Health inspection·July 10, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for four of six residents reviewed (Residents R6, R31, R39, and R45). Residents Affected - Some Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Fingerstick Glucose Measurement reviewed 2/22/24 and 6/11/24, indicated the diabetic residents will have blood glucose levels measured by fingerstick, according to physician ordered schedule. Step 1: Verify physician's order. Step 17: Follow up with insulin administration or physician notification as ordered. Review of the facility policy Physician Notification reviewed 2/22/24 and 6/11/24, indicated upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will preform appropriate clinical observations and data collection and report to physician as indicated. Document findings related to change in condition, physician notification and response, family notifications, and interventions. Page 1 of 14 395870 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility policy Hypoglycemic Protocol reviewed 2/22/24 and 6/11/24, indicated staff will appropriately assess for and respond to and treat resident's experiencing a hypoglycemic episode. Whenever a glucose test indicates hypoglycemia treatment should be provided immediately. Treatment of choice for hypoglycemia is Glucose Gel 15 grams. However, if resident has difficulty swallowing or decreased level of consciousness Glucagon IM (injection given into the muscle) would be given. Recheck the blood sugar. Notify MD. Review of the facility policy Resident Change in Condition or Status reviewed 2/22/24 and 6/11/24, indicated it is facility policy to promptly address all resident changes in condition and to manage them in compliance with all applicable standards of care. When a resident exhibits a change in condition from their baseline, the licensed nurse assigned to the resident will provide any necessary physical assessment, ensure timely notification to the charge nurse, physician, and family. Documentation must be provided in the resident record regarding any assessment of the resident and findings, all applicable diagnostics, all applicable interventions, and all communication. The licensed nurse will notify the resident's attending physician when there is a significant change in the resident's physical, mental, or psychosocial status, when there is a need to alter the residents treatment significantly. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and depression. Review of Resident R6' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/28/24, indicated the diagnoses remain current. Review of a physician's order dated 2/21/24 indicated to inject Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) per sliding scale, if fingerstick is over 400, give 12 units, call MD. An order dated 2/23/24 through 5/23/24, indicated to inject Novolog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) per sliding scale, if blood glucose is over 401 give 12 units and call MD. An order dated 5/23/24, indicated the same Novolog sliding scale parameters. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 2/21/24, at 8:59 p.m. the CBG was noted to be 416. On 3/25/24, at 5:06 p.m. the CBG was noted to be 450. On 6/26/24, at 12:30 p.m. the CBG was noted to be 439. Review of the care plan dated 6/26/14, indicated to monitor Accuchecks as ordered. Monitor/document/report to MD as needed for signs or symptoms of hyper-/hypoglycemia. Diabetes medication as ordered by doctor, monitor/document side effects and effectiveness. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above 395870 Page 2 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0684 listed dates. Level of Harm - Minimal harm or potential for actual harm Review of a clinical record indicated Resident R31 was admitted to the facility on [DATE], with diagnoses that included diabetes, anxiety, and high blood pressure. Residents Affected - Some Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of physician's orders dated 1/30/24, indicated the following orders: Administer four ounces of juice as needed for hypoglycemic protocol for Accucheck less than or equal to 70 and resident asymptomatic (you are not showing any symptoms) and able to swallow. Administer juice by mouth and recheck in 15 minutes. Glucose Oral Gel 15 gm/ml (grams per milliliter) by mouth as needed for hypoglycemic protocol. Glucagon Emergency Injection kit 1 mg (milligram) inject intramuscularly as needed for hypoglycemic protocol and resident is unresponsive. Lantus (long-acting type of insulin that works slowly, over about 24 hours) 25 units in the evening. An order dated 2/7/24, indicated Novolog insulin per sliding scale, if greater than 400 call MD. Review of Resident R31's eMAR revealed that the resident's CBG's were as follows: On 6/17/24, at 7:50 a.m. the CBG was noted to be 51. On 6/22/24, at 6:23 a.m. the CBG was noted to be 51. On 6/23/24, at 6:41 a.m. the CBG was noted to be 52. Review of Resident R31's care plan dated 1/30/24, indicated to check blood sugar levels as ordered. Administer diabetes medications as ordered, monitor for effectiveness and side effects and report them to the physician. Monitor for any signs or symptoms of hypoglycemia. Review of Resident R31's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, and the physician was not notified of abnormal results. Review of the clinical record indicated Resident R39 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and shortness of breath. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 6/10/23, indicated Glucose Gel 40%, give 15 grams by mouth as needed for hypoglycemia, recheck blood sugar in 15 minutes. An order dated 1/1/24, indicated to notify provider of blood sugar less than 70; follow hypoglycemic protocol. Glucagon Emergency kit 1 mg inject as needed for blood sugar. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 4/18/24, at 6:13 a.m. the CBG was noted to be 58. On 4/22/24, at 6:11 a.m. the CBG was noted to be 53. 395870 Page 3 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0684 On 6/19/24, at 6:45 a.m. the CBG was noted to be 57. Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 10/30/22, indicated to administer diabetic medications as ordered by doctor, monitor for effectiveness and the occurrence of any side effects and report them to the physician. Check blood sugars as ordered. Monitor for signs or symptoms of hypoglycemia. Residents Affected - Some Review of Resident R39's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE], with diagnoses that included diabetes, and high blood pressure. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 3/7/24, indicated Novolog insulin per sliding scale, if blood glucose 341 give 12 units, if over 340 notify MD. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 3/17/24, at 12:04 p.m. CBG was noted to be 341. On 3/18/24, at 4:29 p.m. CBG was noted to be 341. On 3/21/24, at 11:07 a.m. CBG was noted to be 341. On 3/23/24, at 11:38 a.m. CBG was noted to be 341. On 3/28/24, at 11:30 a.m. CBG was noted to be 341. On 3/30/24, at 10:35 a.m. CBG was noted to be 341. On 3/31/24, at 11:05 a.m. CBG was noted to be 341. On 4/2/24, at 10:13 a.m. CBG was noted to be 341. On 4/18/24, at 11:37 a.m. CBG was noted to be 341. On 4/20/24, at 10:49 a.m. CBG was noted to be 341. On 4/27/24, at 11:09 a.m. CBG was noted to be 341. On 4/28/24, at 10:32 a.m. CBG was noted to be 341. On 5/13/24, at 5:01 p.m. CBG was noted to be 341. Review of the care plan dated 12/5/22, indicated to check blood sugar levels as ordered. Monitor 395870 Page 4 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0684 for signs or symptoms of hyperglycemia. Level of Harm - Minimal harm or potential for actual harm Review of Resident 45's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Residents Affected - Some During an interview on 7/10/24, at 11:30 a.m. Licensed Practical Nurse (LPN) Employee E10 stated they would check the resident's orders for parameters, if no ordered parameters are noted they would notify the doctor of blood glucose levels under 60 or over 400. They would document in the MAR and progress notes. During an interview on 7/10/24, at 11:35 a.m. LPN Employee E11 stated they would check the orders for parameters, and if they did not find any parameters, they would notify the doctor of blood glucose levels under 60-70, or over 450-500. They would document in the progress notes. During an interview on 7/10/24, at 12:45 p.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition related to blood glucose for Residents R6, R31, R39, and R45. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 395870 Page 5 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent falls for one of three residents (Resident R25). Findings include: Review of the facility policy, Falls: Care During and After dated 6/11/24, indicated, All residents experiencing a fall will receive appropriate care and investigation and interventions will be conducted by the interdisciplinary team. Included in the procedure were the following steps: 5. Remove any causes to fall and implement preventative measures to prevent reoccurrence. 6. Update care plan to reflect new interventions. Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/30/24, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and unsteadiness on feet. Review of a progress note dated 6/25/24, at 6:28 p.m. indicated, LPN (licensed practical nurse) heard someone yelling help me! Ran to see where it was coming from, saw this resident laying on his left side on the floor by the dining room. Other LPN was standing by him assisting him. Resident was very confused per usual. Another resident witnessed the fall and stated that the resident did not hit head and fell to butt and hit elbow on wall. Resident did have a small skin tear to his left elbow that measures 2 cm (centimeters) x 0.8 cm. No other injuries noted at this time. resident moves all extremities. Staff assisted resident back into his chair. Resident has no s/s of distress or discomfort noted. attempted to call wife, and no answer. Review of a facility incident report dated 6/25/24, included the information, Resident declined any pain. Resident's shoes were not non-skid and slid very easily on the floor. Shoes were removed and grip socks put on resident. Review of the report section, Predisposing Situation Factors the check box for improper footwear was not checked. Review of a progress note dated 7/2/24, at 7:27 p.m. indicated, RN (registered nurse) and CNA (nurse aide) and HCV NHA (Nursing Home Administrator from sister facility) were all outside of kitchen and heard resident say, He fell. All of us went immediately to resident. RN assessed and resident re-opened prior skin tear to R (right) elbow. resident moves all extremities. alert and oriented resident sitting and saw entire incident - she said he stood up and tried to walk by himself and slid and fell on his butt. Did not hit head. resident assisted up and back to W/C (wheelchair). resident had tan shoes and socks on feet. [NAME] shoes slide very easily on floor and are similar to black shoes that he wore when falling previously. resident now has nonskid socks on feet. resident has dementia with poor safety awareness. no s/s (signs or symptoms) of distress or discomfort noted. Review of a facility incident report dated 7/2/24, included the information, Resident assessed, removed shoes and applied grip socks. Review of the report section, Predisposing Situation Factors the 395870 Page 6 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0689 check box for improper footwear was checked. Level of Harm - Minimal harm or potential for actual harm Review of Resident R25's plan of care for Altered gait, impaired mobility active from 5/17/24, through 7/3/24, included only the intervention of Monitor for safety, keep in view of staff. Residents Affected - Some Review of Resident R25's plan of care for I have had a fall with no injury initiated 5/20/24, failed to include an intervention for non-skid footwear until 7/3/24. During an interview on 7/10/24, at approximately 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to implement interventions to prevent falls for one of three residents. 28 Pa. Code: 201.14(c) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395870 Page 7 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to provide necessary behavioral health services to a resident to maintain the highest practicable mental and psychosocial well-being for one of six residents (Resident R39). Findings include: Review of the Facility Assessment, dated 5/14/24, indicated the facility will provide care for residents with psychiatric or mood disorders. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R39 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 5/24/24, included diagnoses of persistent mood disorder and depression. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R39 ' s score to be 11. Review of Resident R39 ' s plan of care for depression initiated 10/31/22, indicated for facility staff to monitor Resident R39 for signs and symptoms of depression and report to physician as necessary. Review of Resident R39 ' s plan of care for the use of antidepressant medication initiated 10/31/22, indicated for facility staff to monitor Resident R39 for adverse effects, including suicidal ideations. Review of a progress note dated 6/17/24, at 2:53 p.m. indicated that during a gradual dose reduction (GDR) review, it was recommended to decrease Resident R39 ' s Depakote Sprinkles (anti-seizure medication that can be used to treat mood disorders) to twice daily (previously three times daily). Review of a progress note dated 7/1/24, at 11:01 a.m. indicated that Resident R39 refused his shower and had struck out at the nurse aide. Review of a progress note dated 7/5/24, at 9:28 p.m. indicated Resident expressed to CNA (nurse aide) that he hates in here and he wants to die. This nurse then spoke to resident, who stated that he hates it here, wants to leave but has nowhere to go. This nurse did recognize and validated the normalcy of his feelings of depression and deep sorrow at having lost his home, being a long term care 395870 Page 8 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0740 Level of Harm - Minimal harm or potential for actual harm resident in a skilled nursing facility, and having no family to take him home. (Resident R39) stated he has no plans at this time to harm himself but re-stated how unhappy he is. Review of a progress note dated 7/5/24, at 9:36 p.m. indicated the facility contacted the psychiatrist office and left a message requesting a callback to discuss the possibility of antidepressants for resident. Residents Affected - Few Review of a progress note dated 7/9/24, at 4:49 p.m. indicated the facility received an order to discontinue the Depakote and Remeron (anti-depressant medication), and continue to the Wellbutrin (anti-depressant medication). Review of Resident R39 ' s progress notes for the previous six months prior to his attempting to strike the nurse aide on 7/1/24, failed to include any violent behaviors. During an interview on 8/25/23, at 2:30 p.m. the Nursing Home Administrator and the Assistance Director of Nursing confirmed that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function for one of five residents Review of Resident R39 ' s clinical record failed to reveal an in-person or telehealth evaluation of Resident R39 related to his increased behavioral symptoms and possible suicidality. During an interview on 7/9/24, at approximately 1:00 p.m. the Director of Nursing (DON) confirmed that after the decrease in Depakote sprinkles on 6/19/24, Resident R39 exhibited violent behaviors and a passive death wish. The DON further confirmed that the psychiatrist further decreased medications on 7/9/24, without having evaluated the residents for increasing behaviors and possible suicidality. During an interview on 7/10/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide necessary behavioral health services to a resident to maintain the highest practicable mental and psychosocial well-being for one of six residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395870 Page 9 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0941 Level of Harm - Potential for minimal harm Residents Affected - Some Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on effective communication for four of ten staff members (Employees E2, E4, E6, and E7). Findings include: Review of the Facility Assessment dated 5/14/24, previously reviewed 3/26/24, 12/21/23, indicated Staff training and education consists of the following training topics that are mandatory annually such as abuse, neglect, and misappropriation as well as the Elder Justice Act, residents rights, person centered care, dementia training, and infection control and prevention. Review of facility provided documents and training record for Employees E2, E4, E6, and E7 revealed the following staff members did not have documented training on effective communication. Nurse Aide (NA) Employee E2 had a hire date of 4/21/99, failed to have effective communication in-service education between 4/21/23, and 4/21/24. NA Employee E4 had a hire date of 1/5/22, failed to have effective communication in-service education between 1/5/23, and 1/5/24. Licensed Practical Nurse (LPN) Employee E6 had a hire date of 3/9/22, failed to have effective communication in-service education between 3/9/23, and 3/9/24. Registered Nurse (RN) Employee E7 had a hire date of 4/22/13, failed to have effective communication in-service education between 4/22/23, and 4/22/24. During an interview on 7/10/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on effective communication for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395870 Page 10 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0942 Level of Harm - Potential for minimal harm Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on residents rights for two of ten staff members (Employees E2 and E7). Residents Affected - Some Findings include: Review of the Facility Assessment dated 5/14/24, previously reviewed 3/26/24, 12/21/23, indicated Staff training and education consists of the following training topics that are mandatory annually such as abuse, neglect, and misappropriation as well as the Elder Justice Act, residents rights, person centered care, dementia training, and infection control and prevention. Review of facility provided documents and training record for Employees E2 and E7 revealed the following staff members did not have documented training on residents rights. Nurse Aide (NA) Employee E2 had a hire date of 4/21/99, failed to have residents rights in-service education between 4/21/23, and 4/21/24. Registered Nurse (RN) Employee E7 had a hire date of 4/22/13, failed to have residents rights in-service education between 4/22/23, and 4/22/24. During an interview on 7/10/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on residents rights for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395870 Page 11 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on the prevention of abuse, neglect, and misappropriation for four of ten staff members (Employees E2, E3, E5, and E7). Findings include: Review of the Facility Assessment dated 5/14/24, previously reviewed 3/26/24, 12/21/23, indicated Staff training and education consists of the following training topics that are mandatory annually such as abuse, neglect, and misappropriation as well as the Elder Justice Act, residents rights, person centered care, dementia training, and infection control and prevention. Review of facility provided documents and training record for Employees E2, E3, E5, and E7 revealed the following staff members did not have documented training on effective communication. Nurse Aide (NA) Employee E2 had a hire date of 4/21/99, failed to have prevention of abuse, neglect, and misappropriation in-service education between 4/21/23, and 4/21/24. NA Employee E3 had a hire date of 5/9/11, failed to have prevention of abuse, neglect, and misappropriation in-service education between 5/9/23, and 5/9/24. Registered Nurse (RN) Employee E5 had a hire date of 5/8/17, failed to have prevention of abuse, neglect, and misappropriation in-service education between 5/8/23, and 5/8/24. RN Employee E7 had a hire date of 4/22/13, failed to have prevention of abuse, neglect, and misappropriation in-service education between 4/22/23, and 4/22/24. During an interview on 7/10/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on the prevention of abuse, neglect, and misappropriation for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395870 Page 12 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0944 Level of Harm - Potential for minimal harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for six of ten staff members (Employees E2, E3, E4, E5, E6, and E7). Findings include: Review of the Facility Assessment dated 5/14/24, previously reviewed 3/26/24, 12/21/23, indicated Staff training and education consists of the following training topics that are mandatory annually such as abuse, neglect, and misappropriation as well as the Elder Justice Act, residents rights, person centered care, dementia training, and infection control and prevention. Review of facility provided documents and training records for E2, E3, E4, E5, E6, and E7 revealed the following staff members did not have documented training on QAPI. Nurse Aide (NA) Employee E2 had a hire date of 4/21/99, failed to have QAPI in-service education between 4/21/23, and 4/21/24. NA Employee E3 had a hire date of 5/9/11, failed to have QAPI in-service education between 5/9/23, and 5/9/24. NA Employee E4 had a hire date of 1/5/22, failed to have QAPI in-service education between 1/5/23, and 1/5/24. Registered Nurse (RN) Employee E5 had a hire date of 5/8/17, failed to have QAPI in-service education between 5/8/23, and 5/8/24. Licensed Practical Nurse (LPN) Employee E6 had a hire date of 3/9/22, failed to have QAPI in-service education between 3/9/23, and 3/9/24. Registered Nurse (RN) Employee E7 had a hire date of 4/22/13, failed to have QAPI in-service education between 4/22/23, and 4/22/24. During an interview on 7/10/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on QAPI for six of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395870 Page 13 of 14 395870 07/10/2024 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0946 Provide training in compliance and ethics. Level of Harm - Potential for minimal harm Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for six of ten staff members (Employees E2, E3, E4, E5, E6, and E7). Residents Affected - Some Findings include: Review of the Facility Assessment dated 5/14/24, previously reviewed 3/26/24, 12/21/23, indicated Staff training and education consists of the following training topics that are mandatory annually such as abuse, neglect, and misappropriation as well as the Elder Justice Act, residents rights, person centered care, dementia training, and infection control and prevention. Review of facility provided education documents and training records for E2, E3, E4, E5, E6, and E7 revealed the following staff members did not have documented training on Compliance and Ethics. Nurse Aide (NA) Employee E2 had a hire date of 4/21/99, failed to have Compliance and Ethics in-service education between 4/21/23, and 4/21/24. NA Employee E3 had a hire date of 5/9/11, failed to have Compliance and Ethics in-service education between 5/9/23, and 5/9/24. NA Employee E4 had a hire date of 1/5/22, failed to have Compliance and Ethics in-service education between 1/5/23, and 1/5/24. Registered Nurse (RN) Employee E5 had a hire date of 5/8/17, failed to have Compliance and Ethics in-service education between 5/8/23, and 5/8/24. Licensed Practical Nurse (LPN) Employee E6 had a hire date of 3/9/22, failed to have Compliance and Ethics in-service education between 3/9/23, and 3/9/24. Registered Nurse (RN) Employee E7 had a hire date of 4/22/13, failed to have Compliance and Ethics in-service education between 4/22/23, and 4/22/24. During an interview on 7/10/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Compliance and Ethics for six of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395870 Page 14 of 14