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 (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 3 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 01/28/2025 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)