Health inspection·November 13, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 policy, clinical and facility record review, facility provided documents, and staff interviews, it was determined the facility failed to provide adequate supervision for two residents resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for two of 33 residents (Residents R1 and R2) identified as having a high risk for wandering.Findings include: Review of facility policy Elopement Prevention dated 4/17/25, revealed the facility properly assesses residents and plans their care to prevent accidents related to wandering behavior or elopement. The admitting nurse will perform an initial assessment. A care plan will be developed that reflects the potential for elopement and preventative measures. Admitting nurses or other staff members noting elopement risk and wandering behaviors must notify the nursing Unit Manager/Designee or the ADON (Assistant Director of Nursing). 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 signaling device is indicated, obtain a physician's order for use of the signaling device and document the reason for application of the device in the resident's clinical record. Once the plan of care is determined, the nursing unit manager will notify the staff of the elopement risk and the interventions to be implemented. Photographs of the resident are provided to the receptionist. The receptionist will maintain the list of all residents at risk for elopement, including the resident's name, 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 clinical record revealed Resident R1 was admitted to the facility on [DATE], with active diagnoses of Metabolic Encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain), altered mental status, Dementia (group of symptoms that affects memory, thinking and interferes with daily life), and Alzheimer's Disease (progressive disease that destroys memory and other important mental functions).Review of Resident R1's progress note dated 10/1/25, at 11:52 p.m. revealed, New admission this evening, resident noted to be wandering building with [his/her] cane, continuously going in and out of other resident's rooms, yelling up hallway at staff to help [his/her] roommate who was sick, staff doing what they could until MD (physician) contacted back, [he/she] would call dtr (daughter) and walk around with her on speaker phone, was telling [his/her] dtr that roommate was sick and no one was there to help, they weren't doing anything, so [he/she] would wander around and tell [his/her] dtr different things about not just [his/her] roommate but other residents as well. Trying to help [his/her] roommate as well, staff had to redirect [his/her] not to do so, told [resident] [he/she] could hurt [himself/herself] or accidentally hurt [his/her] roommate, to please allow staff to handle [his/her] roommate's condition. Review of Resident Page 1 of 9 395371 395371 11/13/2025 Quality Life Services - Apollo 151 Goodview Drive Apollo, PA 15613

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few R1's clinical record revealed an admission Wandering/Elopement Risk Evaluation completed on 10/1/25, which consisted of the following questions and documented answers:1. Does the resident have a known history of wandering?Yes2. Behavior/Mood - Select the following, all that apply to resident Loss of self-controlExperiencing feelings of anger/fear of abandonment2a. Resident is exhibiting one or more of the behaviors/moods listed under 2 that could potentially contribute to their risk for wandering.3. Select from the following, all the changes that apply to the resident Change of roommateadmission within the last monthCaregiver or staff change3a. At least one or more of the circumstances under 3 are contributing to the resident's risk for wandering.4. Walk in room: self-performance Independent5. Does the resident use a device for ambulating?No.6. Select any of the following diagnosis that apply to the resident Other Dementia7. Which of the following medications is the resident taking?None of the above8. The following interventions are recommendedRe-evaluation if there is a change in their condition or circumstances Wandering Risk Evaluation Score: 23 - High Risk Review of Resident R1's behavior note, dated 10/3/25 at 2:57 p.m. revealed, Resident seemed to have increased agitation as well as increased anxiety. Seemingly lost, stating, 'I've lost my mind!' Resident was noted to be easily redirected and reassured by staff. Will continue to monitor. Review of Resident R1's progress note, dated 10/3/25, at 5:56 p.m. revealed, RN sup (Registered Nurse Supervisor) notified that patient was located sitting out side. patient was assisted back into the facility. RN sup completed a head to toe assessment. Vss (vital signs stable). Blood pressure 138/70, pulse 68, respirations 18, temp 97.9, oxygen saturation 98% room air. no s/s (signs or symptoms) of distress. No injuries noted at this time. Wander guard (wearable electronic monitoring device) placed on patient left ankle. RN sup assisted patient into transport chair, escorted [him/her] to front entrance sensors, wander guard alarm sounded. assured that wander guard fob working at this time. RN sups educated staff on q 15 min (every 15 minutes) checks, and the risk of elopement for this patient. Review of Resident R1's progress note, dated 10/3/25, at 6:00 p.m. revealed, This nurse spoke with granddaughter regarding staff finding resident outside sitting on the bench. The granddaughter voiced concerns that this resident was supposed to have a wanderguard on, and that she felt that [resident] was not being watched over effectively and correctly. This RN explained to the granddaughter how wanderguards work. Resident had a wanderguard on at time of finding [him/her] outside. RN reported that a new wanderguard was placed on the left ankle and that it was tested and worked accurately. RN also informed granddaughter that Q 15 min checks would be initiated and that everything would be documented accordingly. Staff would also be educated on wandering risks as well as ways to redirect safely and efficiently. A full head to toe was done by 3-11 RN supervisor and documented. Each unit was educated on redirection as well as an update on this resident so that we can keep the resident safe. The granddaughter reported that resident loved going outside, drinking coffee and watching tv. RN discussed ways to involve the resident in the milieu to help decrease resident's urge to wander, and to keep [resident] safe, while also keeping [him/her] engaged on the unit. RN suggested having a staff member walk with [resident] and talk with [him/her] at times throughout the day, bringing the resident to the dining room so she can socialize as well as have coffee, and also involving activities to bring [resident] out into the courtyard with staff so [resident] can go outside and get time outside so [he/she] does not feel so sheltered. Granddaughter agreed with these possible interventions. Granddaughter had no further concerns and was reassured that she can always call if there are any concerns, and that they will be addressed appropriately. ADON notified. Safety interventions in place. All staff educated. Q 15 min checks initiated.Review of a witness statement dated 10/3/25, completed by Nurse Aide (NA) Employee E4 revealed, Assistant Administrator Employee E5 and RN Manager Employee E8 came over to 395371 Page 2 of 9 395371 11/13/2025 Quality Life Services - Apollo 151 Goodview Drive Apollo, PA 15613

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Angel Wing saying that we needed to locate Resident R1, that [his/her] daughter was on the phone saying [resident] was outside. I immediately recalled a conversation I overheard earlier. She [Resident R1] was on speakerphone with a woman as [he/she] was walking from the direction of the ambulance entrance towards the nurses station, the woman said do you see the desk? Make a left at the desk [he/she] turned the corner at the nurses station and saying [he/she] wanted to go outside to clear [his/her] head. The lady on the phone was talking over [resident] and asked [him/her] if [resident] could see the fireplace from where [he/she] was, [resident] told her yes and the lady told [resident] to go in that direction. At first I assumed [he/she] was a visitor but I asked RN Manager Employee E9 just to be sure, she told me it was our new resident. I said [resident] is going to need a wanderguard if [resident] doesn't already have one. RN Manager Employee E9 said [resident] did have one so I went back to what I was doing. As soon as Assistant Administrator Employee E5 and RN Manager Employee E8 said that her daughter thinks [he/she] is outside I said crap [he/she] probably is, someone [resident] was on the phone with told [him/her] how to get to the front of the building. Resident greeter was at the front door and the receptionist was at the desk, the doors were unlocked and the alarm was not going off. I went outside and found [resident] sitting on the bench outside of PC (Personal Care). I approached [resident] and asked [him/her] if [he/she] was Resident R1 and [he/she] said yep! [Resident] was sitting on the phone with her granddaughter on speakerphone, unharmed and joyous about what a beautiful day it is and she was so happy to go outside and clear her mind. Review of witness statement dated 10/4/25, completed by NA Employee E6 revealed, Around 3 p.m. on 10/3/25 I walked over to Angel Wing to go on break with my mom. As I was looking for her I saw Resident R1 walk past me on the phone while someone was saying look for the nurses station. Roughly 20 minutes later RN Manager Employee E8 came rushing over and asking if anyone has seen [Resident R1]. My mom and I went outside to look for [him/her] and saw [resident] sitting outside of PC. We escorted [resident] back inside as [him/her] daughter was on the phone trying to fight with the aides. Review of undated witness statement completed by Assistant Administrator Employee E5 revealed, On 10/3/25 I was in my office when Receptionist, Employee E1 came into my office and told me Resident R1's daughter is on the phone and explained that [Resident R1] is outside. I immediately went back to Angel Wing with RN Manager Employee E8 to see if [he/she] was in [his/her] room first. When [he/she] was not in [his/her] room, RN Manager Employee E8, two CNAs (Certified Nurse Aides), and myself went out the front door. I went right towards the parking lot; the CNAs went left towards Personal Care. I heard the CNAs bring [him/her] back into the building as resident is able to walk on [his/her] own. I then had RN Manager Employee E8 do a complete assessment to make sure everything was okay with resident. I also instructed for resident to immediately have a wander guard placed on [him/her]. I also instructed the nurses to make sure the orders are in the computer and it is care planned as an immediate plan of action to prevent it happening again. RN Manager Employee E8 and I then called the resident representative, which is [resident] granddaughter to report the event. Review of witness statement dated 10/8/25, completed by Receptionist Employee E1 revealed, I was working in the office at the time of the incident, going back and forth from the front desk to the copy room and business office to finish end-of-day tasks. Around 4:00 p.m. or so, I received a call from Resident R1's daughter. She sounded very upset and said she had received a message from someone at our facility saying that [Resident R1] had gotten out and wanted to know what was going on. I asked her to hold while I tried to find out what had happened, then I immediately went to Assistant Administrator Employee E5's office to tell him about the call I had received. He told me to forward it to Resident R1's nurses station, so I returned to my desk to do that. I followed up with a call to the supervisor for that nurse's station 395371 Page 3 of 9 395371 11/13/2025 Quality Life Services - Apollo 151 Goodview Drive Apollo, PA 15613

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few just to make sure someone else was aware, just in case they somehow missed the initial call. Nobody answered, but I assume now that it was probably because they were already looking for Resident R1. After that, I decided to forego the end-of-day tasks in favor of staying at the front desk in case I was immediately needed while the nursing staff went in and out of the building searching for Resident R1. I believe [he/she] was found and returned to the building around 4:15 or 4:20. I remained at the front desk until the end of my shift at 4:30 p.m., at which point I notified Assistant Administrator Employee E5 that I was leaving since I was closing the front office and locking the front door while he was still inside. During an interview on 11/12/25, at 11:22 a.m. the Director of Nursing (DON) stated, I know Resident R1 had a wanderguard placed after the incident on 10/3/25. Multiple staff members attested to overhearing [his/her] daughter telling [resident] on the phone how to get out of the building. During an interview on 11/12/25, at 11:23 a.m. ADON Employee E7 revealed, Resident R1 had a wanderguard placed at admission and it was not on during the elopement.Review of Resident R1's clinical record failed to reveal documented evidence that elopement/wandering interventions had been developed and implemented after Resident R1 was determined to be a high wander risk at admission on [DATE].Review of a facility Resident Elopement List dated 9/24/25, revealed Resident R1's name handwritten on the list with the date 10/3/25.Review of Resident R1's physician order dated 10/3/25, revealed wanderguard on at all times, check placement and skin integrity each shift. During an interview on 11/12/25, at 11:44 a.m. the DON confirmed the facility was unable to locate orders for a wanderguard for Resident R1 prior to the resident's elopement on 10/3/25. The DON stated, The LPN (Licensed Practical Nurse) who filled out the admissions assessment denies placing a wanderguard on Resident R1 at that time. Review of Resident R2's clinical record revealed was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - periodic assessment of care needs) dated 9/18/25, indicated diagnoses of high blood pressure, Anxiety, and Depression.Review of Resident R2's progress note for Resident R2, dated 9/24/25, revealed, Resident has [his/her] belongings packed in a bag and is sitting by the exit door on the Buttercup by the nurse's station. Resident easily redirected back to [his/her] room by this RN. Resident states that [he/she] was unsure if [his/her] room was still covered by the employer. Resident assessed by this nurse. AOx2 (alert and oriented) with trouble with location. Resident denies any pain at this time. Resident sitting in room currently with call bell in reach and watching TV. Review of Resident R2's progress note, dated 9/24/25 revealed, ANHA (Assistant Nursing Home Administrator) performed BIMS (Brief Interview for Mental Status) assessment on resident due to behaviors. Resident scored a 15 which indicates resident is cognitively intact. However as ANHA was sitting with resident, [resident] made some comments that were somewhat bizarre. Resident went into political conspiracies and talking about evil spirits that are al throughout the facility, [he/she] can feel them. Even though resident is able to believe in whatever [he/she] pleases this seems to be out of the ordinary for resident. ANHA notified DON/ADON of behaviors/findings. Review of progress note for Resident R2, dated 9/24/25, revealed, Wanderguard placed on right wrist r/t (related to) exit seeking. Voicemail left with brother. Review of physician order for Resident R2, dated 9/24/25, revealed resident is to have a wanderguard at all times. Check placement and skin integrity each shift. Review of Resident R2's care plan dated 9/24/25, indicated the resident is an elopement risk/wanderer as evidenced by a history of attempts to leave my home unattended, disorientation to place. Interventions include: distract me from wandering by offering me pleasant diversions, structured activities, food, conversation, television, books, etc. 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. Issue a 395371 Page 4 of 9 395371 11/13/2025 Quality Life Services - Apollo 151 Goodview Drive Apollo, PA 15613

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wandering device to me. Monitor my location frequently. Document any wandering behavior and the success of any attempted diversional interventions. Review of progress note for Resident R2, dated 9/28/25, stated, About 630pm I was walking past residents room and noticed [he/she] was attempting to transfer self from wheelchair to bed without assistance or staff present. I went into room and started to speak with resident, first about football game . I walked past room about an hour later and wheelchair was gone and resident was not in bed, bed alarm was turned off, I did turn it on during early interaction. Resident was not in bathroom. CNA and myself looked throughout facility and resident was in bathroom of another room on Angel Hall, resistive to coming out of bathroom. CNA brought to [his/her] room, [resident] said [he/she] wants the police called, RN supervisor asked [resident] why and [he/she] just said because I do. RN supervisor informed [resident] [he/she] needs to tell police nature of [his/her] call and [resident] said someone turned off [his/her] security equipment in room, [he/she] did not feel safe. Resident did propel self to other part of unit and was going into other residents rooms, with other residents being upset about intrusion. RN supervisor did talk [him/her] into taking medications with resident questioning medications and being suspicious. Resident was seen by myself to be in a male occupied room. [Resident] was sitting in the dark then came out on [his/her] own. After [Resident R1] came out, male resident said to me that he was sleeping, felt someone tapping his leg. He woke up and was being spoken to about the shirt that he has on, that resident who wandered into room was speaking to him negatively about wearing same shirt yesterday. Resident then propelled self towards her room and then wandered again through facility. CNA found resident resting in bed in a room on Angel Wing. When CNA attempted to inform that this is not [his/her] room and directed [him/her] to correct room, resident was a bit angry and said this isn't right and I want to the police. Another CNA came in and spoke with resident about situation with resident transferring out of bed into wheelchair, assigned CNA did assist [him/her] to bed with some resistance. Resident is resting in bed at this time. Review of progress note for Resident R2, dated 9/29/25, revealed, Resident wandered around, denying care from aide and medicine from this nurse. Was upset that staff would not sit in [his/her] room to keep [him/her] company. Review of progress note for Resident R2, dated 10/5/25, stated, LPN on GRU (a nursing unit in the facility) front cart called RN supervisor because resident was outside in front of building. Resident was wearing long sleeve shirt, sweatpants, and non-skid socks. ADON notified of resident being outside. Kitchen staff notified RN that resident was in parking lot upon arrival to building. Staff stayed with resident, was able to get resident to return into building upon room change. RN assessed resident, no injuries noted, wander guard placement checked and not found. New wander guard placed on resident's wheelchair. Resident will not receive knives due to possibly cutting previous wander guard off. When asked about wander guard bracelet, resident stated, I believe I cut it off. Maintenance checked wander guard system, system functioning appropriately. MD notified and family notified. Review of witness statement dated 10/5/25, completed by Dietary Aide Employee E2 stated, I was pulling into the parking lot, came through the employee entrance, went towards the kitchen and I looked out the front door and saw Resident R2 outside by the road. I stayed with [him/her] until I was able to get somebody so [he/she] wouldn't get hurt or hit by a car. I was also trying to coach [him/her] in [he/she] wouldn't come. Review of undated witness statement completed by Activity Aide Employee E3 revealed, I arrived at work at 11:15 a.m. on Sunday, October 5, 2025 and entered through the employee ramp. I walked through Rehab Road to report to the front office. Upon arriving at the front office, I noted Resident R2 in the parking lot. I recognized another staff member outside with Resident R2, but unlocked the front door to go out and check to see if everything was ok. Upon going outside, Resident R2 stated that [he/she] was 395371 Page 5 of 9 395371 11/13/2025 Quality Life Services - Apollo 151 Goodview Drive Apollo, PA 15613

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few trying to leave. I sent the other staff member into the building to get help while I stayed with Resident R2 to ensure safety. I stayed with Resident R2 until we were able to get her safely back into the building.Review of a witness statement dated 10/5/25, completed by NA Employee E10 stated, Have not seen resident since this morning around 8 when [he/she] was wondering around hallway. Review of a witness statement dated 10/5/25, completed by LPN Employee E11 stated, I last seen Resident R2 at approximately 8:40 a.m., when I administered her morning meds.Review of a witness statement dated 10/5/25, completed by NA Employee E12 revealed, Around 11:11 a.m. I seen Resident R2 in the kitchen area, she had the wireless cellphone, and told me she was done using it. I got the phone off [him/her] and [he/she] was still in that area near the fish tank.During an interview on 11/12/25, at 11:32 a.m. DON stated, On 10/5 an Activity Aide was covering the front desk, the receptionist was on her way in. The front door was unlocked because someone was at the desk. There is a binder at the front desk with all of the residents identified as an elopement risk. During an interview on 11/12/25, at 11:44 a.m. the DON was informed that Activity Aide Employee E3 revealed in their witness statement that Resident R2 was in the parking lot with another employee when they arrived to work at 11:15 a.m., which contradicts the previous verbal statement that Activity Aide Employee E3 had been covering the front desk at the time that Resident R2 eloped from the building. During this interview, the DON stated, I will get the ADON to try to better explain the timeline. I was on vacation at that time, I'm unsure of all of the facts. During an interview on 11/12/25, at 11:48 a.m. ADON Employee E7 revealed, Dietary Aide Employee E2 was the first person to find Resident R2 outside of the building. Resident R2 went out of the front door, not sure how they got out. During this interview, ADON Employee E7 was unable to state why the front door was unlocked while the front desk was unattended. ADON Employee E7 acknowledged previously stating to the State Agency (SA) that Activity Aide Employee E3 was covering the front desk until the receptionist arrived. When the SA showed Activity Aide Employee E3's written witness statement to ADON Employee E7, they stated, I would have to go with the witness statement. On 11/12/25, at 2:34 p.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) was called due to the elopement of Resident R1 on 10/3/25, and Resident R2 on 10/5/25. The NHA was provided an Immediate Jeopardy template, and a corrective action plan was requested. On 11/12/25, at 5:31 p.m. an acceptable Corrective Action Plan was received which included the following interventions: The facility Administrator, and or designee, will review current elopement policy for accuracy and update as needed, to be completed by 11/13/25. All residents will be evaluated for risk of elopement by the facility Director of Nursing, or designee, this to be completed by 11/13/25. Any new identified residents as at risk of elopement will receive orders from physician for use of wanderguard bracelet and care plan will be updated accordingly by facility Director of Nursing, or designee, to be completed by 11/13/25. An audit of all residents identified as at risk for elopement will have their care plan reviewed to ensure resident centered interventions are in place, completed by facility Director of Nursing, or designee, this to be completed by 11/13/25. All staff, both facility and agency, will be educated by the facility Director of Nursing, or designee, regarding elopement policy, identifying residents at risk, and implementing interventions, this to be completed by 11/14/25. The facility Administrator and Director of Nursing will complete a root cause analysis as to what system failed allowing this elopement to occur, this to be completed by 11/13/25. Facility Administrator and Director of Nursing will review the procedure on the front door monitoring, this to include functionality of wanderguard system, as well as the schedule of personnel monitoring front entrance. This to be completed by 11/13/25. The front door wanderguard codes have been changed and code knowledge limited to administrative staff. Facility door will be secured and code use will be required for 395371 Page 6 of 9 395371 11/13/2025 Quality Life Services - Apollo 151 Goodview Drive Apollo, PA 15613

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few entry or exit. Compliance will be monitored through audits. Audits will consist of door security assessment by facility Administrator, or designee, audit of resident risk assessments will be completed by the facility Director of Nursing, or designee, and an audit of all resident care plans who were identified at risk of elopement will be completed by the Director of Nursing, or designee. Results will be reviewed at QAPI (Quality Assurance and Performance Improvement Committee) to be completed by NHA, this to be completed by 11/14/25. The facility's policy and procedures for elopements were reviewed 11/12/25, no revisions were made. On 11/13/25, at 10:34 a.m. it was confirmed 146/146 residents were reassessed for an elopement risk. 36/146 residents were identified as at risk. 5/146 residents were newly identified as at risk of elopement. 36/36 resident physician orders were verified for an electronic monitoring bracelet. 36/36 care plans were reviewed and updated to include interventions to prevent elopement. Review of facility documents on 11/13/25, revealed the facility had 126 employees and 104 agency employees. 138 employees signed they received formal education on the policy Elopement Prevention. 65 employees signed they received education via phone as they had not been working in the building.During employee interviews on 11/13/25, from 11:33 a.m. through 2:18 p.m. 38 employees confirmed they had received education on the facility's elopement policy and procedures, as indicated above. Review of an ad hoc (an unplanned meeting organized to address specific issues of urgent matters) QAPI meeting dated 11/13/25, revealed during an audit of all residents, 36 residents were identified as at risk of elopement. This audit reviewed wandering assessment, wanderguard orders, and elopement care planning. The audit revealed errors in 18 resident assessments, one care plan was found to be needing updated, and two residents were found to be needing wanderguard orders. The Immediate Jeopardy was lifted on 11/13/25, at 3:07 p.m. when the action plan implementation was verified. During an interview on 11/13/25, at 4:46 p.m. the NHA and DON confirmed the facility failed to ensure each resident received adequate supervision, which resulted in an elopement for two of 33 residents (Residents R1 and R2), resulting in Immediate Jeopardy. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing Services. 395371 Page 7 of 9 395371 11/13/2025 Quality Life Services - Apollo 151 Goodview Drive Apollo, PA 15613

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 review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopement of two resident (Residents R1 and R2), which created an immediate jeopardy situation for two of 33 residents.Findings include: The job description for the NHA specified the purpose of the position is to direct the day-to-day operations of the facility in accordance with current federal, state, and local standards governing long-term care facilities and to ensure that the highest degree of resident care and services are delivered and maintained. The job description for the DON specified the purpose of the position is to provide nursing management, set resident care standards for all direct care providers and provide completer supervision and management for the nursing department. Based on findings identified in this report, the facility failed to prevent the elopement of two residents (Residents R1 and R2), which placed the residents in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 11/12/25, at 2:34 p.m. the NHA and DON were notified that they failed to effectively manage the facility to prevent the elopement of a resident, which created an immediate jeopardy situation for two of 33 residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. Residents Affected - Few 395371 Page 8 of 9 395371 11/13/2025 Quality Life Services - Apollo 151 Goodview Drive Apollo, PA 15613

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Closed Resident Record CR1).A review of the clinical record indicated that Closed Resident Record CR1 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of kidney, major depressive disorder and hypertension (pressure in your blood vessels are too high). A review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 7/30/25, indicated the diagnoses remained current.A review of Closed Resident Record CR1 nurse progress notes 9/30/25 indicating resident ceased to breath (CTB) on 9/26/25 at 1915.A review of Closed Resident Record CR1 nurse progress notes did not include documentation on 9/26/25. During an interview on 11/12/25, at 12:04 p.m. the Director of Nursing confirmed the facility failed to make certain that medical records on accurately documented for Closed Resident Record CR1 and each resident's records are complete as required. 28 Pa. Code: 211.5(f)(g)(h) Clinical records. 395371 Page 9 of 9