Health inspection·December 2, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 documents, facility policy, clinical records, facility tour, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (leaving an area without permission) for one of six residents (Resident R1). Findings include: Review of facility policy Wandering and Elopements last reviewed 5/18/24, indicated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/5/24, indicated diagnoses of high blood pressure, dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), and psychotic disorder (a mental disorder characterized by a disconnection from reality). Review of clinical record revealed that on 5/13/24, Resident R1's care plan included a problem that Resident R1 was identified as an elopement risk/wanderer related to a history of attempts to leave facility unattended, and has impaired safety awareness. Review of clinical record revealed that on 9/23/24, a physician's order was written for Resident R1 to receive a Security Bracelet (a device applied to the resident that alerts staff when they leave a safe area) underneath the wheelchair seat. Review of the clinical record revealed a progress note dated 11/6/24, that Resident R1 attempted to leave facility twice, becoming very combative and hostile towards staff both times. Began swinging at and scratching this writer when I attempted to keep her from getting on the elevator, began swearing loudly, stated she has no problem hitting anyone and that she would punch me in the head. A nurse aide came and convinced her to go to her room to get a few things hoping it would calm her down for a while. Review of the clinical record revealed a progress note dated 11/24/24, that Resident R1 brought back to the unit at 8:30 p.m. by nurse aide after being found in the parking lot in her wheelchair. Resident R1 with a Wanderguard (security bracelet) attached to her wheelchair due to the resident repetitively in the past removing it from her wrist and ankle. Incident reported to nurse supervisor. Page 1 of 4 395790 395790 12/02/2024 Seneca Place 5360 Saltsburg Road Verona, PA 15147

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident in no distress. DON (Director of Nursing) notified of incident by nurse supervisor. DON wants resident to have a one to one (direct supervision) nurse aide assigned to her. Nurse aide assigned to watch resident as of 8:30 p.m. Medications given to resident and presently resting quietly in her wheelchair by the nurse aide near the nursing station. Will continue to monitor. Review of a facility document included a Camera Review of footage from the 11/24/24 elopement that stated the following: · Third Floor Nurse's Station 8:02 p.m. Resident R1 heads toward the elevator from the East Hall. · Third Floor Nurse's Station 8:05 p.m. visitors with name tags head towards the elevator. · Lobby 8:06 p.m. Resident R1 enters the lobby. · Lobby Elevator 8:08 p.m. Visitors exit elevator and head towards the front door. · Lobby 8:09 p.m. Visitors attempt to exit lobby but could not as doors are locked after 8:00 p.m. Resident R1 observed in wheelchair directly behind visitors. · Lobby 8:11 p.m. Visitor leaves lobby and returns with Dietary Supervisor Employee E1 who used her identification badge to open the door to let them out. Dietary Supervisor Employee E1 returned to office prior to visitor/resident exit. · Lobby 8:12 p.m. Visitors get in their car and pull away. · Lobby 8:13 p.m. Resident R1 crosses threshold and alarms activate. Door closes. Dining Services Servers (DSS) Employee E1 and E2 attempt to leave through front doors but are unable due to alarm activation. · Lobby 8:14 p.m. RN (Registered Nurse) Supervisor Employee E4 responds to lobby and attempts to reach Resident R1. 395790 Page 2 of 4 395790 12/02/2024 Seneca Place 5360 Saltsburg Road Verona, PA 15147

F 0689 · Level of Harm - Minimal harm or potential for actual harm Ambulance Entrance 8:14 p.m. DSS Employees E3, E4, and E5 exit. · Residents Affected - Few Ambulance Entrance 8:15 p.m. DSS Employee E5 renters the building. RN Supervisor Employee E3 exits the building. · Lobby 8:16 p.m. Employee E6 responds to alarm in lobby. · Lobby 8:16 p.m. Employee E6 exits lobby toward the Dietary/Laundry Departments. · Ambulance Entrance 8:20 p.m. Nurse Aide (NA) Employee E6 and RN Employee E7 exit. · Ambulance Entrance 8:22 p.m. RN Supervisor Employee E3, NA employee E6, and RN Employee E7 enter the building with Resident R1. Review of Dietary Supervisor Employee E1's written Witness Statement dated 11/25/24, at 1:50 p.m. indicated the following: I was in my office and the visitor came and said that she couldn't get out. I went to the door with her and saw the car outside, so I swiped my badge (which allows the door open). I thought they were together because they were in a group at the door. I heard the alarm going off, but they all left together. The visitors never said that Resident R1 wasn't with them. The visitors started to leave so I turned around and went back to my office. Review of DSS Employee E5's written Witness Statement dated 11/26/24, at 11:40 a.m. indicated the following: I saw Resident R1 near the door when I went to clock out and there were a few people around her, so I didn't think anything was strange. I clocked out and the door wasn't working when I went to leave through the Main Entrance, so I went to the Side Door with DSS Employees E3 and E8. DSS Employee E3 and I looked over and saw Resident R1 outside in a green shirt and a wheelchair. I got worried at the point because it was cold, and I didn't know why she would be outside by herself. I asked her why she was outside, and she said she was looking for her daughter. DSS Employee E3 stayed outside when I went back in to get somebody. I found a nurse in the lobby because the alarm was going off and she came back outside with me, and I went home. Review of NA Employee E9's written Witness Statement dated 11/26/24, at 3:15 p.m. indicated the following: Resident R1 was up and in a pretty good mood. I gave her a bag of chips around 7:30 p.m I didn't see her until they brought her back up. Review of NA Employee E10's written Witness Statement dated 11/26/24, at 3:35 p.m. indicated the following: I was on break when everything went down. I came back from break and the door was locked. 395790 Page 3 of 4 395790 12/02/2024 Seneca Place 5360 Saltsburg Road Verona, PA 15147

F 0689 They had just gotten her back upstairs. I ended up being one on one with her for the rest of the shift. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/2/24, 9:55 a.m. DON stated that Dietary Supervisor Employee E1 let the visitors out with her badge, and thought that Resident R1 was with them. Residents Affected - Few During an interview on 12/2/24, at 12:01 p.m. Maintenance Director (MD) Employee E11 was able to demonstrate how the Wanderguard system worked to prevent residents that were administered a Wanderguard from leaving the building. As MD Employee E11 approached the Front Entrance with a Wanderguard device, an alarm sounded when he was approximately six feet from the door which serves as a warning, and the doors locked. He continued walking towards the door and when he reached the doorway a louder alarm sounded which further alerts the staff that someone with a Wanderguard is attempting to leave the building. MD Employee E11 stated that the system is in proper working order per the demonstration, however when an identification badge is utilized to open the door, it overrides the system, and the doors can be opened. During an interview on 12/2/24 at 2:35 p.m. RN Employee E12 stated that all residents have a white wrist band to help identify them as a resident and the visitors wear name tags that are given to them when they sign in at the front desk. During an interview on 12/13/24, at 3:30 p.m. DON confirmed that the facility failed to identify Resident R1 as a resident of the facility when she was left out of the facility by staff, therefore failed to provide adequate supervision which resulted in an elopement for Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395790 Page 4 of 4