Health inspection·December 27, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records and staff interview, it was determined that the facility failed to revise a care plan for two of six residents (Resident R1, R2) to accurately reflect the current status of the resident. Findings include: Review of clinical record indicated Resident R2 was admitted [DATE], with diagnoses which included adult failure to thrive, Parkinson's disease without dyskinesia and neurocognitive disorder. A review of Resident R2's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 11/4/24, indicated diagnoses remained current. Review of Resident R2's physician orders dated 12/5/24 indicated Safety Devices:Wanderguard on at all times: Check placement & skin integrity each shift. Change every 84 days was discontinued on 11/4/24. Review of Resident R2's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 8/22/24, indicated elopement risk. Care Plan interventions included wandering device Device # A3423-3494. Review of clinical record indicated Resident R1 was admitted [DATE], with diagnoses which included encephalopathy, cognitive communication mood disorder and dysphagia. A review of Resident R1's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 11/21/24, indicated diagnoses remained current. Review of Resident R1's physician orders dated 11/15/24 indicated Safety Devices: Wanderguard on at all times: Check placement & skin integrity each shift. Change every 90 days. Review of Resident R1's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 11/26/24, indicated elopement risk. Care Plan interventions was not updated to include wanderguard or updated for elopement incident. During an interview on 12/27/24, at 1:30 p.m. Director of Nursing confirmed the facility failed to revise care plan for Resident R1 and R2 as required. 28 Pa. Code: 211.11(d) Resident Care Plan Page 1 of 2 395371 395371 12/27/2024 Quality Life Services - Apollo 151 Goodview Drive Apollo, PA 15613

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 facility policy review, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exited to an unsupervised and unauthorized location without staff's knowledge) for one of six resident (Resident R1). Findings include: The facility Resident Elopement policy dated 6/3/24, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Review of clinical record indicated Resident R1 was admitted [DATE], with diagnoses which included encephalopathy, cognitive communication mood disorder and dysphagia. A review of Resident R1's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 11/21/24, indicated diagnoses remained current. Review of Resident R1 nurse progress notes dated 12/18/24 at approximately 1:28 p.m., Nursing home administrator (NHA) notified the Assistant Director of Nursing ADON that Resident R1 was found sitting in the grass outside of the facility. She claimed to be headed to the post office and looking for her daughter. The wanderguard system on the front entrance was found to be faulty. Resident had been noted to have an intact wanderguard bracelet to her L wrist, when system attached to resident was tested at another proximity sensor it was found to be functioning properly During an interview on 12/27/24, at 1:30 p.m. Director of Nursing (DON) confirmed the facility did properly supervise Resident R1 as required. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code: 201.29(a)(b)(c)(I)(n) Resident rights. 28 Pa. Code 201.18(b)(1) Management. 395371 Page 2 of 2