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

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

QUALITY LIFE SERVICES - SARVER
Inspection Results For:

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

Initial comments:

Based on an Abbreviated Survey in response to a complaint, and an incident completed on August 12, 2026, it was determined that Quality Life Services - Sarver 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:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Resident R1). This deficiency is cited as past noncompliance.

Finding include:

Review of facility policy "Resident Protection from Abuse, Neglect, Mistreatment, or Exploitation" dated 8/12/25, indicated it is the policy of the facility to treat all residents with kindness, respect, and in a manner that is at all times free from any abuse, neglect, misappropriation of property, exploitation or mistreatment. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress.

Review of the facility "Bed Mobility Competency" checklist indicated employees are to check Kardex (a snapshot of resident care needs) to determine bed mobility. Stand on the side of the bed to which you want to move the resident. If bed mobility is assist of two, one staff member to stand on each side of the bed. If a resident is a bed mobility of two NEVER leave resident alone or perform task/care with assist of one.

Review of the facility "Nurse Aide Job Description" indicated staff are to review care plans and perform nursing care as outlined, assure residents are given adequate assistance with personal and oral hygiene needs following company's policies and procedures and assist residents with activities of daily living as documented in the resident's care plans.

Review of the clinical record indicated Resident R1 was admitted to the facility on 5/7/25.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/26, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and anxiety.

Review of a physician order dated 6/5/25, indicated care in pairs at all times each shift for medication and personal hygiene.

Review of a physician order dated 5/8/25, indicated low air loss mattress (a specialized support surface used to prevent and treat pressure injuries by continuously circulating a low volume of air), check placement and function QS (every shift).

Review of Resident R1's Kardex dated 7/15/26, indicated bed mobility: assist x2 (two staff members), care in pairs, and low air loss mattress.

Review of facility submitted documentation dated 7/15/26, indicated the following: "At 0700 (7 a.m.) two CNAs (Certified Nurse Aide) went in Resident R1's room to perform ADLs (activities of daily living) with brief change, resident is a care in pairs due to resident's past allegations of abuse in the past and bed mobility assist of 2, requiring 2 people in attendance. AM (morning) care started, then one CNA left room to get supplies and 2nd CNA continued with care, rolling resident onto her left side and resident rolled off bed, landing on the floor. No obvious injury, EMS (emergency medical services) called and took resident to ER (emergency room) for assessment."

Review of a staff witness statement, dated 7/15/26, completed by Nurse Aide (NA) Employee E1 stated, "Writer went in at 0700 to do AM care on resident while doing care other aide went to get wipes while writer was rolling resident over to the left side then resident rolled out of bed. Nurse walked in while aide was checking on resident, RN (Registered Nurse) was notified. Writer waited with resident, resident was talking and awake until EMS arrived."

Review of a staff witness statement, dated 7/15/26, completed by NA Employee E2 stated, "I was helping in Resident R1's room to get resident dressed. I went to get wipes and I answered a call light in another resident room. Then people were yelling for me that they needed me in Resident R1's room, and the resident was on the floor."

Review of a written verbal statement dated 7/15/26, obtained from NA Employee E1 by Interim Director of Nursing Employee E5 stated, "At 0730 (7:30 a.m.) NA Employee E2 and I went into Resident R1's room to do AM care and brief change, NA Employee E2 left to get wipes and I started cleaning her up, rolled resident on to her left side and she rolled off the bed. I didn't know she was a "bed mobility of 2" requiring two people to move her in the bed."

Review of a staff witness statement dated 7/15/26, completed by Licensed Practical Nurse (LPN) Employee E4 stated, "This writer was outside resident's room preparing medications. The aides were doing AM care on resident. Heard a call out for assistance. Upon entering room, resident was on floor in supine position leaning toward right side. Resident was alert and talking. Immediately assessed no open wounds, went to get RN supervisor. Resident remained interactive with staff, expressed being scared, however she was easily reassured. EMS arrived at 0742 (7:42 a.m.) resident left building via ambulance to transport to hospital at 0751 (7:51 a.m.)."

Review of facility onboarding documentation indicated NA Employee E1 was hired on 10/4/21.

During a telephonic interview on 8/12/26, at 11:03 a.m. NA Employee E1 stated, "I went in to do morning care with the resident, the air mattress was set a little higher than it should have been, the mattress puffed up and she rolled out of bed. I was not aware that the resident was an assist of two at the time of the incident. I have worked that assignment multiple times before. I work agency for the company, and the company utilizes the same POC (Plan of Care, electronic medical record containing resident care information) throughout all of the facilities. I do know where to look for the POC and I am aware to look at it. The POC tells us how a resident transfers in and out of bed and their bed mobility requirement. I didn't know the resident was a care in pairs until after the situation. Care in pairs means usually two people because something has happened in the past. The direction I roll a resident [away from or towards staff] depends on the resident. Resident R1 has left sided weakness, she can still help with her right hand, she can usually grab the bed rail."

During an interview on 8/12/26, at 11:20 a.m. NA Employee E5 stated, "To locate resident's bed mobility status, I look in the Kardex in the electronic medical record. We also have binders in every resident hallway with a printout of the Kardex for reference. They are usually kept up to date. I check the Kardex every shift when I come in. We are supposed to have two staff members for residents on an air mattress, so they don't fall off the bed. During care I always roll a resident towards me, I would never roll a resident away from me without having a second person on the other side of the bed. Care in pairs means that we are to have two people in the room at all times. Care in pairs is communicated to the staff in the Kardex and there is also a magnetic tag that is placed outside of the resident rooms to indicate two people are required."

During an interview on 8/12/26, at 11:25 a.m. NA Employee E2 stated, "To know a resident's bed mobility status, I check the Kardex, it's part of the resident's charting in the electronic medical record, we also have binders in the hallways. Therapy is also pretty good about letting us know if someone's mobility status changes. It is always two staff members with an air mattress. While providing care, I roll the resident towards me, event when it's not an air mattress so I have more control. I would never roll a resident away from myself without a second person on the other side of the bed. Care in pair means two people in the room during care. Most of the time there is a picture outside of the room and it is indicated in the resident's electronic medical record."

During an observation on 8/12/26, at 11:35 a.m. a sign was observed outside of Resident R1's room indicating that the resident requires care in pairs.

During an interview on 8/12/26, at 11:40 a.m. NA Employee E6 stated, "I look in the Kardex to know a resident's mobility status. That should probably be checked every shift before you give care. You have to have two people when you're giving care to a resident on an air mattress. During care I roll the resident towards me when I'm by myself, I would never roll someone away from me when I'm providing care by myself."

During an interview on 8/12/26, at 12:40 p.m. the Director of Nursing (DON) confirmed that the facility failed to ensure Resident R1 was free from neglect by failing to provide adequate staff assistance during bed mobility, resulting in a fall from the bed to the floor. This was identified for past noncompliance for Resident R1.

On 7/15/26, the facility implemented a plan of correction that included the following:
Resident R1 was transferred to the hospital for further assessment.Resident R1's care plan was reviewed and verified bed mobility assistance was documented and accurate.On 7/15/26, all verbal residents were interviewed for abuse or neglect concerns. Non-verbal residents had a skin assessment performed for signs and symptoms of abuse or neglect.On 7/15/26, the DON implemented re-education and competency checklists in all departments on abuse prevention policy.As of 7/29/26, facility was >90% with regard to abuse and neglect education.Beginning 7/29/26, the facility is to perform three skin audits on non-verbal residents, three times a week, for three weeks.The facility's next QAPI (Quality Assurance and Performance Improvement) meeting is scheduled for 8/24/26, and the incident will be discussed at that time.

During interviews on 8/12/26, twelve staff members confirmed they have received education and competency evaluation on the facility's abuse and neglect policy.

The facility has demonstrated compliance with the above since 7/29/26. Information was reviewed via Plan of Correction documentation.

During an interview on 8/12/26, at 2:07 p.m. information was disseminated to the Nursing Home Administrator and DON that the facility failed to ensure Resident R1 was free from neglect by failing to provide adequate staff assistance during med mobility, resulting in a fall from the bed to the floor and the facility had implemented a plan of correction and achieved compliance on 7/29/26, after implementing corrective actions.

28 Pa. Code: 201.14(a) Responsibility of licensee
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 08/19/2026

Past noncompliance: no plan of correction required.

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

§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 policy, facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision for bed mobility needs, resulting in a fall for one of four residents (Resident R1).

Finding include:

Review of facility policy "Accidents and Incidents" dated 8/12/25, indicated an accident/incident is any happening, which is not consistent with routine operations or the routine care of the particular resident.

Review of the facility "Bed Mobility Competency" checklist indicated employees are to check Kardex (a snapshot of resident care needs) to determine bed mobility. Stand on the side of the bed to which you want to move the resident. If bed mobility is assist of two, one staff member to stand on each side of the bed. If a resident is a bed mobility of two NEVER leave resident alone or perform task/care with assist of one.

Review of the facility "Nurse Aide Job Description" indicated staff are to review care plans and perform nursing care as outlined, assure residents are given adequate assistance with personal and oral hygiene needs following company's policies and procedures and assist residents with activities of daily living as documented in the resident's care plans.

Review of the clinical record indicated Resident R1 was admitted to the facility on 5/7/25.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/26, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and anxiety.

Review of a physician order dated 6/5/25, indicated care in pairs at all times each shift for medication and personal hygiene.

Review of a physician order dated 5/8/25, indicated low air loss mattress (a specialized support surface used to prevent and treat pressure injuries by continuously circulating a low volume of air), check placement and function QS (every shift).

Review of Resident R1's Kardex dated 7/15/26, indicated bed mobility: assist x2 (two staff members), care in pairs, and low air loss mattress.

Review of facility submitted documentation dated 7/15/26, indicated the following: "At 0700 (7 a.m.) two CNAs (Certified Nurse Aide) went in Resident R1's room to perform ADLs (activities of daily living) with brief change, resident is a care in pairs due to resident's past allegations of abuse in the past and bed mobility assist of 2, requiring 2 people in attendance. AM (morning) care started, then one CNA left room to get supplies and 2nd CNA continued with care, rolling resident onto her left side and resident rolled off bed, landing on the floor. No obvious injury, EMS (emergency medical services) called and took resident to ER (emergency room) for assessment."

Review of a staff witness statement, dated 7/15/26, completed by Nurse Aide (NA) Employee E1 stated, "Writer went in at 0700 to do AM care on resident while doing care other aide went to get wipes while writer was rolling resident over to the left side then resident rolled out of bed. Nurse walked in while aide was checking on resident, RN (Registered Nurse) was notified. Writer waited with resident, resident was talking and awake until EMS arrived."

Review of a staff witness statement, dated 7/15/26, completed by NA Employee E2 stated, "I was helping in Resident R1's room to get resident dressed. I went to get wipes and I answered a call light in another resident room. Then people were yelling for me that they needed me in Resident R1's room, and the resident was on the floor."

Review of a written verbal statement dated 7/15/26, obtained from NA Employee E1 by Interim Director of Nursing Employee E5 stated, "At 0730 (7:30 a.m.) NA Employee E2 and I went into Resident R1's room to do AM care and brief change, NA Employee E2 left to get wipes and I started cleaning her up, rolled resident on to her left side and she rolled off the bed. I didn't know she was a "bed mobility of 2" requiring two people to move her in the bed."

Review of a staff witness statement dated 7/15/26, completed by Licensed Practical Nurse (LPN) Employee E4 stated, "This writer was outside resident's room preparing medications. The aides were doing AM care on resident. Heard a call out for assistance. Upon entering room, resident was on floor in supine position leaning toward right side. Resident was alert and talking. Immediately assessed no open wounds, went to get RN supervisor. Resident remained interactive with staff, expressed being scared, however she was easily reassured. EMS arrived at 0742 (7:42 a.m.) resident left building via ambulance to transport to hospital at 0751 (7:51 a.m.)."

Review of facility onboarding documentation indicated NA Employee E1 was hired on 10/4/21.

During a telephonic interview on 8/12/26, at 11:03 a.m. NA Employee E1 stated, "I went in to do morning care with the resident, the air mattress was set a little higher than it should have been, the mattress puffed up and she rolled out of bed. I was not aware that the resident was an assist of two at the time of the incident. I have worked that assignment multiple times before. I work agency for the company, and the company utilizes the same POC (Plan of Care, electronic medical record containing resident care information) throughout all of the facilities. I do know where to look for the POC and I am aware to look at it. The POC tells us how a resident transfers in and out of bed and their bed mobility requirement. I didn't know the resident was a care in pairs until after the situation. Care in pairs means usually two people because something has happened in the past. The direction I roll a resident (away from or towards staff) depends on the resident. Resident R1 has left sided weakness, she can still help with her right hand, she can usually grab the bed rail."

During an interview on 8/12/26, at 11:20 a.m. NA Employee E5 stated, "To locate resident's bed mobility status, I look in the Kardex in the electronic medical record. We also have binders in every resident hallway with a printout of the Kardex for reference. They are usually kept up to date. I check the Kardex every shift when I come in. We are supposed to have two staff members for residents on an air mattress, so they don't fall off the bed. During care I always roll a resident towards me, I would never roll a resident away from me without having a second person on the other side of the bed. Care in pairs means that we are to have two people in the room at all times. Care in pairs is communicated to the staff in the Kardex and there is also a magnetic tag that is placed outside of the resident rooms to indicate two people are required."

During an interview on 8/12/26, at 11:25 a.m. NA Employee E2 stated, "To know a resident's bed mobility status, I check the Kardex, it's part of the resident's charting in the electronic medical record, we also have binders in the hallways. Therapy is also pretty good about letting us know if someone's mobility status changes. It is always two staff members with an air mattress. While providing care, I roll the resident towards me, event when it's not an air mattress so I have more control. I would never roll a resident away from myself without a second person on the other side of the bed. Care in pair means two people in the room during care. Most of the time there is a picture outside of the room and it is indicated in the resident's electronic medical record."

During an observation on 8/12/26, at 11:35 a.m. a sign was observed outside of Resident R1's room indicating that the resident requires care in pairs.

During an interview on 8/12/26, at 11:40 a.m. NA Employee E6 stated, "I look in the Kardex to know a resident's mobility status. That should probably be checked every shift before you give care. You have to have two people when you're giving care to a resident on an air mattress. During care I roll the resident towards me when I'm by myself, I would never roll someone away from me when I'm providing care by myself."

During an interview on 8/12/26, at 12:40 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide adequate supervision for bed mobility needs, resulting in a fall for one of four residents (Resident R1).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing Services.

Plan of Correction - To be completed: 09/09/2026

1. R's1 incident was submitted under abuse and neglect and subsequent PB22 was completed for alleged perpetrator. Resident R1 was transferred to the hospital for further assessment. Resident R1's care plan was reviewed and verified bed mobility assistance was documented and accurate. The Director of Nursing (DON)/designee completed a house audit of current residents to ensure the bed mobility on the resident's Kardex is accurate and in place for the residents' current bed mobility status. The DON/designee provided re-education to the nursing staff regarding the facilities Accident/Hazard Policy and bed mobility tasks in the Kardex. The DON/designee will perform staff bed mobility competencies on facility nursing staff of 3 nursing staff members per week times 3 weeks to ensure understanding and compliance. Any noted discrepancy will be re-educated and competency re-performed. Results of the auditing will be reviewed at the facilities next Quality Assurance Meeting.

§ 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.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per 10 residents during the day shift for four of 21 days (8/5/26, 8/6/26, 8/7/26, and 8/8/26) and one nurse aide per 11 residents on evening shift for three of 21 days (8/4/26, 8/6/26, and 8/7/26).

Findings include:

Review of facility census data and nursing time schedules from 6/22/26 through 7/5/26, and 8/3/26 through 8/9/26, revealed the following NA staffing shortages.

Day Shift:
8/5/26, Census 64, 6.31 Full-Time Equivalents (FTEs) present, 6.40 FTEs required.8/6/26, Census 62, 5.94 FTEs present, 6.20 FTEs required.8/7/26, Census 61, 5.81 FTEs present, 6.10 FTEs required.8/8/26, Census 60, 5.06 FTEs present, 6.00 FTEs required.

Evening Shift:
8/4/26, Census 63, 5.63 FTEs present, 5.73 FTEs required.8/6/26, Census 62, 5.38 FTEs present, 5.64 FTEs required.8/7/26, Census 61, 5.06 FTEs present, 5.55 FTEs required.

During an interview on 8/13/26, at 11:12 a.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one nurse aide per 10 residents during the day shift and one nurse aide per 11 residents on evening shift as required with no additional excess higher-level staff to compensate this deficiency.

Plan of Correction - To be completed: 09/09/2026

Quality Life Services, Sarver has adopted internal processes as part of our on-going commitment to provide quality care to the residents we serve. The attached information contains Quality Life Services, Sarver's Plan of Correction which we are submitting in response to specific deficiencies identified by the Pennsylvania Department of Health and is required for purposes of our facility's licensure and certification. The information and responses contained in our Plan of Correction are consistent with our own quality improvement efforts and should not be construed as an admission of or agreement with the deficiencies cited in the Department's findings. This Plan of Correction is not an admission of wrongdoing on the part of Quality Life Services, Sarver.
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. The 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 nurse aide 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 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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