Health inspection·April 15, 2025

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 documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (leaving an area without permission) for one of 16 residents (Resident R1), and failed to make certain each resident received adequate monitoring of an elopement prevention device for one of 16 residents (Resident R2). Findings include: Review of facility policy Elopement Prevention last reviewed 6/3/24, indicated that the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident's stay and modifications will be made to the care plan and prevention techniques. If a Wanderguard (a device applied to the resident that alerts staff when they leave a safe area) is indicated, obtain a physician's order for use of the device and document the reason for application of the device in the resident's clinical record. A photograph of at risk residents are provided to the receptionist, who will also maintain the list of all residents at risk for elopement, including the resident's name, and room number. This list will be distributed to the management team of the care community. Appropriate communication should occur with staff members who may be in contact with those residents. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/1/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and Post Traumatic Stress Disorder (PTSD- a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event). Review of clinical record revealed that on 2/19/20, Resident R1's care plan included interventions for elopement risk/wanderer as evidenced by a history of attempts to leave my home unattended, disoriented to place, impaired safety awareness, my aimless wandering. Interventions include but are not limited to Identify any patterns of wandering that I exhibit: purposeful wandering, aimless, or attempting to escape. Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, Resident refuses to maintain Wanderguard in place. Page 1 of 2 395371 395371 04/15/2025 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 Review of clinical record revealed a nursing progress note dated 4/2/25, that stated This nurse received phone call from oncoming nurse at 6:53 p.m. in the parking lot. Nurse stated she saw Resident R1 in the parking lot in her rearview mirror. Nurse exited her car and assisted resident back into facility. Resident was hesitant and did not want to come back in, so two nurse aides and this writer assisted getting Resident back into the facility. Resident did not say what she was doing or how she exited the building. Resident assisted back into the facility by staff. Head to toe assessment performed on resident and resident's assessment is at her baseline. Wanderguard placement attempted. Resident refused; 2 staff members present when resident refused. 1:1 staff member assigned to resident at this time for resident safety. During an interview on 4/15/25, at 11:35 a.m. Director of Nursing (DON) stated that wandering behavior was not new for Resident R1, but that exit seeking was a new development. Resident R1 was placed on one-on-one supervision after she was found in the parking lot, and then transferred on 4/4/25, to a facility with a locked unit. DON stated that it was determined through a tour of the facility, and monitoring of all exit doors' function, that Resident R1 exited through the front door. DON stated that an investigation was completed after the elopement, and it was determined that Resident R1 was out of the facility about two to three minutes. DON confirmed that the facility failed to provide adequate supervision which resulted in an elopement for Resident R1. Review of Resident R2's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], included diagnoses of dementia, high blood pressure, and difficulty swallowing. Review of Resident R2's clinical record revealed a physician's order dated 3/24/25, for a Wanderguard to be on at all times. Check placement and skin integrity each shift. Review of Resident R2's clinical record failed to indicate that staff had checked the placement of Wanderguard since it was applied on 3/24/25. During an interview on 4/15/25, at 3:50 p.m. DON confirmed that the facility failed to conduct adequate monitoring of an elopement prevention device for Resident R2. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395371 Page 2 of 2