Health inspection·June 18, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **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 protect residents from neglect that resulted in insulin not being administered as ordered for four of eight residents (Residents R1, R2, R3, and R4). Findings include: Review of the facility policy, Resident Protection From Abuse, Neglect, Mistreatment or Exploitation dated 6/11/24, defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/6/25, included diagnoses of hypertension (a condition where the force of blood flow is too high against the artery) and Type 2 diabetes. Review of the physician orders 3/19/25, indicated to give Resident R1 insulin aspart (rapid acting insulin) Inject subcutaneously in the morning, do NOT give more than 30 min prior to meal. Review of the progress note dated 6/7/25, at 12:34 pm., indicated that Registered Nurse (RN) Employee E1 obtained a blood sugar at 6:00 am however sliding scale cover prior to breakfast was not administered. Review of the clinical record indicated Resident R2 was admitted to the facility originally on 11/18/23, and readmitted [DATE]. Review of the MDS dated [DATE], included diagnoses of cerebrovascular disease affecting left non-dominant side (condition that impact the brain's blood vessels and blood flow) and Type 2 diabetes. Review of the physician orders 3/19/25, indicated to give Resident R1 insulin regular Inject subcutaneously three times a day. The order specifies times of 7:00 a.m., 11:00 a.m., and 5:00 p.m. Review of the progress note dated 6/7/25 at 12:33 pm., indicated that RN Employee E1 obtained a blood sugar at 6:00 am however insulin coverage was not given before breakfast per orders. Page 1 of 4 395870 395870 06/18/2025 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0600 Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of the MDS dated [DATE], included diagnoses of hypertension and Type 2 diabetes. Residents Affected - Some Review of the physician orders 3/19/25, indicated to give Resident R1 insulin aspart Inject subcutaneously before meals. Review of the progress note dated 6/7/25, at 12:16 pm., indicated that RN Employee E1 do not obtain a blood sugar reading per orders. Since blood sugar reading was not obtained, no sliding scale coverage was given. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of hypertension and type 2 diabetes. Review of the physician orders 3/19/25, indicated to give Resident R1 insulin aspart Inject subcutaneously three times a day. 1st blood sugar needs to be done during breakfast for resident known to drop if given coverage before. Review of the progress note dated 6/7/25 at 12:34 pm., indicated that RN Employee E1 obtained a blood sugar at 6:00 am however insulin coverage was not given per orders. Review of facility submitted information dated 6/7/25, indicated, on 6/7/25 at 930 a.m., the RN Supervisor identified [RN employee E1] had missed medications including insulin for multiple residents. Review of an employee statement written by RN Employee E1 dated 6/7/25, indicated, After obtaining accuchecks on 4 residents I did not cover the residents blood sugars. I did not have my priorities in line and put these residents at risk. During an interview on 6/18/25, at approximately 10:45 p.m. the Director of Nursing, Director of Nursing, and Assistant Director of Nursing confirmed the facility failed to protect residents from neglect that resulted in insulin not being administered as ordered for four of eight residents (Residents R1, R2, R3, and R4). 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) Nursing services. 395870 Page 2 of 4 395870 06/18/2025 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0760 Ensure that residents are free from significant medication errors. 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, observation, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for four of eight residents (Residents R1, R2, R3, and R4). Residents Affected - Some Findings include: Review of facility policy Medication Administration reviewed 6/11/24, indicated that medications will be administered in accordance with written orders of licensed physicians, manufacturer's specifications and professional standards of practice. Review of the National Library of Medicine information dated, indicated insulin aspart is an injectable medication used to treat diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). It further stated, If you are using insulin aspart suspension to treat type 2 diabetes, it is usually injected within 15 minutes before a meal. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/6/25, included diagnoses of hypertension (a condition where the force of blood flow is too high against the artery) and type 2 diabetes. Review of the physician orders 3/19/25, indicated to give Resident R1 insulin aspart Inject subcutaneously in the morning, do NOT give more than 30 min prior to meal. Review of the progress note dated 6/7/25 at 12:34 pm., indicated that Registered Nurse (RN) employee E1 obtained a blood sugar at 6:00 am however sliding scale cover prior to breakfast was not administered. Review of the clinical record indicated Resident R2 was admitted to the facility originally on 11/18/23 and readmitted [DATE]. Review of the MDS dated [DATE], included diagnoses of cerebrovascular disease affecting left non-dominant side (condition that impact the brain's blood vessels and blood flow) and type 2 diabetes. Review of the physician orders 3/19/25, indicated to give Resident R1 insulin regular Inject subcutaneously three times a day. The order specifies times of 7:00 a.m., 11:00 a.m., and 5:00 p.m Review of the progress note dated 6/7/25 at 12:33 pm., indicated that RN Employee E1 obtained a blood sugar at 6:00 am however insulin coverage was not given before breakfast per orders. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of hypertension and type 2 diabetes. Review of the physician orders 3/19/25, indicated to give Resident R1 insulin aspart Inject subcutaneously before meals. 395870 Page 3 of 4 395870 06/18/2025 Quality Life Services - Markleysburg 252 Main Street Markleysburg, PA 15459

F 0760 Level of Harm - Minimal harm or potential for actual harm Review of the progress note dated 6/7/25 at 12:16 pm., indicated that RN Employee E1 did not obtain a blood sugar reading per orders. Since blood sugar reading was not obtained, no sliding scale coverage was given. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Residents Affected - Some Review of the MDS dated [DATE], included diagnoses of hypertension and type 2 diabetes. Review of the physician orders 3/19/25, indicated to give Resident R1 insulin aspart Inject subcutaneously three times a day. 1st blood sugar needs to be done during breakfast for resident known to drop if given coverage before. Review of the progress note dated 6/7/25 at 12:34 pm., indicated that RN Employee E1 obtained a blood sugar at 6:00 am however insulin coverage was not given per orders. Review of RN Employee E1's written statement dated 6/7/25, indicated After obtaining accuchecks on 4 residents I did not cover the residents blood sugars. During an interview on 6/18/25, at approximately 10:45 p.m. the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing confirmed that insulin administrations do not fall under the facility's medication administration policy, and further confirmed that the facility failed to make certain that residents are free of significant medication errors for four of eight residents. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395870 Page 4 of 4