Inspection·June 25, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident [R1], experienced elopement from facility. RN (registered nurse) supervisor received call from neighbor stating a man was outside in a motorized wheelchair saying his name was (Resident R1's last name). Local law enforcement had been notified by neighbors and were on the scene with facility staff arrived to retrieve resident, RN x2 and one CNA (nurse aide). Resident returned to facility without injury. Alert and confused at baseline. Follow-up Action: Resident placed in supervised area for resident safety. Elopement risk observation completed. Electronic bracelet device applied. Elopement risk observation completed for all like residents. Audit of secure locks to exit doors. Audit of current resident with Wanderguard (security bracelet that alerts when an identified resident approaches a monitored door) devices for placement and function. Review in QAPI (Quality Assurance/Performance Improvement). Elopement Observation dated 5/30/24 documents that resident is not a risk for elopement. Documented BIMS of 4.0 on 5/23/24. PIDA (power-mobility indoor driving assessment, assesses indoor mobility of person who use power chairs and who live in institutions) was performed by occupational therapy on 6/12/24, related to resident use of power wheelchair, with a score of 85%, determining he could safely operate his powered wheelchair. Resident was discovered approximately one block from the facility. Weather was clear, with a temperature of around 83 degrees F (Fahrenheit). Resident was and is routinely dressed in a t-shirt, sweatpants, and tennis shoes. He was last seen by staff between 6:30 p.m. and 7:00 p.m., just prior to the elopement. Review of facility investigation information indicated that Resident R1 exited the building via the ambulance entrance hallway. This door is alarmed, and the alarm did sound. Staff member reset the door alarm looked outdoor and saw ambulance with crew members and assumed it was the crew who set the door off and did not see the resident. Per video footage, (Resident R1) went out the door, around the dumpsters, down the back-end parking lot to the street, resident has steady gate and was quick in pace while walking. The receptionist did not see the resident. On 6/22/24, the facility initiated a plan of correction that included: To identify like residents that have the potential to be affected: -The DON (Director of Nursing)/Designee updated elopement assessments on all residents. -A resident headcount was conducted, and all residents were accounted for. -Plans of care were updated as appropriate, logs verified to be updated and accurate, at each appropriate area period all residents. -All facility exit doors were audited to validate proper functioning, and all doors are functioning appropriately. -All facility windows were audited to ensure there is not an opening greater than six inches. To prevent this from happening again, -The DON/Designee will educate all staff on the elopement policy, reporting policy, and response time. -All facility exit doors were audited to validate proper functioning and all doors are functioning appropriate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395682 If continuation sheet Page 2 of 3 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 395682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Health & Rehab Center 900 Third Ave Beaver Falls, PA 15010 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)

F 0689 -All facility windows were audited to ensure there is not an opening greater than sex inches. Level of Harm - Minimal harm or potential for actual harm -Elopement drills were conducted on all three shifts and an ad hoc QAPI meeting was conducted on 6/21/24). -The medical director was contacted via phone. Residents Affected - Few To monitor and maintain ongoing compliance: -The DON/Designee will conduct elopement drills every, daily until each shift has two drills with no errors, every shift weekly for three weeks and every shift monthly for two months. -The social worker will be auditing the elopement books to ensure that the book contains all current residents required information for residents who have elopement risk scores greater than 4.0 daily for 2 weeks, weekly for 2 weeks, and monthly for two months. -The DON/Designee will conduct additional audits of residents with Wanderguards for placement and function weekly for two months. -The Director of Maintenance or Designee will audit function of doors weekly for two months. -The results of these audits will be forwarded to the facility QAPI committee for further review and recommendations. Review of Resident R1's clinical record on 6/25/24, revealed the elopement assessment and care plan were updated to include information on his elopement, risk for further elopement, and interventions. During five interviews on 6/25/24, staff confirmed they received education on elopement prevention and procedures if an elopement occurs. During an interview on 6/25/24, at approximately 11:00 a.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision to prevent elopement for one of five residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395682 If continuation sheet Page 3 of 3