Health inspection·April 9, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of policies, clinical records, and facility reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for one of four residents reviewed (Resident 1). This deficiency was cited as Past Non-Compliance. Findings include: The facility's policy regarding residents who wander, dated January 16, 2025, indicated that the residents in the facility will be provided with a safe environment in which to live. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 5, 2024, indicated that the resident was usually understood and could usually understand others, did not have any wandering behaviors, required supervision with ambulating, and had diagnosis that included Alzheimer's dementia. A care plan intervention for Resident 1, dated April 12, 2024, indicated that the resident was independent with a front-wheeled walker on the unit. A care plan for Resident 1, dated March 25, 2025, indicated that the resident was at risk for injury from falls and included an intervention, dated March 27, 2025, through April 2, 2025, that the resident was to have a door alarm in use. A wandering risk assessment for Resident 1, dated March 26, 2025, indicated that the resident was at moderate risk for wandering, that the resident's family requested a room change, and that the resident comes out of her new room and needs redirected as she is looking for the lobby and dining room on the other unit. She was found in the hall by the offices near the fax room and was easily redirected. A door alarm was to be placed on the door to alert staff if she leaves her room. A risk and environmental safety assessment for Resident 1, dated March 27, 2025, indicated that a new safety intervention was implemented that included a door alarm on the resident's room. An incident note for Resident 1, dated March 30, 2025, at 10:30 p.m. revealed that a staff member received a phone call reporting that Resident 1 was observed outside near the smoke shed. Nurse aides found the resident outside with her front-wheeled walker. After receiving the call, the registered nurse went back to check the resident's room and noted that the door alarm was off. Two licensed practical nurses brought the resident back to the nursing unit and Resident 1 was then provided a room on the Crossroads dementia unit for her safety, as she was a flight risk. A security bracelet was (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 3 Event ID: 396069 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 396069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbutus Park Manor 207 Ottawa Street Johnstown, PA 15904 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)