Quality Life Services - Chicora

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

cart. This writer heard a loud thud followed by the resident yelling for assistance. This writer and nurse aide immediately went down hall and upon entering, the resident was observed to be sitting on the floor between the commode and the sink. Resident stated, I was trying to get back into by wheelchair. Review of Resident Resident R4's hospital dated 10/14/25, stated per nursing home staff, the resident had an unwitnessed fall last night. They put him back into bed. It was revealed around 4 a.m. the facility notified the Nurse Practitioner who recommended the resident was sent to the Emergency Department because the resident was on Eliquis (blood thinning medication). During an interview on 11/9/25, at 2:48 p.m. RN Supervisor, Employee E15, if an incident occurs the physician and family are notified immediately. RN, Supervisor, Employee E15 confirmed the facility failed to timely notify a physician after a resident had a fall. During an

interview on 11/10/25, at 9:52 a.m. Registered Nurse, Employee E14 stated As far as hospital situation, I was unaware he was going. It was revealed the resident fell before midnight on 10/13/25, and then around 5 a.m. all the sudden the ambulance showed up, I had no idea he was going, Supervisor never notified me.

RN, Employee E14 stated I am unsure if I documented a progress note. During an interview on 11/10/25, at 12:06 p.m. Nursing Home Administrator confirmed the facility failed to ensure the physician was appropriately notified of change in condition for one of four residents (Resident Resident R4). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Chicora

160 Medical Center Road Chicora, PA 16025

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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for one of three residents (Resident Resident R8). Findings include: Review of facility Behavior Standard Index policy dated 5/19/25, indicated the purpose is to develop and implement behavioral plans, and medication regimes, in efforts to optimize the functional abilities of residents while monitoring for adverse side effects and improve behaviors. Review of the clinical record indicated Resident Resident R8 was admitted to the facility on [DATE REDACTED]. Review of Resident Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/4/25, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anxiety, and high blood pressure. Review of Resident Resident R8's physician order dated 7/14/25 through 10/14/25, indicated to administer Ativan (used to treat anxiety) 0.5 milligrams every six hours as needed (PRN) for three months. Review of Resident Resident R8's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident Resident R8's Ativan. Review of Resident Resident R8's Medication Administration Record dated September 2025, indicated that residents received Ativan PRN 27 times. Review of Resident Resident R8's Medication Administration Record dated October 2025, indicated that residents received Ativan PRN 22 times. Review of Resident Resident R8's Progress Notes dated September and October 2025, failed to indicate any non-pharmacological interventions used prior to administering Resident Resident R8's Ativan. During an interview on 11/9/25, at 2:56 p.m. Registered Nurse Employee E11 stated we should order psychotropic medications for 14 days and prior to giving PRN medication we would try non-pharma logical interventions (NPI) such as toileting, offering drinks or food to decrease behaviors. If you give a psychotropic medication the behaviors and NPI should be documented. During an interview on 11/9/25, at 4:15 p.m. the Chief Nursing Officer Employee E7 confirmed that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for one of three residents (Resident Resident R8). 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.10(a) Resident care policies

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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Chicora

160 Medical Center Road Chicora, PA 16025

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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

which were reported The Immediate Jeopardy was lifted on 11/9/25, at 2:41 p.m. when the action plan implementation was verified. During an interview on 11/10/25, at 12:05 p.m. the NHA, Chief Nursing Officer, Employee E10, Clinical Operations Specialist, Employee E11 confirmed that the facility failed to ensure all nursing staff were educated on abuse/neglect before working in the facility and annually. The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect. The facility put other residents at risk for abuse/neglect from Licensed Practical Nurse (LPN), Employee E1 by allowing the staff member to continue to work after allegations were made. This failure resulted in an immediate jeopardy situation. 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services.

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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Chicora

160 Medical Center Road Chicora, PA 16025

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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

2:00 p.m. 14/14 staff confirmed education on types of abuse, when to report, and who to report to. All staff are required to verify education prior to the start of their next shift. Facility completed review of clinical records and facility incidents for the past 30 days to audit all allegations of abuse/neglect to ensure accurate reporting was completed. Facility identified 2 allegations of abuse/neglect during audit and reported them to Department of Health and initiated an investigation. Ad Hoc Meeting was conducted on 11/8/25, no changes were made related to abuse and reporting policy. Audits of clinical records revealed two incidents of abuse/neglect which were reported. The Immediate Jeopardy was lifted on 11/9/25, at 2:41 p.m. when the action plan implementation was verified. During an interview on 11/10/25, at 12:05 p.m. the NHA, Chief Nursing Officer, Employee E10, Clinical Operations Specialist, Employee E11 confirmed that

the facility failed to identify and timely report criminal allegations of abuse/neglect to local law enforcement and required agencies for one of five staff members (Licensed Practical Nurse (LPN), Employee E1). This failure created an immediate jeopardy situation. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa.

Code: 211.10(d) Resident care policies. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Chicora

160 Medical Center Road Chicora, PA 16025

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 0658

Ensure services provided by the nursing facility meet professional standards of quality.

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 policies, resident record review, and staff interviews, it was determined that the facility failed to follow professional standards of practice when documenting for one of eight residents. (Resident Resident R4).Findings include: Resident Resident R4 was admitted to the facility on [DATE REDACTED], with diagnoses of anxiety, muscle weakness, and high blood pressure. Review of the clinical record physician order dated 6/3/25, indicated Resident Resident R4 was ordered assist with toileting and hygiene every two hours and as needed. Review of Resident Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/4/25, indicated diagnoses of anxiety, muscles weakness, and high blood pressure. Question C0500 BIMS Summary Score revealed Resident Resident R4's score to be 4, severe impairment. Section GG-Functional Abilities-revealed the resident required substantial/maximal assistance with toileting transfers and hygiene. and with sit to stand.

Review of Resident Resident R4's late entry progress note effective 10/13/25, entered on 10/22/25, by Nursing Home Administrator, stated at approximately 11:30 p.m. this nurse was standing at the med cart in the hall when a loud bang was heard this writer and CNAs on unit immediately went down the hall resident noted to be found sitting on the floor beside the commode. Resident stated, I was trying to get back into my wheelchair Resident told this writer he got dizzy prior to falling he stated he hit his head on the wall and complained of a headache. Resident assessed immediately. Residents noticed that they had a skin tear on right inner forearm, approximately 8x8 RN cleaned and dressed, no other visible injuries noted. Vital signs stable. Neuro checks started prior to the protocol. No other complaints of pain besides having a slight headache. Resident assisted back to bed with assistance x2. RN supervisor aware. Family made aware.

Physician notified. During an interview on 11/9/25, at 2:48 p.m. Registered Nurse Supervisor, Employee E15 stated other staff shouldn't enter a note for someone else. During an interview on 11/9/25, at 3:06 p.m.

the Chief Nursing Officer, Employee E10 confirmed the Nursing Home Administrator is not a nurse and the facility failed to follow professional standards of practice when documenting for one of eight residents. (Resident Resident R4). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Chicora

160 Medical Center Road Chicora, PA 16025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

administering Tylenol, pain is assessed by looking for any indicators like guarding or grimacing. For a change in a resident's condition, physical assessment, vitals, and notification to physician and family must be completed. It was indicated Resident Resident R1 typically screams out and has behaviors. During report on the morning of 9/28/25, LPN, Employee E1 notified LPN, Employee E4 that Resident Resident R1 temps were low. It was indicated LPN, Employee E1 stated it was around 5:00 a.m. when [he/she] first noticed the resident was diaphoretic, cold, clammy, so LPN, Employee E1 turned the fan off. It was revealed a RN Supervisor was not notified. During an interview on 11/5/25, at 12:40 p.m. LPN, Employee E1 stated prn medications are given anytime resident needs it for pain or anxiety. If unable to determine pain, assess based on non-verbal cues, the way they act. When I give PRN, it has option to put progress note attached to medication depending on what's going on, I will add to progress note more info as to why. LPN, Employee E1 stated If change in condition, contact RN immediately. LPN, Employee E1 stated Resident Resident R1's baseline was confused, really unable to tell any of needs. It was indicated Resident Resident R1 was assessed for pain by non-verbal cues, she was yelling out, clutching fists, facial expressions, breathing labored, resident occasions yells out. LPN stated if I gave it, it was the way she was clenching fist. Those are things I would watch with her. Non-pharm interventions must be documented. LPN, Employee E1 stated I honestly don't remember when asked if non-pharmological interventions were implemented and documented prior to administering Resident Resident R1 Tylenol on 9/27/25. During an interview on 11/5/25, at 1:28 p.m. the DON confirmed that the facility failed to ensure a resident is provided with non-pharmacological interventions and

an assessment prior to administering pain medications as needed for one of seven residents (Resident Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa.

Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Chicora

160 Medical Center Road Chicora, PA 16025

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

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

10/13/25, entered on 10/22/25, by Nursing Home Administrator, stated at approximately 11:30 p.m. this nurse was standing at the med cart in the hall when a loud bang was heard this writer and CNAs on unit immediately went down the hall resident noted to be found sitting on the floor beside the commode.

Resident stated, I was trying to get back into my wheelchair Resident told this writer he got dizzy prior to falling he stated he hit his head on the wall and complained of a headache. Resident assessed immediately.

Resident noted to have a skin tear on right inner forearm approximately 8x8 RN cleaned and dressed, no other visible injuries noted. Vital signs stable. Neuro checks started prior per protocol. No other complaints of pain besides having a slight headache. Resident assisted back to bed with assistance x2. RN supervisor aware. Family made aware. Physician notified. A review of Resident Resident R4's clinical record on 10/13/25, and 10/14/25, failed to include evidence that a physical assessment was completed by a Registered Nurse or documentation Q15 minute checks were initiated. During an interview on 11/9/25, at 2:48 p.m. RN Supervisor, Employee E15 stated residents that they are ordered transfer and assist with toileting, it is expected the Nurse Aides (NA) to stay with the resident. If a fall is unwitnessed or the resident hits their head, a body assessment must be completed and documented to ensure there are no injuries, and then neurological checks are started. The physician and family are notified. An assessment must be entered into

the incident report, and a progress note should be entered timely, right after the resident was assessed. RN Supervisor, Employee E15 stated no one should enter a note for someone else. RN Supervisor, Employee E15 confirmed neuro checks first began on 10/14/25, 8:15 p.m. for Resident Resident R4's fall that occurred on 10/13/25. The facility failed to implement neuro checks in a timely manner after an unwitnessed fall.\ During

an interview on 11/10/25, at 9:52 a.m. Registered Nurse, Employee E14 stated the nurse aide took Resident Resident R4 to the bathroom, and the residents tried to take themselves off. As far as hospital situation, I was unaware he was going. It was revealed the resident fell before midnight on 10/13/25, and then around 5 a.m. all the sudden the ambulance showed up, I had no idea he was going, Supervisor never notified me.

RN, Employee E14 stated I am unsure if I documented a progress note. During an interview on 11/10/25, at 12:06 p.m. Nursing Home Administrator confirmed that the facility failed to implement fall prevention interventions and conduct post fall monitoring for one of four residents (Resident Resident R4). 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.29 (a) (c.3) (1) Resident rights 28 Pa. Code 211.12 (d) (1)(3)(5) Nursing services

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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Chicora

160 Medical Center Road Chicora, PA 16025

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 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, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident Resident R6).Findings include: Review of facility policy Medication Administration-General Guidelines reviewed 5/19/25, stated medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. Personnel authorized to administer medication do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). Five rights- Right resident, right drug, right route and right time, and applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away. Review of the clinical record indicated Resident Resident R6 was admitted to the facility on [DATE REDACTED]. Review of Resident Resident R6's clinical record reveal an allergy to Tylenol with

an unknown severity as of 7/22/25. Review of Resident Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/28/25, indicated diagnoses of dementia, aphasia, and malnutrition.

Review of Resident Resident R6's progress note dated 8/22/25, at 5:34 a.m. entered by Registered Nurse, Employee E12 stated resident had a temperature. Floor nurse gave [him/her] Tylenol and then realized the resident was not ordered Tylenol, and it was listed as an allergy. Vitals and assessment completed with no adverse reaction note. The Certified Registered Nurse Practitioner was notified. As needed, Benadryl was ordered but not needed. Ibuprofen was ordered as needed for fever/pain. Vitals obtained every 15 minutes for one hour then every hour for four hours for monitoring. Review of the facility incident report dated 8/22/25, revealed a witness statement entered by LPN, Employee E1 that stated Resident had a fever of 101. Gave Tylenol and realized upon charting that no Tylenol order and was listed as an allergy. Supervisor made aware of error and Nurse Practitioner called. Vital signs were done every 15 minutes for one hour then, every hour for four hours. Resident has no signs and symptoms of reaction at this time. During an interview

on 11/5/25, at 12:43 p.m., Licensed Practical Nurse (LPN), Employee E1 confirmed [he/she] gave Resident Resident R6 Tylenol without an order, and the resident had an allergy. LPN, Employee E1 stated I did not look at chart before I gave Tylenol. During an interview on 11/9/25, at 3:12 p.m. the Chief Nursing Officer, Employee E10, confirmed that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident Resident R6).28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Chicora

160 Medical Center Road Chicora, PA 16025

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 and implement

the facilities abuse and neglect policy, and failed to report alleged criminal activity of a Licensed Practical Nurse (LPN) Employee E1 to the proper authorities, which created an immediate jeopardy situation for all 95 of 95 residents.Findings include: The job description for the Nursing Home Administrator dated 4/14/24, indicated the NHA 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 position is responsible for establishing and maintaining systems that are effective and efficient. Oversee all departments and department supervisors to ensure the Nursing Home is operating safely and efficiently. Operate the company in accordance with the established policies and procedures. The job description for the Director of Nursing dated 5/8/25, indicated

the DON is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management of the nursing department. Assume accountability for the development, organization, and implementation of approved policies and procedures. Ensure compliance with all federal, state, and local regulations. Based on findings identified, the facility failed to implement the facilities Abuse and Neglect policy and failed to report alleged criminal activity to the proper authorities, 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 11/9/25, at 4:15 p.m. the Chief Nursing Officer Employee E7 was notified that the NHA and DON failed to implement the facilities abuse and neglect policy and failed to report allegations of criminal activity, which created an immediate jeopardy situation for all 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 - Many

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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Chicora

160 Medical Center Road Chicora, PA 16025

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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to one of five direct care facility staff reviewed (Employee E5).Findings include: Review of the facility Nursing Assistant Job Description indicated the purpose of your job role is to provide direct care to residents, under the supervision of a licensed nurse, in accordance with policies and procedures and report resident needs and concerns to a licensed nurse. Attend all in-service classes as assigned and complete assignments. During

an interview on 11/9/2025, at 10:30 a.m. Chief Nursing Officer Employee E7 stated that education is conducted by calendar year running January through December. Review of facility education documents for

the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E5's facility provided information did not include training on QAPI. During an interview on 11/9/25, at 10:54 a.m. the Chief Nursing Officer Employee E7 confirmed that the facility failed to provide QAPI training to one of five direct care facility staff reviewed (Employee E5). 28 Pa. Code: 201.14(a) Responsibility of Licensee 28 Pa. Code: 201.20(a) Staff Development

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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Chicora

160 Medical Center Road Chicora, PA 16025

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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for four of four direct care facility staff reviewed (NA Employee E5, E8, E9, and E10). Findings include: Review of the facility Nursing Assistant Job Description indicated the purpose of your job role is to provide direct care to residents, under the supervision of a licensed nurse, in accordance with policies and procedures and report resident needs and concerns to a licensed nurse. Attend all in-service classes as assigned and complete assignments. During an interview on 11/9/2025, at 10:30 a.m. Chief Nursing Officer Employee E7 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of NA Employee E5's facility provided information failed to include the minimum 12-hour NA annual training. Review of NA Employee E8's facility provided information failed to include the minimum 12-hour NA annual training.

Review of NA Employee E9's facility provided information failed to include the minimum 12-hour NA annual training. Review of NA Employee E10's facility provided information failed to include the minimum 12-hour NA annual training. During an interview on 11/9/25, at 10:57 a.m. the Chief Nursing Officer Employee E7 confirmed that the facility failed to provide a minimum of 12 hours of NA training to four of four direct care facility staff reviewed (NA Employee E5, E8, E9, and E10), as required. 28 Pa. Code: 201.14(a) Responsibility of Licensee 28 Pa. Code: 201.20(a) Staff Development

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