Health inspection·February 5, 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. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for one of six residents (Resident 2) identified as an elopement risk. Findings include: The facility's policy regarding elopement, dated October 1, 2023, indicated that if staff discovered that a resident was missing from the facility, the facility would determine if the resident was out on an authorized leave or pass, initiate a search of the building and premises; and if the resident is not located, notify the Nursing Home Administrator and the Director of Nursing Services, the resident's legal representative, the attending physician, and law enforcement officials, provide search teams with resident identification information, and initiate an extensive search of the surrounding area. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 24, 2023, indicated that the resident was moderately cognitively impaired, used a wheelchair, and had diagnoses that included dementia. The resident's care plan, dated September 6, 2018, and elopement risk assessment, dated July 11, 2023, revealed that the resident was a risk for elopement. A resident event report and facility investigation, dated January 29, 2024, revealed that Resident 2 walked out of the building through the front door and wheeled himself to the local shopping center that included a tobacco and liquor store. When Resident 2 was found at the shopping center he appeared intoxicated and the liquor store staff reported that they sold him vodka. Resident 2 reported that he self-propelled down a path to the shopping center. Interview with the Nursing Home Administrator on February 5, 2024, at 4:01 p.m. revealed that no staff member in the facility was aware that Resident 2 had left the building and the resident timed his exit when there was no receptionist at the front door. He confirmed that he searched the local area and found Resident 2 at the shopping center and the resident appeared impaired. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. Page 1 of 2 395331 395331 02/05/2024 Mountain Laurel Healthcare and Rehabilitation Ctr 700 Leonard Street Clearfield, PA 16830

F 0689 28 Pa. Code 211.12(d)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395331 Page 2 of 2