Health inspection·August 18, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on review of clinical records, and facility documents, and staff interview it was determined that the facility failed to ensure each resident received the required mobility assistance using assistive devices to prevent accidents that resulted in actual harm of the right lower leg for one of eight residents reviewed (Closed Record Resident CR2). This deficiency is being cited as past non-compliance. Findings include: Review of Resident CR2's clinical record revealed an admission date of 7/26/23, with diagnoses that included broken left lower leg, lack of coordination, abnormal gait and mobility, falls, and muscle wasting. Review of hospital discharge records dated 7/24/23, included a Closed fracture of left fibula (lower leg) assessment and plan indicated, Patient is partial weight bearing due to distal fibula/ankle fracture. Patient with assistance of caregiver can pivot between bed to chair, wheelchair, and commode with Sit-to-Stand or patient would be confined without the use of a Sit-to-Stand. Review of physician's orders revealed the following orders for Resident CR2: 7/26/23- weight bearing full; 7/26/23- short air cast boot; 7/27/23- transfer with a stand-up lift; and 7/27/23- weight bearing as tolerated with use of walking boot for transfers. Review of Resident CR2's clinical record revealed a nurse aide tasks record dated 7/26/23, that identified Resident CR2 was to be transferred with extensive assistance of two staff. The nurse aide task record did not include the current 7/27/23, physician orders for the use of a stand-up lift for transfers. Review of departmental progress notes dated 8/03/23, revealed that Resident CR2 was working with therapy and was yelling out and grimacing, and his/her right foot was bruised, swollen, and rotated outward. X-rays from 8/03/23, revealed new buckle/angulated fractures of both bones in the right lower leg. The facility began an investigation on 8/03/23, and determined that the therapy order dated 7/27/23, to transfer Resident CR2 using the stand-up lift was not transcribed to the nurse aide tasks and that staff were transferring him/her with extensive assistance of two people. The facility initiated a whole-house audit of residents with transfer orders and identified and reconciled an additional 18 resident transfer orders. Facility obtained statements from staff who provided care to Resident CR2. (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: 395593 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 395593 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Grove City 400 Hillcrest Avenue Grove City, PA 16127 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)