Health inspection·August 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 facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of seven residents (Resident R1) identified as having a high risk for wandering. Findings include: Review of the facility policy Skilled Nursing-Elopement and Wandering Policy dated 2/7/25, indicated this community ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The community is equipped with door locks/alarms/wander management systems to help avoid elopements. Alarms are not a replacement for necessary supervision. Team members are to be vigilant in responding to alarms in a timely manner. The community shall establish and utilize a systematic approach to identifying, monitoring and managing residents at risk for elopement or unsafe wandering, including assessment of risk. Review of the facility policy Skilled Nursing-Comprehensive Care Plans dated 2/7/25, indicated assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/3/25, indicated the diagnoses of altered mental status, encephalitis (inflammation of the brain), and unspecified lack of coordination. Section C0500 the Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of three - severe cognitive impairment. Section GG0170 Mobility indicated Section I walk ten feet required partial to moderate assistance. Review of Resident R1's Elopement evaluation, upon admission, dated 5/30/25, at 9:37 p.m. indicated the following:-History of elopement while at home: No.-Does the resident have a history of elopement or attempted leaving the facility without informing staff: No.-Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: No.-Does the resident wander: No.-Is the wandering behavior a pattern, goal directed: Blank.-Does the resident wander aimlessly or non-goal directed: Blank.-Is the resident's wandering behavior likely to affect the safety or well-being of self/others: No.-Is the resident's wandering behavior likely to affect the privacy of others: No.-Has the resident been recently admitted or re-admitted (within the past 30 days) and is not accepting the situation: No.-Score of one or higher indicates risk of elopement-Risk for wandering/elopement identified: blank. Review of Resident R1's Elopement evaluation, dated 6/5/25, at 11:10 a.m. indicated the following:-History of elopement while at home: No.-Does the resident have a history of elopement or attempted leaving the facility without informing staff: No.-Has the resident verbally expressed the desire to go home, packed belongings Page 1 of 5 395549 395549 08/13/2025 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to go home or stayed near an exit door: No.-Does the resident wander: Yes.-Is the wandering behavior a pattern, goal directed: Yes.-Does the resident wander aimlessly or non-goal directed: Yes.-Is the resident's wandering behavior likely to affect the safety or well-being of self/others: Yes.-Is the resident's wandering behavior likely to affect the privacy of others: Yes.-Has the resident been recently admitted or re-admitted (within the past 30 days) and is not accepting the situation: Yes.-Score of one or higher indicates risk of elopement-Risk for wandering/elopement identified: blank. Review of Resident R1's physician orders dated 6/5/25, indicated wander guard check function every shift. Wander guard check placement every shift placement right lower leg. Review of Resident R1's care plan dated 6/25/25, (twenty days later) indicated the resident is at risk for wandering/elopement per wander risk assessment. Goal - the resident's safety will be maintained. Interventions - engage resident in purposeful activity. Provide care in a calm and reassuring manner. Provide clear, simple instructions. Provide reorientation to surroundings and environment. The resident is at risk of disorientation while on skilled due to being an independent living resident of the community prior to skilled admission. The resident is reoriented to skilled as the current living arrangement and updated on the situation. Review of Resident R1's progress notes indicated the following:-6/5/25, at 11:22 a.m. Resident wandering in the hall looking for the exit to the main building. Resident stated they were looking for the place where all the people and activity took place. Resident was not able to be redirected. Resident not able to answer questions appropriately. Elopement assessment was completed and a wander guard placed on the left ankle.-6/5/25, at 3:01 p.m. resident has confusion to the level of reality. Resident is not on the same level as questions asked. Staff spent 15 minutes with resident during a conversation/assessment and the only questions resident answered yes to were, liking dogs and church. Resident is friendly but has difficulty remaining for duration and comprehension of some activities. -6/6/25, at 12:05 p.m. physician note - resident remains confused since baseline. Resident is alert answering questions vaguely. Acute confusion- temporal lobe abnormalities (usually manifested in neurological and cognitive issues and can contribute to memory problems, language difficulties and psychiatric symptoms).-6/6/25, at 2:17 p.m. resident was wandering this shift stated needing to go to first floor. Redirected to environment and was able to redirect resident effectively.-6/7/25, at 2:10 p.m. resident is happy, smiling, fidgety, and wandering. Resident having increased confusion and exit seeking this shift. Education given and was understanding but can be forgetful. -6/8/25, at 2:49 p.m. resident is happy, pleasant, and wandering. Wandering this shift but effective with redirection.-6/9/26, at 11:37 a.m. resident is pleasant, smiling, wandering, and confused. Looking for father. While looking at the bulletin board resident stated if you call the Ombudsman (individual who investigates and helps resolve complaints) that was the resident's father. Confused and unable to redirect. Answers questions inappropriately. Wanders the halls and tried to sign out but not sure where to go.-6/10/25, at 9:42 a.m. resident is happy and wandering. Alert to self with baseline confusion. -6/11/25, at 10:57 a.m. physician note acute confusion- temporal lobe abnormalities. No significant improvement in cognition to date. The patient is physically able to participate with therapies but needs step by step, constant cues to complete tasks. -6/11/25, at 1:43 p.m. resident was wandering this shift. Multiple redirections made and were effective. Resident did self-transfer this shift three times. Redirected, but is forgetful. -6/12/25, at 2:23 p.m. happy and wandering. Self-transferred four times this shift. Redirection provided. Resident is forgetful. Wander guard in place.-6/13/25, at 2:43 p.m. pleasant and wandering. Wandering into rooms this shift. Redirection given multiple times and effective. Out of bed at this time wandering.-6/16/25, at2:15 p.m. wandering noted this shift with redirection successful. -6/17/25, at 1:30 p.m. pleasant and wandering. 395549 Page 2 of 5 395549 08/13/2025 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident does wander but is easily redirected.-6/18/25, at 1:47 p.m. pleasant and wandering. Resident did wander but was easily redirected.-6/19/25, at 11:44 a.m. of note patient intermittently wandering into other rooms as she is easily disoriented, requiring frequent reorientation.-6/21/25, at 2:11 p.m. pleasant and wandering. Wandering unit but easily directed.-6/22/25, at 2:23 p.m. wandering unit but easily redirected.-6/23/25, at 2:26 p.m. resident remains confused.-6/25/25, at 4:08 p.m. call placed to resident's family. Notified of resident's elopement from the skilled unit. Physician also notified. Review of facility provided documentation dated 6/25/25, at 8:35 a.m. Resident R1 independently navigated off the skilled unit to the lower level of the community center from timeframe of 8:35 a.m. - 8:46 a.m. During this time the resident was previously identified as a wander risk and had a wander management bracelet in place. Assessed with no injuries. Review of Nurse Aide (NA) Employee E1's signed statement form dated 6/25/25, indicated staff saw Resident R1 in the wheelchair on the [NAME] Hall wheeling around the unit. Staff then started providing care to another resident. Review of NA Employee E2's signed statement form dated 6/25/25, indicated staff member came out of a resident room and upon leaving approximately at 8:35 a.m. staff witnessed Resident R1 wheeling independently through the doors on the Founders hallway. Resident indicated being okay. Dietary staff member was right behind resident and guided the resident back inside the skilled unit. Review of NA Employee E3's signed statement form dated 6/25/25, indicated staff member was informed of the incident by another staff member, and did not witness the event; however, did observe resident going down [NAME] Hall in the wheelchair around 7:15 a.m. that morning. Review of Licensed Practical Nurse (LPN) Employee E8's signed statement form dated 6/25/25, indicated Resident R1's last known location was at the nurses station. Review of NA Employee E4's signed statement form dated 6/25/25, indicated staff member wasn't aware Resident R1 was off the unit and didn't hear the alarm go off when resident left the unit. Review of NA Employee E5's signed statement form dated 6/25/25, indicated staff member observed Resident R1 sitting near the elevator around 8:30 a.m. and the alarm was not sounding when resident was sitting there. Review of Registered Nurse (RN) Employee E6's signed statement form dated 6/25/25, indicated staff member observed Resident R1 hanging out near the medication cart with RN for some time this morning, and at some point, resident was noted to be headed away toward the [NAME] Hall. RN continued to pass medications and was not certain to the exact time, but it didn't seem like a long time until RN observed Resident R1 being brought to the unit by another staff member indicating they were bringing resident back. Resident got out the doors, even with the wander guard on. Staff member indicated they were unaware how Resident R1 got out and asked staff to try to keep an eye on resident and keep resident down on this end. Review of RN Employee E7's signed statement form dated 6/25/25, indicated staff member was the RN on the Founder's hall at the time of the event. RN was in the middle of medication pass between 7:30 a.m. and 9:30 a.m. RN did not see Resident R1 until resident returned to the unit through the Founder's Hall entrance. Interview on 8/12/25, at 12:35 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision for one resident resulting in elopement and were notified that Immediate Jeopardy was called due to the elopement of Resident R1 on 6/25/25, and facility staff were provided an Immediate Jeopardy template, and a corrective action plan was requested. On 8/12/25, at 3:55 p.m. an immediate action plan was received and accepted which included the following interventions:Immediate action:-Resident was assessed post elopement when returned to the unit on 6/25/25. No signs or symptoms of any adverse effects from time off the unit.-Resident's care plan was updated to reflect the elopement.-Physician and family notified.-Root cause of elopement - a staff member turned off the wander guard system for the elevator, triggered by another resident without confirming other 395549 Page 3 of 5 395549 08/13/2025 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wandering residents were not in the vicinity. A resident entered the elevator with a disabled alarm. System Correction:-All nursing staff were re-educated on knowing who is in your surroundings when disabling an alarming wander guard.-Wander guard system was reassessed on 6/25/25, by the Maintenance Director. Zone and reset times were adjusted to lower settings to allow for faster system resetting.-All residents will be reassessed by the nursing department for elopement risk, completed by 8/13/25. Plan of care will be updated as indicated. For residents who require updated plans of care, physician and families will be notified.-The policies surrounding elopement risk and wander guard use have been reviewed by the Nursing Home Administrator and Director of Nursing.-All staff will be re-educated on elopement risk and assessments, care plans, supervision of residents and precaution when resetting the wander guard alarm by the DON/designee by 8/13/25.-Facility will review the incident in an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting completed by 8/13/25. Monitoring:New admissions will be audited by the DON/designee weekly for four weeks, monthly for two months to ensure elopement assessments are completed and care plan updated as required. Findings of audits will be submitted through facility QAPI program. Verification of the facility's Corrective Action Plan revealed all elements of plan were met as follows:-Resident R1 was returned to the unit and assessed without injuries. Care plan was updated on 6/25/25, to include engage Resident in purposeful activity. Provide care in a calm and reassuring manner. Provide clear, simple instructions. Provide reorientation to surroundings and environment. The pt is at risk of disorientation while on skilled due to being an independent living resident of campus prior to her admission. The pt is reoriented to skilled as her living arrangements and updated on her situation. -Physician and family were notified on 6/25/25.-Root cause identified as a staff member turned off the wander guard system for the elevator triggered by another resident without confirming other wandering residents were not in the vicinity. Resident R1 entered the elevator when it was disabled of an alarm.-74 of 79 Staff in all departments were re-educated on knowing who is in your surroundings when disabling an alarming wander guard and increasing supervision of exit seeking residents, how to complete the elopement risk assessment, and steps taken once a resident is identified as an elopement risk.-31 in person interviews confirmed training, 21 read receipt via education email, 74 employee signatures received education and ten telephonic calls attempted receiving four confirmations of training and understanding.-Zone and reset times were adjusted to lower settings to allow for faster system resetting on 6/25/25, by the maintenance director.-32 of 32 residents were assessed for elopement risk.- Six of 32 residents at risk for elopement care plans were reviewed or updated. Zero new elopement risk residents were identified. Zero physicians and families required notification of newly identified elopement risk residents.-The policies around elopement risk and wander guard use have been reviewed by NHA and DON on 8/13/25.-The incident was reviewed during an ad hoc QAPI meeting completed on 8/13/25.-The audit tool for future monitoring of new admissions was reviewed and appropriate. The Nursing Home Administrator was made aware the Immediate Jeopardy was lifted on 8/13/25, at 2:35 p.m. Interview on 8/13/25, at 2:35 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision for one resident resulting in elopement. This failure created an immediate jeopardy situation for one of seven residents (Resident R1) identified as having a high risk for wandering. 28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a) Responsibility of Licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.28 Pa. Code 211.10(d) Resident care policies. 395549 Page 4 of 5 395549 08/13/2025 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

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 a review of job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.Findings include:The job description for the NHA specified the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times.The job description for the Director of Nursing specified the primary purpose of the job position was to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility to ensure that the highest degree of quality of care is maintained at all times. Based on the findings in this report that identified that the facility failed to effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation. The facility failed to provide fundamental principal that apply to treatment and care provided to facility residents. The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and facility policies. 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa Code 201.18(b)(1)(e)(1) Management. Residents Affected - Few 395549 Page 5 of 5