Health inspection·December 22, 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 policies and documentation, clinical record reviews, and interviews with staff, it was determined the facility failed to provide adequate supervision to one of twelve residents reviewed (Resident R1) who was inaccurately assessed as a low risk for elopement. This failure resulted in Resident R1 exiting nursing unit via the elevator and walking out the front entrance doors. The facility was not aware Resident R1 was missing until the resident's daughter called and informed the facility Resident R1 had walked to her house crossing multiple busy streets. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1)Findings include: Review of facility policy, titled, wandering and elopements, revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent while maintaining the least restrictive environment for residents. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with the following diagnosis; Parkinson's disease with dyskinesia, without mention of fluctuations (movement disorder of the nervous system that worsens over time); neurocognitive disorder with Lewy bodies (a progressive neurodegenerative disorder characterized by the accumulation of Lewy bodies in the brain, leading to cognitive decline, movement issues, and various other symptoms); muscle weakness (generalized); and difficulty in walking. Review of Resident R1's [NAME]-Elopement Assessment/Evaluation completed on admission dated September 16, 2025, revealed that the facility incorrectly completed the assessment by stating the resident does not have dementia resulting the resident being identified as low risk for wandering instead of moderate risk for elopement. Review of Resident R1's admission MDS (Minimum Data Set- periodic assessment of resident's care needs) completed on September 21, 2025, revealed the resident was assessed with a BIMS (Brief Interview for Mental Status) score of 10. A score of 10 indicates moderate cognitive impairment. Review of facility investigation provided by the facility revealed a timeline dated November 5, 2025. The following is the summary of the timeline: Between 11:00 a.m. and 12:00 p.m. Resident R1 was observed twice by nursing assistant (NA) Employee E1 trying to enter the elevator on the second floor. Employee E1 removed Resident R1 but did not report Resident R1's exit seeking behaviors to her supervisors. Between 12:00 p.m. and 12:30 p.m. registered nurse, Employee (E2) removed Resident R1 from the elevator twice and redirected (him/her) to own room. Employee E2 did not report Resident R1's exit seeking behaviors to her supervisors. At 2:00 p.m. NA Employee E3 observed Resident R1 standing in front of the elevator. Employee E3 redirected Resident R1 back to own room. Employee E3 did not report Resident R1's exit seeking behaviors to the supervisors. Between 2:00 p.m. and 2:15 p.m. licensed Employee E4 was sitting in her car in the facilities parking lot located in a lot across the street from the front entrance and observed Resident R1 walking out of the facility. Employee E4 believed the resident was on leave of absence (LOA) due to observing another individual walking out of the facility at the same time. Employee E4 watched Resident R1 walk up Page 1 of 4 395469 395469 12/22/2025 Emerald Nursing and Rehabilitation 320 South Market Street Elizabethtown, PA 17022

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the street by self. Employee E4 did not report her observations to her supervisor. At 2:30 p.m. Resident R1's daughter called the facility to report Resident R1 had left the facility and walked to her house by (himself/herself). Resident R1 was returned to the facility at 6:05 p.m. by (his/her) daughter. Interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 22, 2025, at 6:15 p.m. revealed Resident R1 followed an unidentified visitor onto the elevator and exited the facility walking alongside the individual; the NHA revealed the resident's proximity to the visitor led a receptionist and Employee E4 to presume the resident was leaving with a family member. Additionally, the NHA and DON confirmed Resident R1's elopement risk assessment was not completed accurately. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to accurately complete an elopement assessment and to provide adequate supervision of a resident who was actively exhibiting exit seeking behaviors. The resident went missing on November 5, 2025. The facility was not aware Resident R1 was missing until Resident's daughter called the facility to report Resident R1 was at her house. An Immediate Jeopardy template (document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator and Immediate Jeopardy was called on December 22, 2025, at 6:49 p.m. The facility provided a Plan of Correction on December 22, 2025, for submission and it was approved at 7:00 p.m. The plan of correction was as follows:a. The Nursing Administration reviewed all resident' electronic health records for accurate elopement/wandering evaluations- completed November 5, 2025.b. Elopement books found at the reception desk, and every unit were reviewed to ensure that all resident's identified as elopement risks were current, and resident's identifiers were available. - completed November 5, 2025.c. Sign posted at reception notifying visitors of the LOA process- completed November 5, 2025. d. Staff were educated on routine resident checks, the wandering and elopement policy, and the wander management and elopement prevention policy. 90% of staff will be educated by November 6, 2025. The remainder were educated prior to the start of their next shift.e. RN (registered nurse) Supervisors/Unit managers were educated on the completion of headcounts of all residents compared to the midnight census and the immediate reporting of any discrepancy to the Director of Nursing (DON). 90% of staff will be educated by November 6, 2025. The remainder will be educated prior to the start of their next shift. f. Staff educated on the LOA process. 90% of staff were educated by November 6, 2025. Remainder were educated prior to the start of their next shift. g. The reception staff were educated on the facility visitor badge protocol, visitor badge process, resident leaves of absence, and signing residents out. 90% of staff were educated by November 6, 2025. The remainder were educated prior to the start of their next shift. h. Staff were educated on the elopement/missing person policy and procedure including the elopement code announcement to notify staff in the center, search on the premises and the surrounding areas, and notification processes. 90% of staff were educated by November 6, 2025. The remainder were educated prior to the start of their next shift. i. Staff were educated on elopement drills including the frequency of drills and expected responses. 90% of staff were educated by November 6, 2025. The remainder were educated prior to the start of their next shift. j. The training regarding elopement were added to the general orientation schedule for new employeescompleted November 6, 2025. k. An elopement drill was completed on November 6, 2025. l. The elevator and keypads were assessed. Elevator keypad code changed. Additional training provided to staff related to not providing keypad codes to visitors and/or residents. 90% of staff were educated by November 7, 2025. The Remainder were educated prior to the start of their next shift.m. Elopement/wandering evaluation updated as needed. REview of facility documentation revealed the facility completed implementation of the action plan on November 9, 2025. On 395469 Page 2 of 4 395469 12/22/2025 Emerald Nursing and Rehabilitation 320 South Market Street Elizabethtown, PA 17022

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few December 22, 2025, the implementation of the action plan was verified. Eleven staff members were interviewed from various units and departments. Facility staff were able to answer questions on recognizing signs of exit seeking behaviors and who to report them to, missing resident response, how often are elopement assessments completed, LOA process, Visitor badges, signing out resident process.Following the verification of the completion of the immediate action plan the Immediate Jeopardy was lifted on December 22, 2025, at 7:15 p.m. and the Immediate Jeopardy situation was determined to exist at the facility from the time of the elopement on November 5, 2025, until the completion of the action plan on November 9, 2025.The facility failed to ensure appropriate supervision of a resident, exhibiting exit seeking behavior and who exited the door of the facility to cross multiple busy streets to arrive at a family member's home. Facility staff were unaware of resident's elopement until the family member contacted the facility. The deficient practice is being cited as past non compliance. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services28 Pa. Code 211.12(d)(2) Nursing services 395469 Page 3 of 4 395469 12/22/2025 Emerald Nursing and Rehabilitation 320 South Market Street Elizabethtown, PA 17022

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 the review of clinical records, job descriptions, review of facility policy, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of one of twelve residents reviewed (Resident R1) with a diagnosis of Dementia who eloped from the facility. This failure resulted in an Immediate Jeopardy situation for Resident R1. (Resident R1)Findings Include:Review of the job description for the Nursing Home Administrator (NHA) states, Position Summary-this position is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet resident's needs in accordance with federal, state and local regulations. Also, develop and maintain systems that are effective and efficient to operate the facility in a financially sound manner.Further review of the NHA job description revealed, Essential Duties and Responsibilities-. Develop, maintain and implement operational policies and procedures to meet residents need in compliance with federal, state and local requirements. Determine the personnel requirements of the facility in collaboration with Department Managers and hire or arrange for sufficient staff to provide for sound resident care and implement the facility policies and procedures.Review of the job description for the Director of Nursing (DON) states, Position Summary- The Director of Nursing functions as the administrative authority for the Department of Nursing. This Director will be responsible for the organization and oversight of all nursing operations and for the supervision of care for all residents at the facility. Further review of the DON job essential requirements revealed, must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality of care.The findings in this report identified the facility failed to maintain the safety of the residents from elopement by ensuring elopement assessments were completed correctly and residents exhibiting behaviors for elopement were prevented from leaving the facility without proper supervision.Refer to F68928 Pa Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(b)(3) Management Residents Affected - Few 395469 Page 4 of 4