Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Quality Life Services - Sarver during CMS and state inspections, most recent first.
The facility failed to ensure residents were free from significant medication errors when ordered medications were not administered as prescribed and when medications were unavailable. Two residents with diabetes did not receive ordered bedtime Insulin Lispro doses, one due to the nurse’s inability to log into the eMAR and deciding it was too close to the next dose, and the other because the resident was sleeping. Another resident with cardiac conditions did not receive an ordered dose of Carvedilol when the medication was not available in the cart and required reordering, while the RN later reported that multiple active medications were missing from the cart, the emergency medication kit was not known to be available, and the eMAR did not display all medications due during the scheduled pass.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for the infection prevention and control program for 12 of 14 months. The ADON was identified as the IP, but stated she had just started in the role and had only recently completed training. Review of IP certificates showed gaps in certification, and the DON confirmed the facility lacked a qualified designated individual during multiple months.
A resident with Huntington’s Disease, dysphagia, and a need for substantial maximal assistance with eating was left waiting while other residents began lunch together. Staff observed the resident’s meal still on the cart, and a GNA said it was being held until someone could feed him. An LPN stated the resident should have been brought to the table when staff were ready to assist so all residents could eat together, and the DON confirmed the dignified dining failure.
A resident’s care plan was not updated to match current transfer orders. The care plan still listed assist of two with handheld assist, while the physician orders directed transfers with a mechanical Sit to Stand lift and assist times two. The resident had diagnoses including HTN, CAD, and unsteadiness on feet, and the LPN assessment coordinator and DON confirmed the care plan should have reflected the current orders.
A resident with diabetes had CBG readings above the ordered call-MD threshold, but the record did not show physician notification. In a separate case, a resident who fell and was being treated for a tibia fracture had an ordered x-ray completed on the wrong resident, delaying the correct imaging until five days later.
Failure to provide required transfer assistance: A resident with HTN, CAD, and unsteadiness on feet was care planned for assist x2 with handheld assist for safety, but while the resident’s call light had been going off and she needed the restroom, no assistance was available. The resident scooted to the bed edge, her knees buckled, and she sat on an LPN’s stabilized knee before being moved to her wheelchair, resulting in a small skin tear to the LLE. The DON confirmed the facility failed to keep the resident free from a preventable accident during the transfer.
Fluid Restriction Not Communicated to Direct Care Staff: A resident with anemia, ESRD, and HF had a 1200 mL/day fluid restriction, but the physician order and care plan did not break the amount down by shift for nursing. The resident was observed with a water pitcher at bedside and a can of ginger ale, and an LPN could not state how much fluid nursing was allowed to provide. The DON confirmed staff were not made aware of the resident’s fluid restriction parameters.
Improper Medication Storage and Labeling: A tuberculin multiple dose vial in a medication room refrigerator and cyclosporine eye ointment and budesonide solution on a medication cart were observed opened without dates opened. An LPN confirmed the findings, and the DON confirmed the facility failed to properly store medications in one medication room and one medication cart.
Failure to Follow Enhanced Barrier Precautions for Resident with Foley Catheter: A resident with a Foley catheter for neurogenic bladder was observed in bed with the catheter bag attached to the bed. Facility policy required EBP, including gown and glove use during high-contact care for device use, but an LPN confirmed the catheter and the DON stated the resident was not on the EBP list and did not have the required physician order for EBP.
Failure to Offer Influenza and Pneumococcal Immunizations: The facility failed to ensure that influenza and pneumococcal vaccines were offered to one resident. The resident had Parkinson's disease, DM, and HTN, and the clinical record lacked documentation that the vaccines were offered, given, or declined. The DON confirmed the omission.
The facility failed to ensure an AED and crash cart were kept in safe operating condition. Surveyors observed the AED box with electrodes present and found no documentation of the required daily and monthly checks, and the crash cart had not been checked daily as expected by nursing staff. An LPN confirmed the limited check dates, and the DON acknowledged the failure.
The facility failed to provide required effective communication training for one of five staff members reviewed, a NA. Review of education documents showed the NA’s record did not include this training, and the NHA confirmed the omission during interview.
A resident sustained a serious right shoulder fracture during a transfer, but the facility did not identify or report the injury as potential abuse or neglect, nor did it conduct a root cause analysis as required by policy. The incident was only reported as a hospital transfer, leaving the potential for similar risks to other residents.
A resident sustained a serious shoulder fracture during a transfer, but the facility did not conduct or document a required investigation into the injury of unknown origin, nor did it complete or submit the necessary PB22 forms for staff involved, as mandated by its abuse and neglect policy.
The facility failed to report injuries of unknown source for three residents, as required by policy and federal regulations. One resident had a large bruise on the shoulder and side, another had bruising on the arm and hand, and a third had bruising under the arm consistent with lift use. Incident reports did not indicate notification to the State office, and the DON confirmed the reporting failure.
A facility failed to resolve a resident's grievance in a timely manner, as required by its policy. The resident reported not receiving medication until lunchtime and that her blood sugar was not checked in the morning. The grievance form lacked documentation of the investigation outcome, corrective actions, and resolution. Interviews confirmed the facility's failure to complete the grievance procedure, with missing signatures from the Nursing Home Administrator and Social Services.
The facility failed to notify a physician of abnormal glucose levels for two residents, as required by physician orders and facility policies. One resident experienced a hypoglycemic event with a blood sugar level of 48 mg/dl, and another had multiple instances of hyperglycemia with levels exceeding 400 mg/dl. Clinical records lacked evidence of physician notification for these critical conditions.
A facility failed to investigate a potential misappropriation of property involving a resident's Morphine Sulfate. Discrepancies in drug records were noted without proper documentation, and accusations of staff refusing end-of-shift narcotic counts were not thoroughly investigated.
The facility failed to communicate necessary resident information to the receiving health care provider for three residents transferred to a hospital. Despite the facility's policy requiring a transfer form and documentation, there was no evidence that care plan goals, advanced directives, and other essential information were shared. The Nursing Home Administrator confirmed this deficiency.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about hospital transfers for five residents, as required by regulations. The Nursing Home Administrator admitted to notifying only the local Ombudsman. The residents had various medical conditions necessitating hospital transfers, but the facility did not document the required notifications.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy and state regulations. This deficiency was identified for five residents with various medical conditions, including high blood pressure, anemia, and chronic kidney disease. The lack of documentation confirming notification was confirmed by a clinical consultant.
A facility failed to update a resident's care plan to include a physician-ordered 1800 ml fluid restriction. The resident, with diagnoses of atrial fibrillation, hypertension, and hypercholesterolemia, had a care plan that did not reflect this critical aspect of their care. The Nursing Home Administrator confirmed the oversight during an interview.
A resident with severe visual impairment and dementia was not provided with necessary assistance during mealtimes, as required by their care plan. Observations showed the resident's food was placed out of reach, and no staff were present to assist, leaving the resident unaware of available food. Interviews confirmed the lack of assistance, violating resident rights and nursing services regulations.
A facility failed to provide appropriate care for a resident receiving IV therapy and did not monitor wounds for two residents. One resident's IV tubing lacked a date, and the midline dressing was lifting, while another resident's skin tear was not documented for two weeks. A third resident's wound measurements were not recorded for over two weeks. These issues were confirmed by staff and the Nursing Home Administrator.
The facility failed to conduct weekly pressure ulcer assessments for two residents, as required by their policy. One resident with dementia and depression developed a stage 2 pressure injury, but a weekly assessment was missed. Another resident with seizure disorder and neurogenic bladder had a care plan for weekly wound assessments, but measurements were not completed on two occasions. These lapses were confirmed by staff interviews.
The facility failed to provide appropriate catheter care for two residents with indwelling urinary catheters. One resident's catheter bag was not covered, and an irrigation set was improperly stored. Another resident's catheter bag lacked a privacy cover and was incorrectly positioned. These deficiencies were confirmed by LPNs and acknowledged by the Nursing Home Administrator.
The facility failed to provide appropriate respiratory care for three residents. A resident's oxygen concentrator and CPAP machine were improperly stored, while two other residents had undated and improperly stored respiratory equipment. LPNs confirmed these deficiencies, and the Nursing Home Administrator acknowledged the failure.
The facility failed to maintain accurate physician's orders and conduct proper assessments for residents using bed rails. One resident had side rails without physician orders or care plan identification, while another had orders for side rails but did not use them. A third resident's assessment lacked a side rail evaluation despite having enabler bars. These deficiencies were confirmed through observations and staff interviews.
The facility failed to follow pharmacy procedures for controlled drug reconciliation on a medication cart. A resident's Morphine Sulfate record showed adjustments due to spillage/dehydration without the required date, time, and witness signatures. The Nursing Home Administrator confirmed this failure.
A facility failed to document and administer a pneumococcal vaccine to a resident with heart failure, depression, and high blood pressure. Despite a physician's order and signed consent, the vaccine was not given due to a scheduling error. This deficiency was identified during a review of the resident's immunization records and an interview with a clinical consultant.
The facility failed to meet state-mandated staffing requirements from mid-July to early August 2024. It did not provide the required number of nurse aides per resident during daylight, evening, and night shifts, and also fell short of the minimum 3.2 hours of direct care per patient daily for several days. These deficiencies were confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment and multiple diagnoses, including dementia, exhibited increased elopement risk and behavioral changes. Despite incidents of wandering, aggression, and exit-seeking, the facility failed to update the care plan to reflect the resident's current status and needs. The care plan did not include new interventions to address these behaviors, as confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to inadequate supervision. Despite wearing a Wanderguard bracelet, the resident managed to exit the facility unsupervised, triggering alarms multiple times. Staff, including a maintenance employee, failed to adequately monitor the resident's movements, leading to the elopement incident.
Failure to Administer Ordered Insulin and Cardiac Medications as Prescribed
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when ordered medications were not administered as prescribed and when medications were unavailable. For one resident with anxiety, depression, and diabetes, a physician’s order directed administration of Insulin Lispro via sliding scale before meals and at bedtime. A progress note documented that the resident did not receive the ordered bedtime Insulin Lispro because the nurse was unable to log into the computer and determined it was too close to the next dose to administer. For a second resident with similar diagnoses and an order for Insulin Lispro via sliding scale before meals and at bedtime, a progress note documented that the resident did not receive the ordered bedtime insulin dose because the resident was sleeping. A third resident with heart failure, hypertension, and atrial fibrillation had a physician’s order for Carvedilol 6.25 mg by mouth twice daily for ventricular tachycardia. The January MAR showed a nurse entry to “see nurse’s note” for an evening dose, and a subsequent progress note documented that the medication was not available in the medication cart and needed to be reordered. In a written statement, the RN reported that multiple active medications were not available in the cart during the scheduled evening medication pass and that they were not informed that an emergency medication kit was available in the facility. The RN also reported that the eMAR did not display all medications due during the scheduled pass, and that additional missed medications were only identified after a later review. An LPN interview confirmed that medications are to be given within one hour before or after the scheduled time and that residents should be awakened to receive medications.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified onsite individual responsible for implementing the infection prevention and control program for 12 out of 14 months. Review of the facility Infection Prevention Program policy dated 10/13/25 showed the program was intended to address detection, prevention, and control of infections among residents and personnel. During the entrance meeting on 11/12/25, the Assistant Director of Nursing was identified as the facility’s Infection Preventionist, but on 11/13/25 the ADON/IP stated, “I just started in this role,” and reported completing infection control training but being unable to take a test or print a certificate. Review of infection preventionist certificates showed the facility did not have a certified IP on multiple dates, including September 2024, 6/26/25, 7/26/25, 8/19/25, 10/11/25, and 11/13/25. On 11/13/25, the ADON/IP provided a Nursing Home Infection Preventionist Training Certificate dated 11/13/25. The DON confirmed these dates and that the facility failed to designate a qualified individual onsite responsible for infection prevention and control activities for 12 out of 14 months.
Delayed Meal Assistance and Dignified Dining Failure
Penalty
Summary
The facility failed to provide a dignified dining experience for Resident R42 by not providing meal assistance in a timely manner. Review of the resident’s record showed diagnoses of Huntington’s Disease, hyperlipidemia, and dysphagia, and the MDS coded Eating as requiring substantial maximal assistance, with the helper doing more than half the effort. During observation, six residents were seated together for lunch and all were served and began eating at the same time except Resident R42. At 12:06 p.m., the resident’s lunch was still on the cart, and a GNA stated it was being kept there so it would not get cold until staff could feed him because he needed help to eat. An LPN stated the other residents should not have been eating in front of him and that he should have been brought to the table when staff were ready to feed him so all residents could eat together. The DON later confirmed the facility failed to provide a dignified dining experience by failing to provide assistance with meals timely for Resident R42.
Care Plan Not Updated to Match Current Transfer Orders
Penalty
Summary
The facility failed to ensure Resident R39 had an updated, person-centered care plan individualized to the resident’s current needs. The resident was admitted to the facility and had an MDS dated 9/25/25 that listed diagnoses of high blood pressure, coronary artery disease, and unsteadiness on feet. The care plan, initiated on 3/25/25, stated the resident transferred with assist of two and handheld assist for safety, but physician orders dated 4/22/25 directed that the resident transfer with a mechanical Sit to Stand lift with assist times two. During interview, the LPN Assessment Coordinator reviewed the care plan and stated the transfer status should have been updated to reflect the current physician orders. The DON later confirmed the facility failed to make certain the resident had an updated, person-centered care plan individualized to the resident’s specific needs.
Failure to Notify Physician of Critical CBG Results and Delay in Ordered X-ray
Penalty
Summary
The facility failed to notify the physician of elevated capillary blood glucose (CBG) results for a resident with Parkinson’s disease, diabetes, and high blood pressure. The resident had a physician order for sliding-scale insulin that also required the MD to be called when the CBG was 401 to 999. The resident’s CBG readings were 407 on 11/7/25 and 460 on 11/8/25, but the clinical record did not show that the physician was notified of either result as ordered. The facility also failed to obtain an ordered x-ray in an appropriate timeframe for a resident who had a witnessed fall while wearing a leg immobilizer and was being treated for a tibia fracture. The physician ordered an x-ray of the right lower extremity due to pain on 9/25/25. A mobile x-ray was completed on 9/26/25, but nursing staff later determined it had been performed on the wrong resident, notified the physician, and obtained a new order. The correct mobile x-ray was then completed on 9/30/25, five days later.
Failure to Provide Required Transfer Assistance
Penalty
Summary
The facility failed to ensure that a resident was free from a preventable accident during a transfer. Resident R39’s clinical record showed diagnoses of high blood pressure, coronary artery disease, and unsteadiness on feet, and the care plan directed transfers with assist times two and handheld assist for safety. The facility’s Accidents and Incidents policy stated that it would promote a safe environment for all residents. A written witness statement from an LPN described that while passing medications, the resident’s call light had been going off for several minutes and the resident stated she needed to use the restroom. The resident scooted to the edge of the bed and placed her feet on the floor, but no assistance could be located. The resident’s knees began to buckle, and she sat on the LPN’s stabilized knee before being shifted to her wheelchair. A small skin tear was noted to the left lower extremity, and the physician was notified with new orders received for treatment. During interviews, NAs stated they would not transfer a resident who was a two-person assist because the resident could fall and be injured, and the DON confirmed the facility failed to ensure the resident was free from a preventable accident during the transfer.
Fluid Restriction Not Communicated to Direct Care Staff
Penalty
Summary
The facility failed to ensure direct care staff were aware of a resident’s fluid restriction order so acceptable parameters of nutritional status were maintained. Resident R27 was admitted with anemia, ESRD, and heart failure. The resident had a physician’s order dated 11/12/25 for a 1200 mL daily fluid restriction, but the order did not include the amount allotted for each shift for nursing staff. The resident’s care plan dated 11/13/25 also identified the fluid restriction, but likewise did not include shift-specific fluid amounts for nursing staff. On 11/14/25 at 9:30 a.m., Resident R27 was observed in bed with a water pitcher on the bedside stand and a can of ginger ale. At 9:35 a.m., an LPN stated the resident was on a 1200 mL/day fluid restriction and should not have a water pitcher in the room, but could not state how much nursing was permitted to provide and said the order was not broken down into each shift. At 11:00 a.m., the DON confirmed the facility failed to ensure direct care staff were aware of residents with fluid restriction orders to maintain acceptable parameters of nutritional status for one of four residents reviewed.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to properly store medications in one of two medication rooms, the Liberty Medication Room, and one of three medication carts, the Market Place Medication Cart. Review of the facility policy on medication storage dated 8/18/25 indicated that certain medications, including multiple dose vials and ophthalmic solutions, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. During an observation on 11/12/25 at 11:45 a.m., the Liberty Medication Room refrigerator contained a tuberculin multiple dose vial that had been opened but was not labeled with the date opened. Licensed Practical Nurse E1 confirmed at 11:46 a.m. that the vial was opened and not labeled as required. During an observation on 11/12/25 at 12:20 p.m., the Market Place Medication Cart contained cyclosporine eye ointment that was opened and did not have the date opened, and budesonide solution that was opened and did not have the date opened. Licensed Practical Nurse E2 confirmed these observations at 12:21 p.m., and the Director of Nursing later confirmed that the facility failed to properly store medications in the Liberty Medication Room and the Market Place Medication Cart.
Failure to Follow Enhanced Barrier Precautions for Resident with Foley Catheter
Penalty
Summary
Enhanced barrier precautions were not followed for one of two residents reviewed, Resident R25, who had an indwelling Foley catheter. Facility policy dated 10/13/25 stated that enhanced barrier precautions include gown and glove use during high-contact resident care activities, including device care or use such as urinary catheters. Resident R25 was admitted with diagnoses including urinary tract infection, rib fractures, and neurogenic bladder, and a physician order dated 11/6/25 directed use of a Foley catheter for neurogenic bladder, size 16 French with a 10 cc balloon. The resident’s care plan also identified an indwelling catheter for neurogenic bladder with a goal of remaining free from catheter-related trauma. On 11/12/25, Resident R25 was observed in bed with an indwelling catheter bag attached to the bed. During an interview that morning, an LPN confirmed the resident had a Foley catheter. Later that day, the DON confirmed that Resident R25 was not on the EBP listing and did not have a physician order for EBP as required, and stated that the facility failed to follow enhanced barrier precautions for this resident.
Failure to Offer Influenza and Pneumococcal Immunizations
Penalty
Summary
The facility failed to make certain that influenza immunization and pneumococcal immunization were offered to one resident. Review of the facility's Standing Orders for Administering Influenza Vaccine to Adults and Standing Orders for Administering Pneumococcal Vaccine to Adults, both dated 10/13/25, showed the policies were intended to reduce morbidity and mortality by vaccinating adults who meet CDC and ACIP criteria. Resident R31 was admitted to the facility on [DATE] and had an MDS dated 8/7/25 that listed Parkinson's disease, diabetes, and high blood pressure. Review of Resident R31's clinical record on 11/14/25 at 10:00 a.m. failed to show documented evidence that the influenza immunization and pneumococcal immunization were offered, administered, or declined. During an interview on 11/14/25 at 12:00 p.m., the DON confirmed that the facility failed to make certain that these immunizations were offered to one of five residents, identified as Resident R31.
AED and Crash Cart Not Properly Maintained
Penalty
Summary
The facility failed to make certain that equipment was in safe operating condition for the Automated External Defibrillator (AED) and crash cart. The facility’s AED policy dated 10/13/25 stated the AED would be available for emergency use and maintained according to manufacturer recommendations, with daily maintenance including checking that the indicator was green and the AED was ready for rescue. However, during observation on 11/12/25 at 12:05 p.m., surveyors found an AED with electrodes attached and an extra set of electrodes in the AED box, and the facility did not provide documentation of the required daily and monthly checks to show the AED was working properly. During observation of the crash cart on the Liberty Nursing Unit on 11/12/25 at 12:30 p.m., the cart’s checks were documented only on 9/27/25, 10/4/25, 10/20/25, 10/24/25, 10/27/25, and 11/10/25. An LPN confirmed these dates and stated the crash cart should be checked daily by nursing staff. The DON later confirmed the facility failed to ensure the AED and crash cart were in safe operating condition.
Failure to Provide Required Effective Communication Training
Penalty
Summary
The facility failed to provide training on effective communication for one of five staff members reviewed, identified as Nurse Aide Employee E3. Review of the facility’s education documents and training records on 11/14/25 showed that Employee E3 was hired on 7/12/17 and did not have education on effective communication included in the record as required. During an interview on 11/14/25 at 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide training on effective communication for this staff member.
Failure to Identify and Investigate Serious Injury as Potential Abuse or Neglect
Penalty
Summary
The facility failed to identify and investigate a serious physical injury as a potential case of abuse or neglect for one resident. The resident sustained a displaced avulsion fracture of the right shoulder during a transfer from bed to wheelchair, which was accompanied by a loud crack, pain, and swelling. An x-ray confirmed the fracture, and the resident was transferred to the hospital for further evaluation. The facility's policy requires that serious physical injuries be reported to the state agency, investigated, and appropriate documentation completed for each alleged perpetrator. However, the facility only notified the state agency of the resident's hospital transfer and did not report the incident as alleged abuse or neglect, as required for injuries of unknown origin. There was no documented evidence that a root cause analysis was conducted to determine if abuse or neglect contributed to the injury. This failure to properly identify, report, and investigate the incident left the potential for other residents to be at risk for abuse or neglect.
Failure to Investigate Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse and neglect policy in response to a serious physical injury of unknown origin sustained by a resident. According to the facility's policy, any serious physical injury resulting in pain and impaired physical functioning requires a thorough investigation, including completion of reports and PB22 forms within five working days. However, after a resident experienced a displaced right humeral fracture during a transfer from bed to wheelchair, there was no documented evidence that the facility conducted or completed the required investigation or submitted the necessary PB22 forms for each alleged perpetrator involved. Review of the resident's medical records indicated that the injury occurred during a pivot transfer, when the resident heard and felt a loud crack in her shoulder, resulting in pain and swelling of the right hand. The injury was confirmed by a hospital emergency room evaluation. Staff interviews further confirmed that the facility did not follow its own abuse or neglect policy, as there was no documentation of a thorough investigation, no verification of return demonstration of the transfer procedure by the alleged perpetrator, and no submission of PB22 forms as required by policy.
Failure to Report Injuries of Unknown Source
Penalty
Summary
The facility failed to report injuries of unknown source for three residents, as required by both facility policy and federal regulations. The facility's policy, dated 11/21/24, mandates that all reports of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, must be investigated and documented, with notification to the PA Department of Health/Long Term Care Division within 24 hours. However, the facility did not adhere to this policy for the residents in question. Resident R1, admitted on 9/9/22, was found with a large bruise on 1/8/25, covering the right shoulder, side, breast, and under the breast. The incident report did not indicate that the State office was notified of this injury of unknown source. Similarly, Resident R2, admitted on 2/24/23, was noted to have bruising on the right arm and left hand on 1/11/25, with no witnessed injury. The incident report for Resident R2 also lacked notification to the State office. Resident R3, admitted on 2/28/23, was reported to have bruising under the right arm on 1/16/25, which was consistent with the use of a Sit-to-Stand lift. Again, the incident report did not show that the State office was notified. The Director of Nursing confirmed during an interview that the facility failed to report these injuries of unknown source for all three residents, as required by regulations.
Failure to Resolve Resident Grievances Timely
Penalty
Summary
The facility failed to effectively resolve and provide timely responses to resident grievances, as evidenced by a review of facility policy, resident grievances, and interviews with residents and staff. The facility's policy, dated 8/17/23, emphasizes the importance of addressing grievances promptly to maximize quality of care and satisfaction. However, the review of the Grievance/Complaint Logs for October and November 2024 revealed that a grievance filed by a resident on 10/27/24 was not addressed in a timely manner. The resident reported not receiving medication until lunchtime and that her blood sugar was not checked in the morning. The grievance form lacked documentation of the investigation outcome, corrective actions, and resolution, indicating a failure to adhere to the facility's grievance policy. Interviews conducted on 11/19/24 confirmed the facility's failure to resolve and respond to grievances effectively. The Director of Nursing acknowledged that the grievance procedure was not completed in its entirety for one of the three grievances reviewed. Additionally, the concern form was missing signatures from the Nursing Home Administrator and Social Services, further highlighting the facility's non-compliance with its grievance policy. This deficiency is in violation of several Pennsylvania Code regulations, including those related to the responsibility of the licensee, management, resident care policies, and resident rights.
Failure to Notify Physician of Abnormal Glucose Levels
Penalty
Summary
The facility failed to notify a physician of abnormal glucose levels for two residents, as required by the physician's orders and facility policies. Resident R33, who has diagnoses including diabetes, renal insufficiency, and heart failure, experienced a hypoglycemic event with a blood sugar level of 48 mg/dl. Despite the administration of orange juice and a carbohydrate snack, the clinical record did not document any notification to the physician about this critical condition, which was a requirement per the facility's hypoglycemia protocol. Similarly, Resident R20, who has diabetes and other chronic conditions, exhibited multiple instances of hyperglycemia with blood glucose levels exceeding 400 mg/dl on several occasions in September 2024. The facility's records, including clinical nurse notes and physician documentation, lacked evidence of physician notification for these abnormal glucose readings, as mandated by the resident's physician orders. Interviews with Clinical Consultant Employee E2 confirmed these lapses in communication for both residents.
Failure to Investigate Misappropriation of Property
Penalty
Summary
The facility failed to thoroughly investigate a potential allegation of abuse/neglect related to the misappropriation of property for a resident. The facility's policy on resident protection from abuse, neglect, mistreatment, or exploitation requires that all reports of such incidents be investigated and documented thoroughly. However, the facility did not adhere to this policy when discrepancies were noted in the controlled drug records for a resident's Morphine Sulfate. The records showed adjustments in the drug amount with reasons cited as spillage/dehydration, but lacked proper documentation such as date, time, and witness signatures. Additionally, there were accusations that nursing staff refused to perform end-of-shift narcotic counts, which were not thoroughly investigated. Witness statements from LPNs indicated that some nurses did not want to perform the narcotic count at the end of their shifts, and the facility failed to provide additional documentation to show that these accusations were investigated. The Nursing Home Administrator was unsure if further statements were obtained, and the facility did not provide evidence of a thorough investigation into these allegations.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for three residents who were transferred to a hospital and expected to return. The facility's policy on medical emergencies, dated 12/1/23, required that a transfer form be completed and appropriate documentation be sent with the resident. However, for Residents R28, R34, and R40, there was no documented evidence that specific information, such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information, was communicated to the receiving facility. Resident R28, diagnosed with high blood pressure, hyperlipidemia, and hip pain, was transferred on 12/12/23. Resident R34, with anemia, respiratory failure, and depression, was transferred on 2/9/24. Resident R40, diagnosed with high blood pressure, asthma, and muscle weakness, was transferred on 6/27/24. In each case, the clinical records lacked documentation of the necessary communication to the receiving health care provider. The Nursing Home Administrator confirmed this failure during an interview on 9/26/24.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five residents. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The residents involved were transferred to the hospital on various dates, but the facility did not document evidence of notifying the Ombudsman as required. The Nursing Home Administrator confirmed during an interview that the facility only notified the local Ombudsman, not the state Ombudsman, which is a violation of the regulations. The residents affected had various medical conditions, including high blood pressure, hyperlipidemia, anemia, respiratory failure, depression, asthma, muscle weakness, encephalopathy, chronic kidney disease, acute respiratory failure, diabetes, and chronic respiratory failure. These conditions necessitated hospital transfers, but the facility's failure to notify the Ombudsman was consistent across all cases reviewed. The deficiency was noted under 28 Pa. Code 201.29 (a)(c)(3)(2) regarding resident rights.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their own policy and state regulations. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 12/1/23, mandates that nursing staff provide a copy of the bed-hold notice to residents upon transfer. However, for five residents who were transferred to the hospital, there was no documented evidence that this notification was provided. These residents included individuals with various medical conditions such as high blood pressure, hyperlipidemia, anemia, respiratory failure, and chronic kidney disease. The clinical records of these residents, identified as R20, R28, R34, R40, and R67, showed that they were transferred to the hospital on different dates, but none had documentation of receiving the bed-hold policy notice. For instance, Resident R28 was transferred on 12/12/23, and Resident R34 on 2/9/24, among others. The deficiency was confirmed during an interview with Clinical Consultant Employee E2, who acknowledged the facility's failure to comply with the notification requirement for all five hospital transfers.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan for Resident R123 to accurately reflect the current status of the resident. Resident R123 was admitted with diagnoses including atrial fibrillation, hypertension, and hypercholesterolemia. The Minimum Data Set (MDS) assessment confirmed these diagnoses as current. Physician orders dated 9/17/24 indicated a 1800 ml fluid restriction for the resident. However, the Resident Care Plan Summary Report, also dated 9/17/24, did not include this fluid restriction. During an interview, the Nursing Home Administrator confirmed the failure to revise the care plan as required, which is a violation of 28 Pa. Code: 211.11(d) regarding resident care plans.
Failure to Assist Resident with ADLs During Mealtimes
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for a resident, identified as Resident R39, who was observed to require partial to moderate assistance for eating due to severe visual impairment and other medical conditions such as high blood pressure and dementia. The facility's policy mandates a program of ADL assistance to maintain residents' functional abilities, yet during observations on two consecutive days, Resident R39 was left unattended during mealtimes. The resident's lunch tray was placed in a manner that left several food items out of reach, and no staff were present to assist her, despite her care plan indicating the need for staff assistance during meals. Interviews with the resident and staff confirmed the lack of assistance. Resident R39, who is legally blind, was unaware of the food items on her tray and expressed hunger when informed of the remaining food. A nurse aide, upon being notified, confirmed that the resident had not been assisted as required and that the food was cold. The clinical consultant also confirmed the facility's failure to provide the necessary ADL assistance, which is a violation of the resident's rights and nursing services regulations.
Deficiencies in IV Therapy and Wound Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services for a resident receiving intravenous therapy. Resident R34, who had diagnoses of anemia, respiratory failure, and depression, was observed with an IV catheter in her right upper extremity. The facility's policy required that midline catheter dressings be changed at specified intervals to prevent infections. However, during an observation, it was noted that Resident R34's IV tubing did not have a date, and the midline dressing was lifting away from the skin and lacked a date. This was confirmed by an LPN and the Nursing Home Administrator. Additionally, the facility did not adequately monitor and document the wounds of two residents. Resident R37, who had high blood pressure, muscle wasting, and unsteadiness, had a skin tear on the left shin. Weekly skin assessments were not documented for the weeks of 9/8/24 and 9/15/24, despite the facility's policy requiring weekly documentation. Similarly, Resident R52, with high blood pressure, non-Alzheimer's dementia, and peripheral vascular disease, had a wound on the right calf. The last documented measurements were on 9/10/24, and no further measurements were recorded until 9/25/24, as confirmed by an LPN. These deficiencies indicate a failure to adhere to the facility's policies on intravenous therapy and wound management, resulting in inadequate care for the residents involved. The lack of proper documentation and monitoring of wounds and IV therapy could potentially lead to adverse outcomes for the residents, as confirmed by the Nursing Home Administrator.
Failure to Conduct Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to properly assess pressure ulcers for two residents, R2 and R60, as per their policy on Skin Integrity and Wound Management. Resident R2, who has diagnoses of dementia and depression, developed a stage 2 pressure injury in-house on the sacrum/coccyx/anal area. The facility's policy required weekly wound assessments, but a Weekly Skin and Wound Note was not completed for the week of 9/16 - 9/20/24. This lapse was confirmed by Clinical Consultant Employee E2 during an interview. Similarly, Resident R60, with diagnoses of seizure disorder, epilepsy, and neurogenic bladder, had a physician's order for weekly skin checks and a care plan that required weekly wound assessments. However, the last recorded measurements were on 9/6/24, and assessments were not completed on 9/13/24 and 9/20/24, as confirmed by LPN Employee E9. The Clinical Consultant Employee E2 confirmed the facility's failure to properly assess pressure ulcers for these residents.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with indwelling urinary catheters. Resident R25, who was admitted with diagnoses including obstructive uropathy and heart failure, had a care plan indicating a risk for urinary tract infection due to the presence of an indwelling catheter. During an observation, it was noted that Resident R25's catheter drainage bag was not covered with a dignity pouch as required by facility policy. Additionally, an irrigation set was found undated and improperly stored, with acetic acid not secured or dated, which was confirmed by an LPN. Similarly, Resident R34, who had an indwelling Foley catheter, was observed with a catheter bag lacking a privacy cover and positioned facing the entrance of the room, contrary to care plan interventions. This was confirmed by an LPN. The Nursing Home Administrator acknowledged the facility's failure to ensure appropriate treatment and services for both residents, as required by state regulations.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as observed during a survey. Resident R33, who has diagnoses of renal insufficiency, heart failure, and high blood pressure, was found with an oxygen concentrator and nasal cannula tubing lying uncovered on the floor, without a date as required by facility policy. Additionally, the CPAP machine's headgear tubing was resting in a cobweb on the floor. Licensed Practical Nurse (LPN) Employee E4 confirmed these observations, indicating non-compliance with the facility's policy to replace and store respiratory equipment properly. Resident R34, diagnosed with anemia, respiratory failure, and depression, was observed with nasal cannula tubing and a humidification bottle that lacked a date. The nebulizer machine's face mask was hanging on the oxygen concentrator and was not stored in a plastic bag when not in use. Similarly, Resident R40, with high blood pressure, asthma, and muscle weakness, had a nebulizer machine with the mouthpiece and medication cup lying on a table, undated and not stored in a plastic bag. LPN Employee E1 confirmed these deficiencies, and the Nursing Home Administrator acknowledged the facility's failure to provide appropriate respiratory care for these residents.
Inaccurate Physician Orders and Assessments for Bed Rail Use
Penalty
Summary
The facility failed to maintain accurate physician's orders and conduct proper assessments for residents using bed rails. For Resident R25, the physician's orders did not include the use of side rails, and the care plan did not identify their use, despite the resident being observed with rails on both sides of the bed. The assessment for Resident R25 also failed to indicate a side rail evaluation. Similarly, Resident R26's physician orders included side rails for repositioning, but the care plan did not specify the adaptive equipment in use, and the resident was observed without side rails, which she confirmed she did not want. The clinical consultant confirmed that the physician orders should have been discontinued. For Resident R33, the physician's orders and care plan included the use of enabler bars to promote mobility and independence, but the assessment failed to indicate a side rail evaluation. The resident was observed with bilateral rails on the upper half of the bed. The clinical consultant confirmed the facility's failure to have accurate physician's orders for two residents and to conduct ongoing accurate assessments for another resident. These deficiencies were identified through observations, clinical record reviews, and staff interviews.
Failure to Implement Controlled Drug Reconciliation Procedures
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs on one of its medication carts, specifically the Pennsylvania Medication Cart. According to the facility's policy on the management of controlled drugs, any destruction of drugs must be witnessed by another licensed staff member, and both the person who destroys the drug and the witness must sign the documentation. Additionally, a complete count of all controlled drugs is required at the change of shifts, with two licensed nurses performing the count and signing the inventory. However, the facility did not adhere to these procedures. The clinical record review revealed that a resident, who was admitted with diagnoses including high blood pressure, muscle wasting, and unsteadiness on feet, had a physician's order for Morphine Sulfate, a controlled pain medication. The Controlled Drug Record for this resident showed adjustments in the medication amount due to spillage/dehydration, but these entries lacked the required date, time, and witness signatures. The Nursing Home Administrator confirmed the failure to implement the necessary pharmacy procedures during an interview.
Failure to Document and Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to accurately document education and immunization administration related to pneumococcal vaccines for a resident identified as R26. The facility's policy on administering pneumococcal vaccines requires identifying adults in need of vaccination, screening for contraindications, providing the Vaccine Information Statement (VIS), and recording the vaccination details in the medical record. However, for Resident R26, who was admitted with diagnoses of heart failure, depression, and high blood pressure, there was no evidence in the clinical record that the pneumococcal vaccine was administered despite a physician's order dated 5/20/24. The deficiency was identified during a review of Resident R26's immunization consent records, which showed an initial consent on 4/12/24 that was not addressed by 9/26/24. A second consent was signed on 5/20/24, but the vaccination was not administered. An interview with Clinical Consultant Employee E2 revealed that the order was entered into the computer but was not scheduled to be given, leading to the failure in documentation and administration of the vaccine. This deficiency was noted under the Pennsylvania Code sections related to nursing services and resident rights.
Facility Fails to Meet State-Mandated Staffing Requirements
Penalty
Summary
The facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements from July 15, 2024, to August 5, 2024. According to the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, the facility was required to have a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. The facility did not meet these requirements for the entire period reviewed, with specific deficiencies noted on each shift. For the daylight shift, the facility consistently had fewer nurse aides than required, failing to meet the minimum staffing levels for all 21 days reviewed. The evening and night shifts also experienced significant staffing shortages. The facility failed to provide the required number of nurse aides for 18 out of 21 evening shifts and 20 out of 21 night shifts. Additionally, the facility did not meet the minimum requirement of 3.2 hours of direct resident care per patient daily for 11 out of the 21 days reviewed. These deficiencies were confirmed by the Nursing Home Administrator during a telephonic interview on August 6, 2024.
Failure to Update Care Plan for Resident with Elopement Risk
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident R1, to accurately reflect the current status and needs of the resident. The resident was admitted with diagnoses including Non-Alzheimer's Dementia, renal insufficiency, high blood pressure, and anxiety, and was assessed with severe cognitive impairment. The care plan initially included interventions for elopement risk, such as the use of a Wanderguard bracelet and providing distractions to prevent wandering. Despite multiple incidents indicating increased elopement risk and behavioral changes, the care plan was not revised to include new interventions. The resident exhibited behaviors such as ramming a wheelchair into a heater, wandering into unauthorized areas, and making threats. The resident was also found attempting to exit the facility multiple times, triggering the Wanderguard alarm, and was involved in incidents of verbal aggression and confusion. The facility's failure to update the care plan was confirmed by the Nursing Home Administrator. The care plan did not reflect the resident's ongoing behaviors of exit-seeking, confusion, agitation, and wandering, which were documented in progress notes. This lack of updates and revisions to the care plan did not align with the facility's policy on comprehensive care planning and elopement prevention.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in an elopement incident. The resident, who had severe cognitive impairment due to non-Alzheimer's dementia, was identified as being at risk for elopement and was equipped with a Wanderguard bracelet. Despite this, the resident managed to exit the facility unsupervised, triggering the Wanderguard alarm multiple times. The resident's care plan included measures to distract him from wandering, but these were not effectively implemented. The resident exhibited behaviors such as wandering, attempting to exit the facility, and becoming agitated and aggressive. Progress notes indicated multiple instances where the resident attempted to leave the facility, including opening the front doors and activating the Wanderguard alarm. On one occasion, the resident was able to access an elevator with a maintenance employee who was unaware of the resident's restrictions, leading to the resident's unsupervised movement within the facility. Interviews and documentation revealed that staff, including a maintenance employee, were not adequately attentive to the alarms or the resident's movements. The facility's policies on elopement prevention and accident prevention were not effectively followed, contributing to the resident's ability to elope. The nursing home administrator confirmed the failure to provide adequate supervision, which resulted in the elopement incident.
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What surveyors actually found near you
We read the 936 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sarver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concordia Lutheran Health And Human Care | 5.2 mi | ★★★★★ | 0 | 0 |
| Embassy Of Saxonburg | 6.3 mi | ★★★★★ | 46 | 2 |
| Platinum Ridge Ctr For Rehab & Healing | 9.5 mi | ★★★★★ | 6 | 0 |
| Snu Armstrong Co Memorial Hosp | 10.1 mi | ★★★★★ | 0 | 0 |
| Armstrong Rehabilitation And Nursing Center | 10.3 mi | ★★★★★ | 64 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.