Pennsylvania Department of Health
QUALITY LIFE SERVICES - CHICORA
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

QUALITY LIFE SERVICES - CHICORA
Inspection Results For:

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QUALITY LIFE SERVICES - CHICORA - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to three complaints, and an incident completed on 6/26/26, it was determined that Quality Life Services - Chicora was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations: Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for nine of sixteen residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, and R9). Findings Include: Interview on 6/26/26, at approximately 12:00 p.m. the Director of Nursing indicated the facility did not have a policy specific to safe, clean, and homelike. During an observation on 6/26/26, at 10:45 a.m. Resident R1's former room had large patches of paint missing with exposed drywall. The floor around the commode in the in-room restroom was damaged with the subfloor visible in spots, potentially causing a fall risk and infection control risk. During an observation on 6/26/26, at 10:49 a.m., the room assigned to Resident R2, R3, R4, and R5 revealed numerous gouges in the floor. Additionally, a wooden closet door had a hole in it, approximately four inches across, with jagged wood present. During an observation on 6/26/26, at 10:49 a.m., the room assigned to Resident R6 and R7 revealed a large section of peeling paint in the restroom and the wall behind the bed had gouges. During an observation on 6/26/26, at 10:51 a.m., the room assigned to Resident R8 and R9 revealed exposed sheetrock and the radiator cover unattached. During an interview on 6/26/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment for nine of sixteen residents. 28 Pa. code: 201.14 (b) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights.

Plan of Correction - To be completed: 07/31/2026

The facility had the Environmental Services Department assess and plan for the repairs to the identified rooms for Residents R1-9 on 7/10/2026 and those repairs will be completed by 7/31/2026.
Weekly environmental rounds will be completed to identify other resident rooms in need for repair for project planning.
The Environmental Director and Assistant were educated by the NHA on weekly rounding to ensure a safe, clean, comfortable homelike environment is maintained.
The weekly environmental rounding form audits for safe, clean, comfortable homelike environment will be turned into the NHA weekly for 4 weeks and reviewed monthly at QAPI until deemed resolved.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of facility documents, facility policy, clinical records, observation, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of ten residents identified to be elopement risks not who did not reside on a secured unit (Resident R10). This was identified as past non-compliance.

Findings include:

Based on facility policy "Elopement Prevention" dated 12/1/25, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Assessment. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the residents' stay and modifications will be made to the care plan and prevention techniques.

Review of the clinical record indicated Resident R10 was admitted to the facility on 5/22/24.

Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/5/26, included diagnoses of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

Review of the "Wandering / Elopement Risk Evaluation" dated 4/9/26, indicated, "Noted increased confusion and does wander throughout the facility and will go outside with electric w/c (wheelchair) propelling self."

Review of Resident R10's plan of care for elopement risk / wandering initiated 4/9/26, indicated Resident R10 exhibited aimless wandering and included the intervention (dated 5/4/26) of, "Monitor for entering restricted areas unattended or statements about going outside with IDT (interdisciplinary team) review for modifications if need warranted."

Review of a facility submitted information dated 5/13/26, indicated that on 5/12/26, "PT (Physical Therapy) Manager informed DON (Director of Nursing) on 5/12/2026 that she had been notified resident was reportedly found within enclosed secure courtyard residential area the previous evening by another staff member. Information was immediately escalated to RN (Registered Nurse) Supervisor, CRNP (Certified Registered Nurse Practitioner), and DON. Follow-up staff interviews initiated with all scheduled staff from evening 5/11/2026. CNA (Nurse Aide) from previous shift questioned and confirmed resident had been found present within enclosed secure courtyard residential area. Two witness statements obtained reporting consistent findings. RN Supervisor and licensed nurses on unit reported they had not been notified of resident presence in courtyard area at time of occurrence and were unaware resident had accessed courtyard area."

Review of facility investigation information indicated that Resident R10 was not accounted for approximately 15 minutes last seen in common area near nurse's station."

Review of an employee statement dated 5/12/26, Nurse Aide Employee E1 stated, "On Monday May 11th on 6p-6a (6:00 p.m. to 6:00 a.m.), I found [Resident R10] in the courtyard stuck behind the door and in a chair. I told the aid [NA Employee E2] who I was working with and we notified the nurse on our floor [Registered Nurse Employee E3].

Review of an employee statement dated 5/22/26, Nurse Aide Employee E2 stated, "[Employee E4] asked [Employee E1] and I to keep an eye on [Resident R1]. After a few minutes [Employee E1] and I came up to hall and [Resident R1] was outside the doors at the courtyard. His wheelchair was stuck on the cement. [Employee E1] and I assisted him back to his room."

On 5/12/26, the facility initiated a plan of correction that included:
-Resident placed on one-to-one observation.
- Flow Sheet for mentation and wheelchair mobility initiated.
-Immediate placement of two door alarms to courtyard access doors to alert staff of entry into eh courtyard area.
-Vendor contacted on 5/13/26, regarding implementation of keypad locking mechanisms and additional environmental safety measures needed.
-Installation of interior exit buttons
-Staff education initiated regarding immediate escalation of impaired safety awareness concerns, resident supervision expectations, and chain of command notification requirements.
-A resident headcount was conducted, and all residents were accounted for.
-Plans of care were updated as appropriate.
-Audits of exit doors completed.
-Incident reviewed with the Safety Committee.

The facility demonstrated compliance by 5/13/26.

During an observation on 6/26/26, at approximately 12:00 p.m. the outdoor courtyard was noted to have numeric keypad locks to enter the courtyard.

During an interview on 6/26/26, at approximately 1:30 p.m. the Nursing Home Administrator and DON confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one of ten residents identified to be elopement risks not who did not reside on a secured unit. This was identified as past non-compliance.

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

Plan of Correction - To be completed: 07/13/2026

Past noncompliance: no plan of correction required.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 07/31/2026

The facility was unable to make corrective action for the nurse aide ratio for identified days that have already passed. All residents received care in accordance with their care plans and physician orders.
DON or designee will re-educate the labor manager and the RN supervisors on the 7/1/2024 requirements.
Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions.
Admin, DON, and Labor manager will conduct daily staffing meetings Monday – Friday to review ratios throughout the day, the following day, and the weekend. In the event of vacancies the facility will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier.
DON or designee will audit daily staffing ratios and ppd along with all steps taken to fill vacancies 5 days a week and ongoing.
Results of the audits will be reviewed and recorded in the monthly QAPI meeting.

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