Health inspection·October 17, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility as being at risk for elopement. The following residents were included on the facility's elopement risk list: Resident 2 was identified by the facility as being at risk for elopement on October 2, 2025. Documentation showed a wander guard bracelet (a small, battery-operated monitoring device designed to alert staff when a resident wearing the device approaches an exit or restricted area) was applied on October 2, 2024. Resident 3 was identified as an elopement risk on July 29, 2024, and a wander guard bracelet was applied on the same date. Resident 4 was identified as an elopement risk on September 30, 2024, and a wander guard bracelet was applied the same date. Resident 5 was identified as an elopement risk on August 19, 2024, and a wander guard bracelet was applied on the same date. Resident 6 was identified as an elopement risk on March 3, 2025, and a wander guard bracelet was applied on the same date. Resident 7 was identified as an elopement risk on April 5, 2024, and a wander guard bracelet was applied on the same date. Resident 8 was identified as an elopement risk on August 2, 2024, and a wander guard bracelet was applied on the same date. Resident 9 was identified as an elopement risk on May 27, 2024, and a wander guard bracelet was applied on the same date. Resident 10 was identified as an elopement risk on March 1, 2025, and a wander guard bracelet was applied the same date. Resident 11 was identified as an elopement risk on April 11, 2025, and a wander guard bracelet was applied the same date. Resident 12 was identified as an elopement risk on October 2, 2025, and a wander guard bracelet was applied the same date. Resident 1 was admitted [DATE], with diagnoses including vascular dementia (a progressive decline in thinking and reasoning caused by reduced blood flow to the brain), glaucoma (a chronic eye disease that can lead to blindness), and abnormality of gait A review of a quarterly MDS assessment (Minimum Data Set, federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 4, 2025, revealed the resident to have a BIMS score of 3 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information. A score of 0 to 7 indicates severe cognitive impairment) and required assistance with activities of daily living. Review of Resident 1's care plan for behavioral symptoms initiated June 4, 2025, addressed wandering and exit-seeking behaviors (often stated going home) and included interventions to approach the resident calmly, redirect safely, assure proper footwear, maintain a functional wander guard bracelet, and check the device each shift. The planned goal was that the resident would wander safely within boundaries. A corresponding elopement risk assessment dated [DATE], revealed that Resident 1 was at risk for wandering/elopement and included a physician's order for a wander guard bracelet. Review of facility documentation between admission and September 28, 2025, reflected ongoing wandering and exit-seeking behaviors. A review of facility investigative documentation completed by Employee 1, Registered Nurse Supervisor (RNS), on October 13, 2025, at 2:26 AM revealed that Resident 1 exited the building and was seen outside the laundry-area doors on October 11, 2025, at approximately 8:48 PM. Employee 1 (RN) reported she became aware of the elopement during her shift on October 13, 2025, when she reviewed a written statement left by Employee 2 (laundry aide) describing the event. Employee 1 stated she had not read the statement until that time and had not realized earlier that the resident had left the building. Employee 1 explained that while on duty the evening of the incident (October 11, 2025, 7:00 PM to 7:00AM), several door alarms sounded at least three separate times. During a telephone interview on October 16, 2025, at 4:19 PM Employee 1 stated she arrived for her 7:00 PM to 7:00AM shift and entered through the front lobby. At that time, Resident 2 attempted to exit through the lobby doors, triggering a wander-guard alarm. Employee 1 deactivated the alarm using the control box inside the lobby doors and observed that the smoking-area door across the hallway was unlocked. She locked and re-armed that door, instructed staff to complete a headcount on the second (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 2 of 8 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few floor because the first-floor smoking door had been unsecured, and then proceeded upstairs to begin her medication pass. She stated no written record of the headcount was completed. This was the first door alarm activation that evening. Employee 1 stated that around 8:30 PM a second wander-guard alarm sounded while she was passing medications on the east nursing unit. She checked the indicator panel at the nurses' station but stated that there was no posted chart showing which zone corresponded to each exit door. She inspected both east-wing exit doors and the central elevator area but did not locate the source. She then went to the first floor, where she observed that the front lobby door alarm was sounding. Looking outside, she saw a man walking toward parked vehicles and assumed the alarm had been triggered by a departing visitor. She could not identify the man. Employee 1 turned off the alarm and resumed her medication pass.This was the second alarm activation that evening. Employee 1 stated that shortly thereafter, another alarm sounded, her estimate again around 8:30 PM to 8:35 PM. She checked the first floor, including the lobby and administrative areas, and was told by Employee 2 (laundry aide) that no alarms were active on the first floor. When she returned to the second floor west nursing unit, she noted the alarm panel lighted near the west dining-room stairwell door and reset the alarm at 8:35 PM. This was the third alarm activation that evening. At approximately 8:45 PM, Employee 1 stated she went downstairs again and observed Employee 2 (laundry aide) walking with Resident 1 in the administrative hallway. Employee 2 reportedly told her, I brought her back. Employee 1 stated that Resident 1 appeared clean and dry and that she did not complete vital signs or a physical assessment. No investigative report or investigation was initiated at that time. Employee 1 further stated that Employee 2 had left a written statement on the nurse's desk the same evening, but she did not review it. When she returned for her next scheduled shift on October 12, 2025, at 7:00 PM, she heard staff discussing an elopement that had occurred the previous night. She then reviewed the statement and realized Resident 1 had been outside the facility. At 2:45 AM. on October 13, 2025, she completed the investigative report and notified the Director of Nursing (DON). Two written witness statements completed by Employee 1 (RN) and dated October 13, 2025 (no time indicated) provided additional detail:In the first statement, Employee 1 wrote that while passing medications on the east-wing short hall, the code alert (wander-guard alarm) activated. She checked the indicator panel but found no zone list. After inspecting the east-wing exits, first-floor doors, and elevators, she determined the alarm originated from the second-floor west-wing stairwell leading to the laundry area. She went downstairs and saw Employee 2 walking with Resident 1. Employee 2 later told her that the resident had been outside knocking on the door. Employee 1 wrote, Today, after hearing that Resident 1 was outside, I remembered the laundry aide had laid a statement on the nurses' desk on October 11. I read it and made the DON aware. In the second written statement, Employee 1 reiterated that at approximately 8:30 p.m. to 8:40 p.m. she heard an alarm, checked multiple exits, and eventually located the alarm near the west-unit dining-room door. She again described seeing Employee 2 with Resident 1 but stated that Resident 1 could not have been outside very long. It was raining outside, and she did not appear to be very wet. Her arm was not wet at all. She stated, I looked at her arms/legs and there were no marks noted. She wrote that she did not review the aide's statement until Sunday night (October 12) and therefore did not know the resident had been outdoors at the time A review of a written witness statement dated October 11, 2025, (no time indicated) revealed that Employee 2 (laundry aide) was in the facility laundry room at approximately 8:40 PM when she received a call from the east nursing unit regarding the downstairs alarm. She stated, The nurse had already turned the alarm off. Then I heard knocking at the outside ambulance entrance door. Resident 1 was standing outside wearing wet slipper socks. I brought her back inside and walked her down the hallway (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 3 of 8 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few toward the elevator. I explained the situation to the nurse. A telephone interview on October 16, 2025, at 5:31 PM with Employee 2, confirmed that the alarm sounded only when she opened the door to let Resident 1 inside. She silenced the alarm and proceeded through the interior wander-guarded door, which did not activate. The resident said several times that she was cold while being escorted back to her unit. An additional witness statement dated October 15, 2025, indicated that earlier in the evening, around 7:00 PM, on October 11, 2025, the lobby alarm at the inner double doors had sounded for about 10 minutes. Employee 2 stated, The nurse (Employee 1) turned the alarm off. At the same time the front exit doors were also alarming. The nurse told the aide who was taking the smokers out to turn the alarm off. A written statement dated October 15, 2025, revealed that Employee 3 (nurse aide) was providing care to another resident on the second floor when she heard an unfamiliar alarm. She stated, I saw a light flashing on the wall panel. I didn't know which door it was (the light location could not be identified at that time). The nurse said it was the kitchen door and went down in the elevator to check. She said she had it under control, and shortly after, the alarm stopped. At the end of her shift, Employee 1 told her, It was Resident 1 that got out of the building. She stated that she last saw Resident 1 at supper, walking and appearing agitated between the east and west units. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 3 (nurse aide) stated, I was with another resident providing care on the second floor when I heard an alarm go off. It wasn't an alarm sound that I recognized, so I went to the wall panel and saw a light flashing. It wasn't on the door panel, and the location of the light could not be identified at that time. I walked toward the elevator by the ice machine and saw the nurse (Employee 1, RN). I told her that I didn't know which door was alarming. She said it was the kitchen door, then got into the elevator and went down to the first floor. She told me she had the situation under control, so I went back to my unit. Shortly after that, the alarm was turned off. Employee 3 further stated, At the end of the shift, the nurse (Employee 1) came to the floor to get her clipboard and said it was Resident 1 that got out of the building. I had last seen Resident 1 at supper in the dining room. She was agitated and kept walking the hallway between the east and west nursing units. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 4 (nurse aide) stated, Around 8:30 PM. to 9:00 PM I heard an alarm while I was in a resident's room with Employee 3 (aide) providing care. I came out of the room into the hallway and saw the nurse (Employee 1, RN) walking on the second floor toward the east unit. Employee 3 and I checked the resident rooms, and I didn't notice that Resident 1 was missing. The nurse came back to the unit and told us to check the exit doors. I saw the nurse turn off the alarm by the door at the west dining-room stairwell. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 5 (LPN), who was assigned to the 3:00 PM to 11:00 PM. shift, stated, I was in the middle of my medication pass when I heard the door alarm going off. I'm not sure of the exact time, but it was after dinner. I was in a resident's room administering medication and couldn't leave right away. The alarm was sounding for about five to ten minutes. Employee 5 further stated, I went to the nurses' station where Employees 3 and 4 were sitting. They said a resident got out of the kitchen entrance downstairs. The nurse (Employee 1, RN) told me it was Resident 1 who got out. She asked if I knew that Resident 1 was the missing resident. I told her I did not. The nurse said Resident 1 got out down the steps and the laundry aide had the resident because she was called to let her know of the incident. Employee 5 added, I told the nurse that staff on the second-floor west unit were told the missing resident lived on the first-floor nursing unit, so no headcount was done. I saw the nurse (Employee 1) turn off the alarm by the second-floor west dining-room door. A review of a written (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 4 of 8 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few witness statement dated October 15, 2025 (no time indicated) revealed that Employee 6 (nurse aide) stated, I was on the second-floor east nursing unit providing evening care to a resident between 8:00 PM and 9:00 PM when I heard something ‘buzzing,' but it wasn't loud. When I came out of the resident's room, the alarm turned off. Another nurse aide told me that Resident 1 was outside knocking on the door. Resident 1 had been seen on the second-floor east unit about an hour earlier. I escorted the resident down the hallway past the elevator to the west unit and told her to keep walking. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 7 (nurse aide) stated, I was working on the second-floor east unit when I heard an alarm go off, but I'm not sure what time it was. I saw Employee 8 (nurse aide) at the nurses' desk calling someone. I saw her look at the alarm panel to see which alarm it was. The alarm was going off for maybe five minutes, less than ten. A review of written witness statements dated October 13, and October 15, 2025 (no times indicated) revealed that Employee 8 (nurse aide) stated, The alarm box at the east nurses' station was showing red, indicating the kitchen alarm. I called the kitchen, but there was no answer. I called the laundry to shut the alarm off, and the laundry aide (Employee 2) said she would. The alarm kept going off, so I called the nurse (Employee 1, RN) to turn it off. The alarm was turned off after that. In an additional statement dated October 15, 2025, Employee 8 stated, The door alarm went off after the 6:30 PM smoke break. The wall panel read Zone 5 and the paper on the wall said kitchen alarm. I called the kitchen and the laundry. I talked to the girl with glasses and asked her to turn the alarm off. The alarm was still going off, so I called the west wing and talked to Employee 11 (agency nurse aide); she said she would turn it off. Shortly after, the alarm stopped. The nurse (Employee 1) said we had to do a resident headcount because the smoking door was left open. I did a headcount on the east wing, and all residents were accounted for. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 9 (nurse aide) stated, I don't remember the exact time the alarm went off. I was coming back in from my fifteen-minute break and entered the building through the employee entrance. I started walking toward the front hallway. Employee 2 (laundry aide) was handing Resident 1 over to the nurse (Employee 1, RN). Employee 2 kept saying, ‘I want the nurse to know I brought Resident 1 back inside.' I didn't turn any alarms off. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 10 (nurse aide) stated, I was working on the first-floor nursing unit providing resident care when I heard an alarm. The sounds were different for the door and the wander-guard alarms, one of them is higher pitched. It sounded like both were going off at the same time. I turned around and saw the laundry aide (Employee 2) walking Resident 1 from the laundry-room area toward the first floor. The elevator opened, and the nurse (Employee 1, RN) came off saying, What are you doing? An alarm is going off.' I was walking another resident back to her room because she was a fall risk. The nurse (Employee 1) said that Resident 1 got down the stairs. At that time, the alarm was turned off. I don't know which alarm it was. Employee 10 further stated, At about 6:30 PM. the nurse aide (Employee 9) took the resident smokers outside. She told me she had never taken the smokers out before, so I helped her get them set up and then went back to the resident floor. Both the inner and outer exit doors were propped open, and the smoking cart was wedged between them. She was behind the cart. I told her to close the first door (the inner door) when she went outside to keep the cold air from coming in. A review of a written witness statement dated October 13, 2025 (no time indicated) revealed that Employee 11 (agency nurse aide) stated, I was on the west wing. I saw Resident 1 walking in the hallway right before another nurse aide and I started evening care. It was right after dinner. We were in the middle of care when we heard the alarm go off. I looked out into the hallway and saw (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 5 of 8 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Employee 3 (nurse aide). She said it was the kitchen door alarm and that Resident 1 got out of the building and the nurse (Employee 1, RN) was taking care of it. The alarm wasn't going off for long, maybe five to seven minutes. It was the stairwell by the lounge that leads down to the ambulance entrance. I didn't turn off the alarm and I'm not sure who did. I didn't see Resident 1 near the door, but she does wander a lot. The east-wing staff said the laundry aide told them she found Resident 1 outside knocking on the door to be let in. During an interview conducted on October 16, 2025, at 4:00 PM. the Nursing Home Administrator (NHA) stated the incident involving Resident 1 was not communicated to administration or investigated for 30 hours after it occurred. The NHA stated, No interventions were implemented to ensure the safety of residents at risk for elopement. She explained that multiple staff witness statements were collected due to conflicting accounts of the event and confirmed the facility had not determined where the resident exited the building. Based on review of facility documentation, staff interviews, and administrative statements, it was determined the facility failed to ensure an effective and timely response to multiple activated door alarms; failed to identify that a resident had exited the building unsupervised; failed to complete a licensed nurse assessment or initiate the Code [NAME] procedure; and failed to promptly report and investigate the event in accordance with facility policy These systemic failures, combined with staff's inability to interpret alarm panels, the lack of posted zone identifiers, the repeated silencing of alarms without confirmation of resident safety, and the absence of an immediate administrative response, constituted a breakdown in supervision, communication, and safety systems necessary to protect residents identified as being at risk for elopement. As a result, the facility's noncompliance placed Resident 1 and all other residents at risk for elopement in an Immediate Jeopardy situation, as serious injury, harm, impairment, or death could have occurred while the resident was outside unsupervised and while other alarms went uninvestigated. The facility was notified of the Immediate Jeopardy on October 16, 2025, at 3:15 PM, and the Immediate Jeopardy template was provided to the facility at that time. In response, the facility submitted a written Immediate Jeopardy action plan on October 16, 2025, at 6:30 PM. The corrective action plan submitted by the facility included the following measures:1. The resident was accounted for, safe, and exhibited no adverse effects from the incident. An initial skin assessment was completed on October 13, 2025, and a follow-up skin assessment was completed on October 16, 2025. The resident's wander-guard bracelet remained intact and functional. Fifteen-minute safety checks were initiated on October 13, 2025, and continued thereafter. The resident's care plan was updated to reflect current interventions.2. The facility's elopement policy and door alarm protocol were reviewed and revised.3. All staff received education on elopement prevention, wandering, resident safety, and identification of alarm zones.4. All wander-guard door boxes and door alarms were checked and confirmed to be functioning.5. All residents with wander-guard bracelets were checked for proper device placement and functionality.6. Audits were completed to ensure that no other residents in the facility were affected by alarm or supervision concerns.7. New elopement risk assessments were completed for all residents.8. Elopement binders and resident care plans were reviewed and updated.9. Door checks were initiated on each shift to be completed by the Maintenance Director or designee daily for four weeks.10. Elopement drills were scheduled to be conducted weekly for four weeks by the Maintenance Director or designee.11. Results of the education, audits, and drills were to be reviewed at the next QAPI (Quality Assurance and Performance Improvement) meeting for continued monitoring. Following verification of the facility's corrective actions, including observation of door alarm function, confirmation of staff education, and tour of the premises, the Immediate Jeopardy was determined to be removed on October 17, 2025, at 12:00 PM. 28 Pa. Code 201.18 (e)(1) Management 28 Pa (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 6 of 8 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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)

F 0689 Code 211.10 (a)(c) Resident care policies 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing services Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 7 of 8 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 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 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)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of clinical records, review of select facility policies, review of job descriptions, documentation provided by the facility, and interviews with residents and staff, it was determined the facility's administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental well-being of residents. The facility failed to ensure that measures were implemented to prevent one of twelve residents identified as being at risk for wandering (Resident 1) from exiting the building unattended into an unsafe environment. This deficient practice placed all residents at risk for harm and resulted in immediate jeopardy to residents' health and safety.Findings include:A review of the job description for the Nursing Home Administrator (NHA) dated and signed September 12, 2024, indicated the administrator will lead and manage the overall operations of the facility in accordance with policies, procedures, and current federal, state, and local standards, guidelines, and regulations. The NHA's essential duties and responsibilities include hiring, training, and developing department staff, verifying the physical environment is maintained appropriately, and directs overall activities and programs in accordance with current rules and regulations. The job description for Director of Nursing (DON) Services dated and signed May 11, 2025, documents the DON directs the overall operations of nursing service and collaborates with the NHA and medical director to ensure the highest degree of quality of care for all residents. The DON maintains maintenance of the master staffing schedule, ensuring daily work assignments are in place and appropriate staffing levels are present. In the absence of the NHA, the job description writes the DON will assume responsibility for the daily facility operations. The facility failed to ensure administrative responsibilities were carried out to maintain resident safety. On October 11, 2025, Resident 1 exited the facility without staff supervision and entered an unsafe area outside. This demonstrated that facility systems and oversight were not effective in preventing residents from leaving the building unsupervised. Residents identified as being at risk for wandering were not adequately protected, placing them in danger of injury or harm. Interviews with staff, residents, and facility the Nursing Home Administrator and Director of Nursing on October 16, 2025, at 3:00 PM confirmed that established safety measures were not followed and that both equipment and staff procedures failed. Staff reported uncertainty about their roles in monitoring exit doors and about communication protocols when a resident was missing. This lack of coordination and communication delayed identification of the incident and assessment of other residents at risk for wandering or elopement (leaving the facility or safe area without staff knowledge or supervision) and the potential for harm. The Administrator and Director of Nursing failed to fulfill their essential administrative duties to monitor departmental operations, identify systemic risks, and ensure the implementation of facility policies to maintain resident safety. This lack of oversight and failure to use available resources to identify and correct system problems resulted in conditions that placed residents in immediate jeopardy. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (e)(1) Management. 28 Pa. Code 211.12 (d)(3) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 8 of 8