Health inspection·September 19, 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 facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) for one of seven sampled residents at risk for elopement. (Resident 1) This failure resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Elopements/Elopement Policy, last reviewed March 25, 2025, revealed that staff were to assure the safety and security of all residents and that facility staff were to list prevention strategies on residents' care plans. The policy further indicated that residents capable of removing their alert bracelets (an electronic device that prevents doors from opening and/or sounds an alarm) were to be issued a stronger tamper resistant band. If the resident was able to remove the stronger band and was independently ambulatory (walked without assistance), the resident would require a one to one (1:1) observation. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia, syncope and collapse (fainting), and cerebral infarction (stroke). According to the Minimum Data Set assessment (a periodic evaluation of resident care needs) dated August 27, 2025, the resident had memory impairment and could walk without assistance. Review of the elopement assessment dated [DATE], revealed the resident wandered and was at risk for elopement. On August 20, 2025, a nurse noted that an alert bracelet was applied to the resident's leg. On September 13, 2025, a nurse noted that he had self-removed his alert bracelet and the nurse questioned if the unlocked unit was appropriate for the resident. On September 17, 2025, at 2:20 p.m., a nurse noted that Resident 1 was observed on the first floor. The resident was returned to the second-floor unit where he resided, and a new alert bracelet was applied. On September 17, 2025, at 2:54 p.m., another nurse noted that Resident 1's alert bracelet could not be located, and another new one was applied. At 4:11 p.m., a nurse noted that the physician group ordered for Resident 1 to be on every 15 minute checks due to wandering and removing his alert bracelet. Review of the facility documentation dated September 17, 2025, revealed that Resident 1 could not be located on the unit at 4:30 p.m., and the facility began a search. When Resident 1 could not be located on the facility grounds, the police were contacted. The police observed the resident walking along a road one mile from the facility. He was returned to the facility by the police on September 17, 2025, at 8:10 p.m. There was no documented evidence that Resident 1 was provided a stronger alert bracelet band or placed on 1:1 observation after removing his alert bracelet on September 13 and 17, 2025, as per facility policy. There was no documented evidence that Resident 1 had care plan interventions developed to address his elopement risk, wandering behavior, and alert bracelet use. In an interview on September 19, 2025, at 11:55 a.m., the Director of Nursing confirmed that there was no documented evidence that Resident 1 was issued a stronger alert bracelet band per policy and that no care plan interventions were developed to Page 1 of 2 395476 395476 09/19/2025 Northampton County-Gracedale Gracedale Avenue Nazareth, PA 18064

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few address his elopement risk, wandering behavior, and alert bracelet. On September 19, 2025, at 1:28 p.m., the Administrator was notified that the failure to provide adequate supervision to prevent elopement constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented the following corrective action plan: 1. Resident 1's room was changed to a secure unit, and a new alert bracelet was placed on the resident. The resident's care plan was updated to include risk for elopement. Resident 1 was placed on 1:1 observation.2. The facility conducted an immediate audit of all residents with alert bracelets to ensure they were intact and with the appropriate band.3. The facility conducted an audit to ensure all residents with an alert bracelet had an appropriate care plan in place.4. The facility created a log to monitor each alert bracelet and band to ensure the correct band is in place, and that the policy regarding stronger bands is being followed.5. The receptionists will review the binder of at risk residents at the start of their shifts for changes and initial a log.6. The facility will update the template for 1:1 orders in the electronic health record on September 22, 2025.7. The facility educated all staff in the facility on the facility's procedure for alert bracelets, stronger bands, and resident care plans. All staff that were available on September 19, 2025, were immediately educated. Other staff will be re-educated prior to the start of their next shift. 8. Weekly audits of alert bracelets, bands, logs, and care plans will be completed and the results discussed at QAPI (Quality assurance, performance improvement) committee. 9. Signs are posted with instructions to not share door codes and to be aware of residents who may try to exit. The survey team validated that the Immediate Jeopardy was removed on September 19, 2025, at 7:00 p.m., through review of the facility training and review of facility procedures following the facility's implementation of the corrective action plan for removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 212.12(d)(1)(3)(5) Nursing services 395476 Page 2 of 2