Health inspection·November 19, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of facility policy, resident grievances for 60 days, resident and staff interviews, it was determined that the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for one of three grievances reviewed. Findings include: Review of facility policy Communication of Resident, Family and Staff Concerns and Grievances dated 8/17/23, indicated to encourage residents, family members and staff to ask questions and express their concerns will maximize their quality of care and promote higher levels of staff and customer satisfaction through timely responses to questions and resolution of issues concerns and grievances. Once we receive a grievance, we will make every effort to respond as quickly and effectively as we can with the goal of always providing outstanding customer service. Our goal is to resolve all concerns within five days of the report with all parties in agreement of the resolution, If the concern cannot be resolved in five days, the reason must be documented on the Concern form and the resident or resident representative notified of the delay in resolution. Review of the facility's Grievance/Complaint Logs for October and November of 2024 indicated the following grievance had not been responded to in a timely manner: -10/27/24: Resident R1 filed a Concern Form stating she did not receive medication until around lunch. Blood sugar was not checked on daylight. States she had to ask the nurse for her medications. The Concern form Outcome of Investigation, Signature of person completing investigation and date, Was the concern confirmed, partially confirmed or not confirmed, Corrective action taken, Resolution, Resolution reviewed with resident or family, Did resident receive a written decision sections were all blank. The facility failed to provide documented evidence that they made prompt efforts to resolve Resident R1's grievance. During review of the concern form on 11/19/24, at 1:05 p.m. revealed the Nursing Home Administrator and Social service signatures were missing and documented on concern log was blank. During an interview on 11/19/24, at 1:10 p.m. the Director of Nursing (DON) confirmed that the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for one of three grievances reviewed. 28 Pa. Code 201.14(a) Responsibility of licensee. (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: 395534 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 11/19/2024 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)