Review of Resident R1's progress notes dated 7/22/24, at 3:11 a.m. indicated physician on call called for an order of intramuscular injection (IM) Haldol (antipsychotic medication) due to resident becoming violent after waking up agitated while looking for his wife and children. Resident was reminded his wife was sleeping and his children were at home. He was asked to go back to his room then he began threatening staff and attempting to punch nursing staff. Review of Resident R1's progress notes dated 7/22/24, at 11:46 a.m. indicated social services spoke with family regarding Dementia Unit placement. Review of Resident R1's progress notes dated 7/22/24, at 9:06 p.m. indicated resident opened front doors, wanderguard alarm sounding. Redirected. Then went up ramp in Personal Care, alarm sounding again, made it all the way up the ramp and opened fire tower doors as staff was approaching. Resident was walking without walker or wheelchair . When asked what he was looking for he stated, I'm sorry. Review of Resident R1' Psychiatric Provider note dated 7/23/24 at 1:00 a.m. indicated short term memory poor, concentration/attention poor- distracted. Insight - poor, lack of insight concerning matters of self. Judgement poor, lacks judgement regarding everyday activities. The patient misses his wife, and he often wanders through the facility looking for her. He is easily agitated and can be hard to redirect. Becomes anxious when told that this wife and truck are not here. Often awake at night. Review of Resident R1's progress notes dated 7/24/24, at 3:30 p.m. indicated resident up in his wheelchair self-propelling looking for the place that you eat - dining area and at 8:09 p.m. nurse aide reported observing Resident R1 urinating in the shower stall of shower room. Review of Resident R1's progress notes dated 7/25/24, at 6:03 a.m. indicated resident was exit seeking and opened the front doors, activating the wanderguard alarm. He was walking without a walker or wheelchair. Every 15-minute checks were ordered. Review of Resident R1's progress notes dated 7/26/24, at 12:56 a.m. Indicated resident was verbally aggressive and yelling at staff. Staff were able to calm resident, get him to his room and into bed. Review of Resident R1's progress notes dated 7/27/24, at 1:28 p.m. indicated staff notified the family and physician about the elopement. Review of Resident R1's progress notes dated 7/27/24, at 1:57 p.m. Staff heard the wanderguard alarm going off. Noted it was for the [NAME] Hall and went down to the Personal Care to investigate. I found the Personal Care Aide who stated she didn't see anyone, and I could not locate anyone. When I went back upstairs, I saw Resident R1 upstairs eating lunch. Staff informed me somehow, he got downstairs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395534 If continuation sheet Page 5 of 6 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 395534 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sarver 126 Iron Bridge Road Sarver, PA 16055 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 Review of the facility provided investigation dated 7/27/24, indicated that Maintenance Employee E1's witness statement I went to get on the elevator and another one of the residents was also waiting. I got on, as well as Resident R1 did. Went down one floor and we both got off. Review of the Nursing Home Administrators interview with Maintenance Employee E1's witness statement dated 7/29/24, indicated Maintenance Employee E1 indicated he was not paying attention to alarms, but did accompany resident down elevator, unaware that he wasn't supposed to be on it. Interview on 8/5/24, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to make certain each resident received adequate supervision that resulted in one elopement for one of four residents (Resident R1). 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code: 201.29(b)(d)(j) Resident rights. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395534 If continuation sheet Page 6 of 6