Pennsylvania Department of Health
 LIFEQUEST NURSING CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LIFEQUEST NURSING CENTER
Inspection Results For:

There are  120 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
LIFEQUEST NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance survey completed on April 3, 2025, it was determined that Lifequest Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.









 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation, it was determined that the facility failed to store food and equipment under sanitary conditions in the kitchen and on one of four nursing units. (Unit DEF)

Findings include:

A tour of the main kitchen on April 2, 2025, at 10:27 a.m., revealed the following:

There was no hand soap at a handwashing station. There was an uncovered garbage can next to a food preparation surface. Garbage was piled over the top of the garbage can and in contact with the table top can opener. There was an accumulation of dust on the vent cover to the ice machine. There were particles of debris, rust, and water on the top of the ice machine.

In dry storage, there was a dented can of pumpkin on the can rack. There was a container of cereal with a use by date of March 22, 2025. There was a container of cous cous with a use by date of November 2024.

There was an uncovered garbage can, that contained garbage, by the beverage station. Boxes of gloves were stored over the garbage can. Clean gloves were hanging out of the boxes and in contact with the garbage can. There was a rack of clean mugs that were used for resident trays stored next to the uncovered garbage can.

There was an accumulation of a brown substance on the cover to the flour bin. There was a pan of pickles in the walk in refrigerator, the plastic wrap was not covering the pan and the items were left open to air. In the walk in freezer, there was a package of turkey bacon and a box of ground beef patties. The packages had been opened, were not re sealed, and the contents were left open to air.

Observation of the microwave on the DEF nursing unit on April 3, 2025, at 12:53 p.m., revealed an accumulation of splatter from unknown substances on the inside of the door and inside walls of the microwave. The top of the inside of the microwave was discolored, chipped, and corroded.

28 Pa. Code 210.14(a) Responsibility of licensee.

28 Pa. Code 201.18(e)(2.1) Management









 Plan of Correction - To be completed: 05/30/2025

Immediate correction was initiated during survey, including replacing hand soap at the hand washing station, replacement of garbage cans and lids, cleaning of flour bin cover, removal of expired food items, dented can removed to dented can area, glove boxes moved to existing enclosed wall mounted holders, uncovered food items discarded, microwave on DEF replaced with a new microwave, ice machine vent cleaned and inspected by maintenance for leaks. Ice machine rusted area repaired.

All kitchen staff will be in-serviced on proper storage of gloves, proper storage of clean equipment, stocking of handwashing station, emptying trash, appropriate storage of product, expiration date monitoring, and dented can procedure.

An audit of the kitchen environment capturing all items identified will be completed weekly x 4 weeks, and monthly x3 months.

All nourishment room microwaves will be audited weekly x4 weeks and monthly x3 months to ensure cleanliness and integrity.

The results of the audits will be presented to the Quality Assurance Committee for review and further recommendations as appropriate.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing: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.
§483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:

Based on review of the Resident Assessment Instrument (RAI) user manual, clinical record review, and staff interview, it was determined that the facility failed to complete Minimum Data Set (MDS) assessments in accordance with specified time frames for two of 22 sampled residents. (Residents 92 and 360)

Findings include:

Review of the Long Term Care Facility RAI user manual dated October 2024, which provided instructions and guidelines for completion of federally required MDS assessments, revealed that admission assessments were to be completed no later than 13 days after the resident's entry date and that a quarterly assessment must be completed every quarter.

Clinical record review revealed that Resident 92 had a quarterly MDS assessment due for the reference date of January 24, 2025. There was no evidence that a quarterly assessment was completed as per the time requirements.

Clinical record review revealed that Resident 360 had an admission MDS assessment dated March 17, 2025, noted as still in progress and had not been completed as per the time requirements.

In an interview on April 3, 2025, at 11:24 a.m., the Administrator confirmed that the MDS assessments were not completed within the required time frames.









 Plan of Correction - To be completed: 05/30/2025

An in-Service on appropriate completion of Comprehensive Assessments (MDS) per RAI manual is to be completed with all RNACs and department head staff that complete designated sections of the MDS.

The facility is actively recruiting for an additional Full Time RNAC to assist the facility with remaining in compliance.

The NHA and/or her designee will complete a facility wide random audit of the MDS schedule to ensure completion within RAI manual guidelines. This audit will continue weekly x4 weeks, then monthly x3 months.

The results of the audits will be presented to the Quality Assurance Committee for review and further recommendations as appropriate.

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 clinical record review and observation, it was determined that the facility failed to ensure that safety interventions for falls were in place for one of 22 sampled residents. (Resident 2)

Findings include:

Clinical record review revealed that Resident 2 had diagnoses that included dementia and hemiplegia (paralysis to one side of the body). The Minimum Data Set assessment dated December 20, 2024, revealed that Resident 2 required staff assistance for bed mobility and transfers. Review of progress notes dated October 7, November 8, and December 1, 2024, and March 11, 2025, revealed that the resident was found on the floor in her room by her bed. Review of the care plan identified that the resident was at risk for falls related to poor communication and cognitive loss. The intervention was for staff to place the bed in the low position with floor mats on both sides of the bed while the resident was in bed. Observations on April 1, 2025, at 10:10 a.m., and 2:14 p.m., April 2, 2025, at 10:50 a.m., and April 3, 2025, at 9:00 a.m., revealed Resident 2 was in bed. The floor mats were not in place.

In an interview on April 3, 2025, at 11:30 a.m., the Director of Nursing confirmed that the fall mats should have been in place.

28 Pa. Code 211.12(d)(1)(5) Nursing services.








 Plan of Correction - To be completed: 05/30/2025

The placement of floor mats for resident R2 was addressed immediately upon discovery.

A facility wide audit was conducted immediately at time of survey to ensure that floor mats were in place as ordered for all residents.

An in-Service on F483.25 Free of Accident Hazards/Supervision/Devices re: resident safety intervention placements per Physician order
is to be completed with all appropriate staff including all RNs, LPNs, D.O.N, A.D.O.N, and CNAs.

The D.O.N. and/or her designee will complete a facility wide audit of all residents with safety intervention orders to ensure appropriate placement. This audit will continue weekly x4 weeks, then monthly x3 months.

The results of the audits will be presented to the Quality Assurance Committee for review and further recommendations as appropriate.

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for two of 22 sampled residents. (Residents 13 and 87)

Findings include:

Review of the facility policy entitled, "Pain Management," last reviewed January 14, 2025, revealed that non-pharmacological interventions should be attempted prior to administration of pain medication that was prescribed on an as needed basis.

Clinical record review revealed that Resident 13 had diagnoses that included dementia, abnormalities of mobility, and pain in right arm and left lower leg. A physician's order dated February 10, 2025, directed staff to administer tramadol (a pain medication) every six hours, as needed, for moderate pain. Review of the medication administration records (MARs) for February and March 2025, revealed no evidence that staff attempted non-pharmacological interventions to alleviate pain prior to the administration of tramadol on 17 occasions in February and 26 occasions in January. There were no documented refusals of non-pharmacological interventions.

Clinical record review revealed that Resident 87 had diagnoses that included dementia, weakness, and low back pain. A physician's order dated February 7, 2025, directed staff to administer tramadol every eight hours, as needed, for all levels of pain. Review of the MARs for February and March 2025, revealed no evidence that staff attempted non-pharmacological interventions to alleviate pain prior to the administration of tramadol on four occasions in February and 12 occasions in March. There were no documented refusals of non-pharmacological interventions.

In an interview on April 3, 2025, at 12:21 p.m., the Director of Nursing confirmed that non- pharmacological interventions should be documented in the MAR and that there was no evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed pain medication.

28 Pa. Code 211.12(d)(1)(5) Nursing services.








 Plan of Correction - To be completed: 05/30/2025

An in-Service on F483.25 Pain Management and non-pharmalogical intervention documentation is to be completed with all appropriate staff including RNs, LPNs, D.O.N, and A.D.O.N.

The D.O.N. and/or her designee will complete a facility wide audit of pain medication administration re: non-pharmalogical intervention documentation. This audit will continue weekly x4 weeks, then monthly x3 months.

The results of the audits will be presented to the Quality Assurance Committee for review and further recommendations as appropriate.


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