Health inspection·September 10, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, observations, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (Resident R1). Findings include: Review of the facility's policy Elopement Protocol dated 1/24, indicated to promote the safety of all residents and maintains a process to assess residents for risk of elopement, implement prevention strategies for those identified as an elopement risk and conduct a missing resident protocol. Review of the facility's policy Accidents and Incidents-Investigation and Reporting dated 1/24, indicated will provide a safe and secure environment in order to prevent incidents and accidents from occurring. Review of Residents R1's clinical record indicated admission to facility to on 6/29/24. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/6/24, indicated the diagnosis of benign prostatic hyperplasia (enlargement of the prostate gland affecting urinary system), Parkinson's disease (brain condition that causes slow movements, rigidity and tremors) and anxiety Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident 1's MDS assessment dated [DATE], Section C0500-BIMS screening indicated a score of 14 revealing that Resident R1 was alert and oriented to person, place, and situation. Review of Resident R1's admission elopement risk evaluation completed on 6/29/24, indicated (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395001 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)