F 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Potential for
minimal harm
Based on group interview and staff interviews, it was determined that the facility failed to provide access to
mail delivered on Saturdays for three of 8 residents (Residents R200, R201, and R202).
Residents Affected - Some
Findings include:
During the group interview on 8/30/23, at 9:45 a.m. three of eight residents verbalized a concern that the
facility holds all mail delivered Saturdays until Monday.
During an interview on 8/31/23, at 12:35 p.m. Licensed Practical Nurse Employee E1 stated that mail is
delivered by Activities department staff, Monday through Friday.
During an interview on 8/31/23, at 12:40 p.m. Activities Department Employee E2 stated that during the
week, Activities staff receive the mail from Administrative Employee E3. She further stated We don ' t
usually deliver the mail on the weekend because she (Administrative Employee E3) is out of office.
During an interview on 8/31/23, at 1:11 p.m. Administrative Employee E3 confirmed that all mail to the
facility comes to her office Monday through Friday, and she separates facility mail from resident mail, and
Activities staff distribute the resident mail. She further confirmed that mail received on Saturdays is placed
in a box on her door, and distributed on Monday.
During an interview on 8/31/23, at 1:45 p.m. the Nursing Home Administrator confirmed that the facility
failed to provide access to mail delivered on Saturdays for three of 8 residents.
28 Pa. Code 201.29(j) Resident rights.
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:
395906
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
395906
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/31/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quality Life Services - Henry Clay
5253 National Pike
Markleysburg, PA 15459
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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, clinical records, and staff interview, it was determined that the facility failed to
provide ordered fall mats to prevent possible injuries for one of four residents (Resident R60).
Findings include:
Review of the facility policy Accidents and Incidents dated 1/26/23, indicated the facility will promote a safe
environment for all residents. The policy further indicated the licensed nurse responsible for the resident will
update residents plan of care as necessary related to the incident / accident.
Review of Resident R60's admission record indicated she was admitted to the facility on [DATE].
Review of Resident R60's Minimum Data Set (MDS) assessment (mandated assessment of a resident's
abilities and care needs) dated 8/10/23, indicated diagnoses of dementia (a group of symptoms that affects
memory, thinking and interferes with daily life), osteoporosis (condition when the bones become brittle and
fragile), and a seizure disorder.
Review of nursing review assessment and progress note, completed 8/5/23, at 4:14 a.m. indicated Resident
R60 was at high risk for falls.
Review of a facility provided Fall Huddle Tip Sheet dated 8/11/23, indicated Resident R60 had sustained a
fall, and an immediate intervention of fall mats was put into place.
Review of a physician's order dated 8/11/23, indicated, Mats and bed pillows to both sides of bed for her
safety.
Review of a facility provided incident report dated 8/14/23, at 11:10 p.m. indicated Resident R60 had
sustained a fall with no injury, and further indicated new intervention was to apply floor mats.
During an interview on 8/31/23, at 12:33 p.m. the Director of Nursing confirmed that fall mats were not in
place at the time of the second fall, as ordered.
During an interview on 8/31/23, at 1:45 p.m the Nursing Home Administrator and the Director of Nursing
confirmed that the facility failed to provide ordered fall mats to prevent possible injuries for one of four
residents.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 201.29(a) Resident rights.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa Code 211.12(d)(1)(2)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395906
If continuation sheet
Page 2 of 2
