Health inspection·August 25, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, clinical record review, and staff and resident interview, it was determined that the facility did not develop and implement a comprehensive person-centered care plan to include a resident's specific need for a roam alert bracelet and interventions to protect against elopement for one of three residents reviewed for elopement risk (Resident 71). Findings include: Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 28, 2023, for Resident 71 revealed the resident's BIMS (BIMS, Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; a score of 13-15 indicates an intact cognitive response) was 15. During an interview with Resident 71 on August 22, 2023, at 11:55 AM, the resident reported that he must wear this thing around his ankle because he left the building when at a routine appointment and he wished that it would be taken off. The resident was referring to a wander alert bracelet (a bracelet that triggers alarms and can lock monitored doors to prevent a resident from leaving unattended). The resident described going to an appointment three days a week. He indicated that the staff from the nursing facility transport him to and from the appointments. He also indicated that he cannot go off the floor where he resides without help from staff when they are available, and he can only go outside when the staff are available. Clinical record review for Resident 71 revealed a care plan that was initiated June 27, 2023, that indicates the resident has a history of wandering. The goal was that the resident would remain safe inside the buildings and accept redirection as needed. The interventions included to encourage the roam alert at all times, check the roam alert per policy, and ensure that the resident wears well fitting, non-skid footwear. There was no documented evidence in the care plan to indicate why Resident 71 who had a BIMS of 15 needed a roam alert bracelet. During an interview with the Director of Nursing on August 25, 2023, at 12:46 PM the surveyor asked why Resident 71 who has a BIMS of 15 requires a roam alert bracelet and how his rights are not violated by restricting his movement in the facility. The Director of Nursing reported the following about the resident. Resident 71 left the appointment before staff arrived to pick him up and he was found wandering in a parking lot. Resident 71's mental status changes frequently due to a chronic medical condition, his cognition (thinking ability) changes throughout the day, and he had made statements that he is leaving. The facility communicated with the staff at the off-site appointment to watch (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 395533 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Ridge Senior Living at Windy Hill 100 Dogwood Drive Philipsburg, PA 16866 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)