Quality Life Services - Apollo

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

entry or exit. Compliance will be monitored through audits. Audits will consist of door security assessment by facility Administrator, or designee, audit of resident risk assessments will be completed by the facility Director of Nursing, or designee, and an audit of all resident care plans who were identified at risk of elopement will be completed by the Director of Nursing, or designee. Results will be reviewed at QAPI (Quality Assurance and Performance Improvement Committee) to be completed by NHA, this to be completed by 11/14/25. The facility's policy and procedures for elopements were reviewed 11/12/25, no revisions were made. On 11/13/25, at 10:34 a.m. it was confirmed 146/146 residents were reassessed for

an elopement risk. 36/146 residents were identified as at risk. 5/146 residents were newly identified as at risk of elopement. 36/36 resident physician orders were verified for an electronic monitoring bracelet. 36/36 care plans were reviewed and updated to include interventions to prevent elopement. Review of facility documents on 11/13/25, revealed the facility had 126 employees and 104 agency employees. 138 employees signed they received formal education on the policy Elopement Prevention. 65 employees signed they received education via phone as they had not been working in the building.During employee interviews on 11/13/25, from 11:33 a.m. through 2:18 p.m. 38 employees confirmed they had received education on the facility's elopement policy and procedures, as indicated above. Review of an ad hoc (an unplanned meeting organized to address specific issues of urgent matters) QAPI meeting dated 11/13/25, revealed during an audit of all residents, 36 residents were identified as at risk of elopement. This audit reviewed wandering assessment, wanderguard orders, and elopement care planning. The audit revealed errors in 18 resident assessments, one care plan was found to be needing updated, and two residents were found to be needing wanderguard orders. The Immediate Jeopardy was lifted on 11/13/25, at 3:07 p.m. when the action plan implementation was verified. During an interview on 11/13/25, at 4:46 p.m. the NHA and DON confirmed the facility failed to ensure each resident received adequate supervision, which resulted in an elopement for two of 33 residents (Residents Resident R1 and Resident R2), resulting in Immediate Jeopardy. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa.

Code: 211.12(d)(1)(5) Nursing Services.

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Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Apollo

151 Goodview Drive Apollo, PA 15613

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 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopement of two resident (Residents Resident R1 and Resident R2), which created an immediate jeopardy situation for two of 33 residents.Findings include: The job description for the NHA specified the purpose of

the position is to direct the day-to-day operations of the facility in accordance with current federal, state, and local standards governing long-term care facilities and to ensure that the highest degree of resident care and services are delivered and maintained. The job description for the DON specified the purpose of the position is to provide nursing management, set resident care standards for all direct care providers and provide completer supervision and management for the nursing department. Based on findings identified in

this report, the facility failed to prevent the elopement of two residents (Residents Resident R1 and Resident R2), which placed

the residents in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 11/12/25, at 2:34 p.m. the NHA and DON were notified that they failed to effectively manage the facility to prevent the elopement of a resident, which created an immediate jeopardy situation for two of 33 residents. 28 Pa.

Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Apollo

151 Goodview Drive Apollo, PA 15613

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Closed Resident Record CR1).A review of the clinical record indicated that Closed Resident Record CR1 was admitted to the facility on [DATE REDACTED] with diagnoses that included malignant neoplasm of kidney, major depressive disorder and hypertension (pressure in your blood vessels are too high). A review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 7/30/25, indicated the diagnoses remained current.A review of Closed Resident Record CR1 nurse progress notes 9/30/25 indicating resident ceased to breath (CTB) on 9/26/25 at 1915.A review of Closed Resident Record CR1 nurse progress notes did not include documentation on 9/26/25. During an interview on 11/12/25, at 12:04 p.m. the Director of Nursing confirmed the facility failed to make certain that medical records on accurately documented for Closed Resident Record CR1 and each resident's records are complete as required. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Event ID:

Facility ID:

If continuation sheet