Health inspection·September 8, 2023

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 a review of clinical records and resident incident/accident reports, and staff interviews, it was determined that the facility failed to provide adequate staff supervision as planned to monitor a resident with known unsafe behavior to prevent an unsupervised exit from the facility and threat to the resident's safety while ambulating outside the facility for one resident (Resident 1) out of seven reviewed. Findings included: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses of alcohol use and repeated falls. A review of Resident 1's Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 25, 2023, revealed that the resident's cognition was moderately impaired. A review of an admission Elopement assessment dated [DATE], revealed that the resident was assessed to be at high risk for eloping from the facility. A progress note dated June 6, 2023, at 1:29 PM revealed that the facility's director of maintenance saw the resident coming out of the building from the exit near the staff time clock. The resident stated he wanted to go outside and followed the staff in front of him from the time clock. An incident report dated June 6, 2023, at 1:16 PM revealed the Employee 1, the Maintenance Director, witnessed Resident 1 exiting the building. Nursing staff brought the resident back into the facility and assessed for injuries at that time. Further it was indicated the resident exited the facility through a door Employee 2 Housekeeping had just exited out of due to the door not closing all the way shut. Employee 1 followed the resident while Employee 2 went to get nursing staff to help him back into the building. Employee 1's witness statement dated June 6, 2023, indicated that Employee 1 watched the resident walk out of the time clock exit door and started walking down the sidewalk towards the rear of dietary. Employee 1 stated she followed the resident around the building where he had stopped, talking to dietary workers. A written witness statement from Employee 2 dated June 6, 2023, revealed that Employee 2 stated that after she left the building from the time clock door and got into her car, she noticed Resident 1 was outside the facility and went to get staff inside the facility to help bring him back inside. (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: 395067 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 395067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Ridge Care Center 2741 Boulevard Avenue Scranton, PA 18509 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)