Health inspection·March 12, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on a review of facility policies, documents, resident medical records, and staff interviews it was determined that the facility failed to identify and determine the root cause of a physical injury as the potential for abuse or neglect for one of 59 residents. (Resident R1) Findings include: A review of facility Resident Protection from Abuse, Neglect, Mistreatment or Exploitation policy dated 11/21/24, revealed that serious physical injuries are to be reported to the state agency, investigated and PB 22s completed for each alleged perpetrator. A review of the facility's documents revealed that on 2/16/25, Resident R1 sustained a serious physical injury while being transferred from her bed to a wheelchair. While pivoting during the transfer procedure the resident heard and felt a loud crack in her right shoulder. Due to the resident's increased pain and edema to her right hand the facility obtain a physician order for an xray. The xray revealed a displaced 2.2 X 1.3 centimeter avulsion fracture of the lateral aspect of the humeral head in the right shoulder. Resident R1 was transferred to the hospital for further evaluation. A review of the state agency reporting documents revealed that the facility notified the state agency that Resident R1 was transferred to the hospital for an evaluation which resulted in confirmation by the hospital of a displaced right humeral fracture. The notifying document submit to the state agency indicated Resident R1's transfer to the hospital and failed to properly be reported as alleged abuse or neglect as required for serious physical injuries with unknown origin of the injury. A review of the facility's documents failed to provide documented evidence that the facility implemented a root cause analysis of Resident R1's serious physical injury which resulted in the potential for other residents to be at risk for abuse or neglect. During an interview on 3/11/25, at 9:15 am the Corporate Clinical Coordinator Employee E1 and Nursing Home Administrator confirmed that the facility failed to notify the state agency of the potential for abuse or neglect to Resident R1 as the result of a physical injury of unknown origin and the facility's failure to identify the incident as the potential for abuse or neglect with the potential for other residents to be at risk. Pa Code: 201.18(b)(1)(2) Management. Page 1 of 2 395534 395534 03/12/2025 Quality Life Services - Sarver 126 Iron Bridge Road Sarver, PA 16055

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policies, documents, resident medical records and staff interviews, it was detrmined that the facility failed to implement an abuse and neglect policy to properly investigation of a physical injury or unknown origin for one of 59 residents (Resident R1). Residents Affected - Few Finding include: During a review of facility Resident Protection from Abuse, Neglect, Mistreatment or Exploitation date 11/21/24, it was revealed that the facility is to implement and complete an investigation for serious physical injury that has resulted in pain, and impairs physical functioning temporally or permanently. The results of the investigation including reports and PB22s must be completed with in five working days. During a review Resident R1's progress notes it was revealed that on 2/16/25, the resident sustained a serious physical injury of unknown origin resulting from transfer procedures from her bed to a wheelchair. While pivoting during the transfer procedure the resident heard and felt a loud crack in her shoulder resulting in pain and edema of her right hand. A hospital emergency room evaluation confirmed that the residnet sustained a displaced right humeral fracture. A review of facility documents failed to provide evidence of the facility implementing an investigation of Resident R1's serious physical injury or unknown origin. The facility failed to provide documented evidence of the results of a through investigation and the competition and submission of a PB 22 for each alleged perpetrator identified as required. During an interview on 3/11/25, at 10:45 am Corporate Clinical Coordinator Employee E1 confirmed that the facility failed to implement their abuse or neglect policy and procedure to thoroughly investigate a resident's physical injury of unknown origin. She confirmed that the facility failed to provide documented evidence of the results of a through investigation which was to include documented evidence to verify the alleged perpetrator preformed return demonstration of the transfer procedure for Resident R1 and the submission of PB 22 forms for each identified alleged perpetrator as required. PA Code: 201.14(c)(d)(e) Responsibility of Licensee 395534 Page 2 of 2