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 policy, facility submitted documents, clinical records, and staff interviews, it was determined
that the facility failed to make certain each resident received adequate supervision and assistance to
prevent accidents for one out of 12 residents reviewed (Resident R1).
Findings include:
The facility Accidents and Incidents policy dated 1/25/24, indicated that it is the policy of the facility to
promote a safe environment for all residents.
Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses
that included cerebral infarct (stroke - interruption of blood flow within your brain that causes death of brain
cells), hemiplegia (paralysis or weakness of one side of the body) affecting right dominant side, and
aphasia (comprehension and communication -reading, speaking, or writing - disorder resulting from
damage or injury to the specific area in the brain).
Review of Resident R1's Minimum Data Set assessment (MDS- periodic assessment of resident care
needs) dated 2/8/24, indicated that the diagnoses were current upon review.
Review of a physician order dated 2/27/24, indicated for Resident R1 to have built up red foam utensil and
divided plate for all meals. Further review indicated the order was updated following the incident to include
using a sip-a-cup for hot beverages.
Review of the Kardex dated 3/10/24, indicated eating/swallowing to maintain current level of function and
prevent avoidable decline.
Review of the care plan dated 12/8/23, indicated to engage in simple, structured activities that avoid overly
demanding tasks, anticipate needs and meet them, ensure to provide a safe environment: make sure call
light is always in reach, and that he is not isolated, and encourage to participate to the fullest extent
possible.
Review of a facility submitted documents dated 3/10/24, indicated Resident R1 was given a cup of coffee in
a styrofoam cup during the Coffee Club activity. The cup was placed in the resident's left hand
(non-dominant) and spilled the coffee on himself resulting in two areas of redness on his abdomen
measuring 10.0 centimeters (cm) by 5.0 cm, and 5.0 cm by 5.0 cm. The resident had on a cloth clothing
protector and a t-shirt. Resident R1's skin remained intact.
(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:
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
04/01/2024
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
During an interview on 4/1/24, at 11:08 a.m. Activity Director, Employee E1 stated she was not working the
date of the incident. She stated the Coffee Club coffee was provided by the kitchen on 3/10/24, and usually
everyone gets styrofoam cups, and Resident R1 does not usually come to the activity. The activity takes
place in the East Dining Room for all residents that wish to attend.
During a telephone interview on 4/1/24, at 11:30 a.m. Activities Aide Employee E2 stated she worked the
day of the incident and Resident R1 was not brought to Coffee Club activity. He was brought to the
Resident Lounge by the Nurse Aid (NA) Employee E3. She served coffee to the residents involved in the
activity, a nurse aide came in and asked if Resident R1 could get a coffee, and a coffee was provided to NA
Employee E3 to give to Resident R1.
During an telephone interview on 4/1/24, at 12:15 p.m. NA Employee E3 stated Resident R1 was brought to
the resident lounge to watch television. When he saw the coffee being delivered to the activity he started
pointing and screaming. Resident R1 is unable to speak. Resident R1 was holding the coffee in his left
hand and sipping at it. Other resident's in the lounge stated they wanted coffee also, so NA Employee E3
returned to the East Dining Room to obtain more coffee, when she heard Resident R1 yell out. She states
she put down the other resident's coffee and went out of the dining room into the lounge, and saw Resident
R1 had spilled his coffee on himself. NA Employee E3 stated Resident R1 has previously held styrofoam
cups of hot chocolate with no issues. She moved the soaked clothing away from Resident R1's skin and
notified nursing.
During an interview on 4/1/24, at 1:11 p.m. the Nursing Home Administrator confirmed that the facility failed
to make certain Resident R1 received adequate supervision and assistance to prevent accidents as
required.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(1) Management.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395906
If continuation sheet
Page 2 of 2
