Health inspection·January 28, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical records, investigation documents and staff interview, it was determined that the facility failed to report injuries of unknown source for three of three residents (Resident R1, R2, and R3) reviewed. Findings include: Review of facility policy Resident Protection from Abuse, Neglect, Mistreatment or Exploitation, dated 11/21/24, indicated that nursing homes treat all residents with kindness, respect and in a manner that is at all times free from any form of abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our resident, each home will implement procedures in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. All reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source, and misappropriation of resident property will be investigated and documented. The Administrator or Director of Nursing will notify the PA Department of Health/Long Term Care Division via electronic reporting system (ERS) within 24 hours of the incident. Review of Title 42 Code of Federal Regulations (CFR) §483.12(c) states in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Review of the clinical record indicated that Resident R1 was admitted to the facility 9/9/22. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/22/24, indicated diagnoses of spinal stenosis (condition characterized by the narrowing of spaces in the spine, which can compress the spinal cord and nerves), dysphagia (difficulty swallowing), and generalized muscle weakness. Review of Resident R1's clinical progress note dated 1/8/25, indicated Resident R1 was assessed for one or more wounds that are non-pressure related. Resident has a wound on the chest:right Page 1 of 3 395534 395534 01/28/2025 Quality Life Services - Sarver 126 Iron Bridge Road Sarver, PA 16055

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few breast/side and front of shoulder. 01/08/2025 is when the wound was found acquired in-house. Dark purple bruising to bottom, yellow on top. The primary tissue type is 100% intact. This presents as bruising. Review of an incident report dated 1/8/25, indicated nurse on unit was alerted that resident (R1) had a bruised area. Upon assessment writer observed a large bruise from the right shoulder, along the right side, breast and under the breast. Observed yellow coloring to the top then into a dark purple for the remainder of the area. The document did not include that the State office had been notified of the injury of unknown source. Review of the clinical record indicated that Resident R2 was admitted to the facility 2/24/23. Review of Resident R2's MDS dated [DATE], indicated diagnoses of hypo-osmolality (condition where the plasma osmolality is low) and hyponatremia (condition when the sodium concentration in the blood is low), altered mental status, and lack of coordination. Review of Resident R2's clinical progress note dated 1/11/25, at 5:50 a.m., indicated that resident (R2) has bruising to right arm and left hand. Right upper forearm with 4 cm (centimeter) x 2.5 cm bruise noted. Scattered bruising to lower right forearm and back of left hand. No injury witnessed. Review of incident report dated 1/11/25, indicated scattered bruising to right upper forearm with 4 cm x 2.5 cm bruise noted. Scattered bruising to lower right forearm and left hand noted. Reported by Nurse Aide (NA). The document did not include that the State office had been notified of the injury of unknown source. Review of the clinical record indicated that Resident R3 was admitted to the facility 2/28/23. Review of Resident R3's MDS dated [DATE], indicated diagnoses of aortic stenosis (condition where the aortic valve in the heart is narrowed or blocked), Alzheimer's disease (neurologic disorder that causes irreversible changes in memory, thinking, and behavior), and diabetes mellitus (group of diseases that affect how the body uses blood sugar). Review of Resident R3's clinical progress note dated 1/16/25, indicated writer was informed of bruising to resident right underarm area. Bruising is in line with straps of STS (Sit-to-stand) lift, which resident was using up until 6 days ago. Bruising partially surrounds right axilla, running along upper inner right arm and off to the side of right breast, and is varying degrees of color ranging from dark purple to greenish. Review of incident report dated 1/16/25, indicated that writer was informed by Nurse Aide (NA) of bruising to resident (R3) right underarm area. Bruising is in line with straps of STS (Sit-to-stand) lift, which resident was using up until 6 days ago. Bruising partially surrounds right axilla, running along upper inner right arm and off to the side of right breast, and is varying degrees of color ranging from dark purple to greenish. The document did not include that the State office had been notified of the injury of unknown source. Review of the reporting system for the facility's state survey agency did not show evidence that the state survey agency was notified, and the results of any investigation was reported regarding the referenced injuries of unknown source. 395534 Page 2 of 3 395534 01/28/2025 Quality Life Services - Sarver 126 Iron Bridge Road Sarver, PA 16055

F 0609 During an interview on 1/28/25, at 1:00 p.m., the Director of Nursing (DON) confirmed that the facility failed to report injuries of unknown source for three of three residents (Resident R1, R2, and R3) as required. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code: 201.14 (a) Responsibility of Management Residents Affected - Few 28 Pa Code: 201.18 (e )(1) Management. 395534 Page 3 of 3