Quality Life Services - Westmont

Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F-F609 on November 7, 2024. 28 Pa.

Code 201.14(a) Responsibility of Licensee. 28 Pa.

Code 201.18(e)(1) Management. 28 Pa.

Code 211.12(d)(5) Nursing Services.

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Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

assessments for three of 26 residents reviewed (Residents 14, 24, 32).

Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of MDS assessments, dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven-day assessment period, that any type of injection, insulin, and/or select medications were received by the resident.

Section N0415A was to be coded if the resident received an antipsychotic medication during the seven-day assessment period, and Section N0451K was to be coded if the resident received an anticonvulsant medication during the seven-day assessment period.

Physician's orders for Resident 14, dated January 16, 2021, included an order for the resident to receive 100 milligrams (mg) of gabapentin (anticonvulsant medication) twice a day for rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness) and 300 mg of gabapentin at bedtime for rheumatoid arthritis.

Medication Administration Records (MARs) for Resident 14, dated January and February 2025, revealed that staff administered 100 mg of gabapentin twice a day and 300 mg at bedtime from January 16 through February 19, 2025.

However, Section N0415K1 of Resident 14's quarterly MDS assessment, dated February 3, 2025, was coded to indicate that the resident did not receive an anticonvulsant medication during the seven-day assessment.

Physician's orders for Resident 24, dated January 10, 2025, included an order for the resident to receive 25 milligrams (mg) Seroquel (antipsychotic medication) every day. A quarterly MDS assessment for Resident 24, dated January 15, 2025, revealed that Section N0415A was coded indicating that the resident had not received an antipsychotic medication.

Physician's orders for Resident 32, dated December 30, 2024, included an order for the resident to receive 100 mg of gabapentin three times a day for polyneuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). MARs for Resident 32, dated December 2024 and January 2025, revealed that staff administered 100 mg of gabapentin three times a day from December 31 through January 3, 2025.

However, Section N0415K1 of Resident 32's quarterly MDS assessment, dated January 3, 2025, was coded to indicate that the resident did not receive an anticonvulsant medication during the seven-day assessment.

Interview with the Nursing Home Administrator on January 30, 2025, at 11:35 a.m. confirmed that MDS assessments for Residents 14, 24, and 32 were coded inaccurately. 28 Pa.

Code 211.5(f) Clinical Records.

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Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

actions that can be measured.

determined that the facility failed to ensure that resident-centered care plans were developed and

(EBP) for having a surgically implanted drain.

Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 5, 2025, revealed that the resident was cognitively intact and dependent on staff for daily care tasks.

Physician's orders for Resident 6, dated May 16, 2024, included an order that the resident may not be showered due to his surgically implanted percutaneous drain (gallbladder drain).

Physician's order, dated June 12, 2024, included an order for the staff to flush the gallbladder drain vigorously daily.

Observations of Resident 6 on February 18, 2024, at 10:08 a.m. revealed that the resident had a sign on his door indicating that he was on EBP and had personal protective equipment outside his door for staff to wear.

There was no documented evidence that a care plan was developed to address Resident 6's care needs related to EBP.

Interview with Nurse Aide 5 on February 18, 2025, at 10:08 a.m. revealed that Resident 6 was on Enhanced Barrier Precautions and that staff must wear a gown when entering his room and providing care for him.

Interview with Nursing Home Administrator on February 20, 2025, at 10:29 a.m. confirmed that Resident 6's care plan did not address his care needs related to EBP. 28 Pa.

Code 201.24(e)(4) admission Policy.

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Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

9, 2024, included orders for the resident to receive health shakes twice a day and a reduced

A nursing note, dated December 30, 2024, at 9:22 p.m. revealed that Resident 14 was re-admitted from

receive a reduced concentrated sweets diet, soft and bite sized texture, and bread.

A dietitian note, dated January 30, 2025, revealed that the resident had a weight loss and supplemental nutrition was ordered, which included health shakes twice a day and fortified foods at all meals.

Interview with the Dietitian on February 19, 2025, at 2:29 p.m. revealed that she re-ordered the health shakes and fortified foods on January 30, 2025, when she realized that they were not ordered upon her re-admission from the hospital on December 30, 2024.

She indicated that Resident 14 continued to receive health shakes twice a day and fortified foods with all meals, despite not having a physician's order.

Interview with the Dietary Manager on February 19, 2025, at 2:50 p.m. confirmed that the resident continued to receive health shakes twice a day and fortified foods with all meals since her re-admission on [DATE], according to her dietary supplement information. 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing Services.

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Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

that they were in compliance with F-F692 on February 1, 2025.

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Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

services of a licensed pharmacist.

failed to maintain a complete and accurate accounting of controlled medications (medications with

Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated December 23, 2024, revealed that the resident was understood, could understand others, and had a diagnosis of anxiety. A care plan for the resident, dated October 14, 2024, revealed that the resident uses anti-anxiety medications related to an anxiety disorder, and staff was to administer the anti-anxiety medications to the resident as ordered by the physician.

Physician's orders for Resident 33, dated December 20, 2024, included an order for the resident to receive a one milligram (mg) tablet of Clonazepam (a narcotic medication used to prevent and treat anxiety disorders) every eight hours as needed. Resident 33's controlled drug logs for January and February 2025 revealed that staff signed out doses of Clonazepam for administration to the resident on January 7, 2025, at 7:07 p.m.; January 12, 2025, at 7:05 a.m.; January 14, 2025, at 8:20 a.m.; January 29, 2025, at 6:30 a.m.; January 29, 2025, at 8:00 p.m.; February 5, 2025, at 4:00 a.m.; and on February 8, 2025, at 9:30 a.m.

However, the resident's clinical record, including the Medication Administration Records (MARs) and the nursing notes, revealed no documented evidence that the Clonazepam was administered to the resident on these dates and times.

Interview with the Nursing Home Administrator on February 20, 2025, at 3:40 p.m. confirmed that there was no documented evidence that the Clonazepam was administered to Resident 33 on the above-mentioned dates and times. 28 Pa.

Code 211.9(j)(3) Pharmacy Services. 28 Pa.

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

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Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

was no documented evidence that staff attempted non-medication interventions prior to administering

28 Pa.

Code 211.12(d)(5) Nursing Services.

medication errors for one of 26 residents reviewed (Resident 32).

Findings include: The facility's policy regarding medication administration, dated April 8, 2024, indicated that facility was to administer medications to residents in a safe manner that correlated with their daily activity and natural schedules.

The facility's policy regarding physician's orders, dated April 8, 2024, revealed that physician's orders were to be followed in accordance with good nursing principles and practice and were to be transcribed and carried out by the persons legally authorized to do so.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated January 3, 2024, indicated that the resident was alert and oriented, received insulin, and had diagnoses that included diabetes.

Physician's orders for Resident 32, dated January 2, 2025, included an order for the resident to receive 5 units of Insulin Lispro (fast acting insulin) subcutaneously (beneath the skin) before meals for diabetes and to hold the insulin if the resident's blood sugar was less than 140 milligrams/deciliter (mg/dL). Resident 32's Medication Administration Records (MARs) for December 2024 and January 2025 revealed that the resident's blood sugar at 8:00 a.m. on February 4 was 133 mg/dL and February 6 was 124 mg/dL; at 11:00 a.m. on January 9 was 126 mg/dL, January 23 was 125 mg/dL, February 15 was 98 mg/dL, and February 15 was 98 mg/dL; and at 4:00 p.m. on February 1 was 114 mg/dL and February 6 was 83 mg/dL.

There was no documented evidence that Resident 32's insulin was held according to the physician-ordered parameters on the dates and times above.

Interview with the Nursing Home Administrator on February 20, 2025, at 2:31 p.m. confirmed that the Insulin Lispro was not held as ordered on the dates and times above. 28 Pa.

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

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Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

serve food in accordance with professional standards.

observations and staff interviews, it was determined that the facility failed to ensure that food was

Findings include: Observations in the main kitchen on February 18, 2025, at 9:01 a.m.; February 19, 2025, at 11:15 a.m.; and on February 20, 2025, at 8:51 a.m. revealed that there was an accumulation of dust and food debris, a clear drinking glass, a small red bowl, and a [NAME] Cup (a lightweight, easy-to-grip adapted drinking cup designed to prevent spills) under and behind the ice machine, and there was an accumulation of dust and food debris under the stove.

Interview with the Dietary Manager on February 20, 2025, at 8:58 a.m. confirmed that there was an accumulation of dust and food debris, a clear a drinking glass, small red bowl, and a [NAME] Cup under and behind the ice machine, and an accumulation of dust and food debris under the stove. 28 Pa.

Code 211.6(f) Dietary Services.

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Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

regulations regarding residents being free from significant medication errors.

conditions, cited during the survey ending April 3, 2024, revealed that the facility developed a plan of

committee for review.

The results of the current survey, cited under F-F812, revealed that the QAPI committee was ineffective in correcting deficient practices related to food procurement-storing/preparing/serving food under sanitary conditions.

Refer to F-F641, F-F656, F-F684, F-F755, F-F760, F-F812. 28 Pa.

Code 201.14(a) Responsibility of Licensee. 28 Pa.

Code 201.18(e)(1) Management.

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Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F-F600 on November 7, 2024.

potential for actual harm 28 Pa.

Code 201.14(a) Responsibility of Licensee.

28 Pa.

Code 201.29(j) Resident Rights.

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Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 396132 B.

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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F-F609 on November 7, 2024.

potential for actual harm 28 Pa.

Code 201.14(a) Responsibility of Licensee.

28 Pa.

Code 211.12(d)(5) Nursing Services.

396132

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 396132 B.

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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F-F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments.

The facility's plan of correction for a deficiency regarding the development of a comprehensive person-centered care plan, cited during a survey ending April 3, 2024, revealed that audits would be completed.

The results of the current survey, cited under

F-F656, revealed that the QAPI committee was ineffective in correcting deficient practices related to the development of a comprehensive person-centered care plan.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending April 3, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review.

The results of the current survey, cited under

F-F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.

The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the surveys ending April 3, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance.

The results of the current survey, cited under

F-F692 on February 1, 2025.

28 Pa.

Code 211.12(d)(3)(5) Nursing Services.

396132

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 396132 B.

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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F-F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.

396132

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 396132 B.

Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F-F760, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding residents being

The facility's plan of correction for a deficiency regarding labeling and storing food under sanitary conditions, cited during the survey ending April 3, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review.

The results of the current survey, cited under

F-F812.

28 Pa.

Code 201.14(a) Responsibility of Licensee.

28 Pa.

Code 201.18(e)(1) Management.

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