Health inspection·February 22, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, investigation documentation, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) to rule out neglect for one of two residents (Resident R5). Residents Affected - Few Findings include: Review of facility policy Elopement last reviewed 11/9/23, indicated staff shall investigate and report all cases of missing residents. When a departing individual returns to the facility, the Director of Nursing or Charge Nurse shall examine the resident for injuries, obtain vital signs, notify the attending physician, notify the resident's legal representative of the incident, and complete and file the report of the incident/accident, note length of time gone and outside temperature. Review of facility policy Abuse last reviewed 11/9/23, indicated neglect is defined as the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reports of abuse (mistreatment, neglect, or abuse) are promptly and thoroughly investigated. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/20/23, indicated diagnoses of dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), glaucoma (a group of eye conditions that can cause blindness), and unsteadiness on feet. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident 5's MDS assessment dated [DATE], Section C0500-BIMS screening indicated a score of 13 revealing that Resident R5 was alert and oriented to person, place and situation. Page 1 of 6 395882 395882 02/22/2024 Longwood at Oakmont 500 Route 909 Verona, PA 15147

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R5's Behavior Monitoring documentation indicated that Resident R5 displayed behaviors of agitation, restlessness, and pacing on 1/25/24, 1/26/24, 1/27/24, and 1/28/24. Review of a progress note dated 1/29/24, at 6:23 a.m. stated, Shortly before 6 am this writer was made aware by Dietary chef that resident made it outside of secondary entrance outside of sliding doors. Resident stated to this writer she was trying to go to church. She had pushed the inner sliding doors of track and made it outside of the sliding door entrance. Just prior to this resident was taken to bathroom and sitting in her recliner chair in her room. Resident was safely returned to her room. Physician and family to be made aware. Review of the clinical record failed to indicate a physical assessment and vital signs were obtained after Resident R5 was returned to her room. Review of an Incident Report failed to include at which time Resident R5 was last seen in the facility, who last saw her, and length of time gone. Review of incidents submitted to the State indicated that during the elopement Resident R5 was wearing a brief, socks, and a t-shirt. The outdoor temperature was 32 degrees Fahrenheit. During an interview on 2/22/24, at 11:54 a.m. the Director of Nursing (DON) stated, We didn't do much of an investigation because it was pretty cut and dry from the nurse's note. During an interview on 2/22/24, at 1:11 p.m. the DON confirmed that the facility did not obtain witness statements from the staff on duty at the time of Resident R5's elopement. The DON also confirmed the facility was unable to locate documentation to indicate that a physical assessment and vital signs were performed after Resident R5 was returned to her room. During an interview on 2/22/24, at 1:11 p.m. the DON confirmed that the facility failed to conduct a thorough investigation of an elopement to rule out neglect for one of two residents (Resident R5). 28 Pa Code: 201.18 (e)(1)(2) Management 28 Pa Code: 201.29 (a )(c)(d) Resident Rights 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services 395882 Page 2 of 6 395882 02/22/2024 Longwood at Oakmont 500 Route 909 Verona, PA 15147

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based review of facility policy, clinical records, facility documents and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans for four out of six sampled resident records (Resident R5, R8, R16, and R22). Findings include: The facility Comprehensive care plans policy dated 11/9/23, indicated that the facility's interdisciplinary team, in coordination with the resident, family or representative, develops and maintains a comprehensive care plan for each resident. Each resident's comprehensive person-centered care plan is designed to incorporate identified problems, reflect treatment goals, and aid in preventing and reducing declines in resident functional status. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/20/23, indicated diagnoses of dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), glaucoma (a group of eye conditions that can cause blindness), and unsteadiness on feet. Review of a progress note dated 1/29/24, at 6:23 a.m. stated, Shortly before 6 am this writer was made aware by Dietary chef that resident made it outside of secondary entrance outside of sliding doors. Resident stated to this writer she was trying to go to church. She had pushed the inner sliding doors of track and made it outside of the sliding door entrance. Just prior to this resident was taken to bathroom and sitting in her recliner chair in her room. Resident was safely returned to her room. Physician and family to be made aware. Review of a physician's order dated 1/29/24, indicated to apply a watch mate (a safety device used to protect residents at risk of wandering) and check function every shift. Review of Resident R5's care plan did not include goals and interventions related to wandering behaviors. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia, and muscle weakness. Review of a physician's order dated 6/5/23, indicated to apply a watchmate and check function every shift. Review of Resident R8's care plan did not include goals and interventions related to wandering behaviors. Review of Resident R16's admission record indicated she was admitted on [DATE], with diagnoses that included repeated falls, adult failure to thrive (a condition characterizing the impact of multiple 395882 Page 3 of 6 395882 02/22/2024 Longwood at Oakmont 500 Route 909 Verona, PA 15147

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medical conditions resulting in a downward spiral of poor nutrition, weight loss, inactivity, and decrease in functional ability), and spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness). Review of Resident R16's MDS assessment (Minimum Data Set assessment: MDS - a periodic assessment of resident care needs) dated 2/1/24, indicated that the diagnoses were current upon review. Section M-Skin conditions F-eschar (dry, dead tissue within a wound) indicated a 1, meaning one wound was present. Section M-Skin conditions G-Unstageable Deep tissue injury indicated a 1, meaning another wound was present. Review of Resident R16's clinical nurse note dated 11/1/23, indicated that staff notified by nurse aide for nurse to come to Resident R16 room due to a blackened areas to her right foot. Nurse noted a blackened area with a trace of concave appearance of measuring 1.0 cm x 1.2 cm x 0.0 cm and a area on the left inner foot measuring 1.0 cm x 1.0 cm x 0.0 cm. Charge Nurse was notified. Review of Resident R16's clinical record dated 2/20/24, indicated that she had wounds on her Left Medial Heel with measurements (2.5cm length x 2.2cm width x 0.1 cm), a Right Lateral Heel an Unstageable Pressure Injury with measurements (0.6cm length x 0.5cm width x 0.4 cm depth) and a Right Lateral Foot Deep Tissue Pressure Injury with measurements (0.6cm length x 0.5cm width and no measurable depth). Review of Resident R16's care plans dated 11/10/23 did not include any concerns with skin integrity, pressure areas, or skin break down. Review of the clinical record indicated Resident R22 was admitted to the facility on [DATE]. Review of Resident R22's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (too much sugar in the blood), and reduced mobility. Review of a progress note dated 10/21/23, indicated a watchmate was applied after Resident R22 was found on the elevator stating he was, going to find his guys at the farm to go hunting for deer. The progress note stated, Shortly after 1:00 p.m., stairwell alarm sounded and Resident R22 was observed trying to open the door and head down the stairs. Review of Resident R22's care plan did not include goals and interventions related to wandering behaviors. During an interview on 2/22/24, at 1:04 p.m. the Director of Nursing (DON) confirmed that the facility failed to develop and implement comprehensive care plans for Residents R5, R8, R16, and R22 as required. 28 Pa. Code: 211.11 (a)(c)(d) Resident care plan. 395882 Page 4 of 6 395882 02/22/2024 Longwood at Oakmont 500 Route 909 Verona, PA 15147

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, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of two residents (Resident R5). Findings include: Review of facility policy Elopement last reviewed 11/9/23, indicated staff shall investigate and report all cases of missing residents. When a departing individual returns to the facility, the Director of Nursing or Charge Nurse shall examine the resident for injuries, obtain vital signs, notify the attending physician, notify the resident's legal representative of the incident, and complete and file the report of the incident/accident, note length of time gone and outside temperature. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/20/23, indicated diagnoses of dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), glaucoma (a group of eye conditions that can cause blindness), and unsteadiness on feet. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident 5's MDS assessment dated [DATE], Section C0500-BIMS screening indicated a score of 13 revealing that Resident R5 was alert and oriented to person, place and situation. Review of Resident R5's Behavior Monitoring documentation indicated that Resident R5 displayed behaviors of agitation, restlessness, and pacing on 1/25/24, 1/26/24, 1/27/24, and 1/28/24. Review of a progress note dated 1/29/24, at 6:23 a.m. stated, Shortly before 6 am this writer was made aware by Dietary chef that resident made it outside of secondary entrance outside of sliding doors. Resident stated to this writer she was trying to go to church. She had pushed the inner sliding doors of track and made it outside of the sliding door entrance. Just prior to this resident was taken to bathroom and sitting in her recliner chair in her room. Resident was safely returned to her room. Physician and family to be made aware. Review of the clinical record failed to indicate a physical assessment and vital signs were obtained after Resident R5 was returned to her room. 395882 Page 5 of 6 395882 02/22/2024 Longwood at Oakmont 500 Route 909 Verona, PA 15147

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of incidents submitted to the State indicated that during the elopement Resident R5 was wearing a brief, socks, and a t-shirt. The outdoor temperature was 32 degrees Fahrenheit. During an interview on 2/22/24, at 11:54 a.m. the Director of Nursing (DON) stated, We didn't do much of an investigation because it was pretty cut and dry from the nurse's note. Residents Affected - Few During an interview on 2/22/24, at 1:11 p.m. the DON confirmed that the facility did not obtain witness statements from the staff on duty at the time of Resident R5's elopement. The DON also confirmed the facility was unable to locate documentation to indicate that a physical assessment and vital signs were performed after Resident R5 was returned to her room. During an interview on 2/22/24, at 1:11 p.m. the DON confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one of two residents (Resident R5). 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. 395882 Page 6 of 6