**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that a provider (physician or designee) was notified in a timely manner of a resident who left the facility against medical advice (AMA). In addition, the facility failed to ensure that a resident was capable of safely making the decision to independently discharge from the facility without interventions or services for one of six sampled residents (Resident 1). This failure resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Discharging a Resident without a Physician's Approval, last reviewed March 2025, revealed that if a resident or representative requested a discharge earlier than outlined in the plan of care and without approval from the physician or provider (against medical advice), the resident's physician or provider was to be notified promptly. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included problems related to living alone, altered mental status, history of cerebral vascular accident (a stroke, a medical condition involving the interruption of blood flow to a part of the brain resulting in brain damage), muscle weakness, cognitive communication deficit (difficulty with communication from impaired cognitive function), metabolic encephalopathy (brain dysfunction from metabolic disturbances), and below the knee amputation. Review of the care plan revealed that the resident had a performance deficit with activities of daily living, limited physical mobility, impaired cognitive function, and short-term memory loss, and his discharge plan was uncertain. Review of Resident 1's history and physical, dated September 22, 2025, revealed that the resident's physician documented that the resident had hospital induced delirium, his decision-making capacity was to be re-evaluated before discharge, and that he seemed to lack the ability to understand potential problems after leaving the facility, which included not having a home and not being able to drive. On September 22, 2025, a nurse documented that the resident required assistance with opening and closing medication bottles, was not able to state what time medications were to be taken, was not able to state the proper doses of medications and was not able to dispense the proper number of medications. A social services note dated September 22, 2025, revealed that the discharge plan was uncertain, and indicated that the resident's family members did not wish to be involved in his care and he no longer had a home or a vehicle. A social worker's note dated September 25, 2025, indicated that the resident was in the facility lobby and expressed a desire to call a taxi to leave the facility and that Physician Assistant (PA) 1 assessed the resident and stated that he had capacity to make his own decisions and the discharge would be against medical advice (AMA). There was a lack of evidence to indicate that PA 1 performed a capacity evaluation at any point while Resident 1 was in the facility. In an interview on October 2, 2025, at 12:54 p.m., PA 1 stated that he did not perform a capacity evaluation on Resident 1 and that assessment was to be done by a resident's physician. PA 1 also confirmed that there was no evidence that the resident was re-evaluated to determine capacity to make his own decisions, he was not notified about Resident 1's AMA discharge until September 29, 2025, and notification should be at the time of the discharge. PA 1 confirmed that he did not perform an assessment to determine Resident 1's decision-making capacity, despite the social worker's note dated September 25, 2025, which indicated he had made that determination. On September 25, 2025, a nurse noted that the resident did not seem to have the insight regarding the level of care required for him at home, how he would perform aspects of care, or how he would get to any follow-up appointments. A nursing note dated September 25, 2025, revealed that Resident 1 required assistance from two staff members for transfers, continued to attempt to transfer himself independently, and was not compliant with using the safe level of assistance to transfer. On September 27, 2025, at 2:30 p.m., a nurse documented that the resident stated that he wanted to sign himself out of the facility and signed the paperwork to leave AMA. At 2:45 p.m., staff documented that the resident left the facility AMA with his belongings, no medications, no confirmed or safe destination, and had only a wheelchair for transportation. In an interview on October 2, 2025, at 11:25 a.m., Registered Nurse (RN) 1, stated that the resident signed his own AMA paperwork. RN 1 also stated that staff outside of the building had contacted the nursing supervisor's office to inform them that the resident had left the building in the wheelchair. There was no further instruction provided or intervention implemented at that time. RN 1 stated that approximately 10 minutes later, the police contacted the nursing supervisors' office to inquire if the facility was familiar with Resident 1. RN 1 was unaware of Resident 1's location at the time of that phone call. Review of facility documentation entitled, Discharge Against Medical Advice, revealed that the resident and nursing supervisors signed the form on September 27, 2025. There was no evidence that the resident's practitioner or any on call provider was notified of the AMA discharge in a timely manner. There was no evidence that a provider was made aware until September 29, 2025, two days after the resident had signed himself out of the facility. In an interview on October 2, 2024, at 1:37 p.m., Medical Doctor (MD) 1 confirmed that at the time of Resident 1's history and physical assessment on September 22, 2025, the resident's capacity to make decisions needed to be re-evaluated before his discharge from the facility, and that a re-evaluation was not completed. There was a lack of evidence to support that any practitioner was promptly notified of Resident 1's AMA discharge, that staff accurately documented on the re-evaluation of the resident's decision-making capacity, or that any interventions were attempted to ensure the safety of a resident with unconfirmed decision-making capacity who had left the building without any means of transportation, social support, medical supplies, or resources. On October 2, 2025, at 4:55 p.m., the Administrator was notified that the failure to notify a provider of a resident who left the facility AMA and failure to ensure that a resident was capable of safely making the decision to independently discharge from the facility without interventions or services constituted an Immediate Jeopardy situation at F628-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented the following corrective action plan: 1. The facility policy, Discharging a Resident Without a Physician's Approval, was updated on October 2, 2025, and compliance with the updated policy will be implemented. The updates included that when a resident desires to leave AMA, staff will reference the resident's capacity in the medical record for consideration with management of the discharge and any AMA discharge will now require an incident report that will prompt staff to contact the provider. Physicians will be notified of AMA discharges immediately. The incident reports are audited by the risk management nurse. Compliance with the policy will be audited through High Risk Event and Quality Assurance and Performance Improvement (QAPI) meetings. 2. Nursing staff onsite were re-educated on the updated policy, and notification to the Pennsylvania Department of Health and the local Area Agency on Aging at the time of an AMA discharge. The remainder of nursing staff will be educated by October 6, 2025. 3. A new physician's order set was implemented on October 2, 2025, to clearly communicate to the interdisciplinary team when a resident lacks capacity, has capacity, or if capacity is to be determined. Resident capacity will be documented with the order set. Nursing supervisors will audit new admissions for implementation of the order set. 4. The interdisciplinary team will be educated by October 6, 2025, on the new order set, and to document resident capacity based only on physician documentation. Compliance will be reviewed at QAPI meetings. The survey team validated that the Immediate Jeopardy was removed on October 2, 2025, at 9:58 p.m., through review of facility procedures and training, and interviews with staff following the facility's implementation of the corrective action plan for removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) for one of ten sampled residents at risk for elopement. (Resident 2) In addition, the facility failed to provide required education to staff related to elopement prevention on nursing unit Tower 3, affecting 29 residents assessed as at risk for elopement. This failure resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Elopements/Elopement Policy, last reviewed September 19, 2025, revealed that staff were to assure the safety and security of all residents. Review of the facility policy entitled, One to one (1:1), Behavioral Intervention, last reviewed September 19, 2025, revealed that staff would remain within arm's length or within visual sight of the resident at all times when receiving 1:1 intervention. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], and had diagnoses that included dementia, insomnia (difficulty falling or staying asleep), wandering, restlessness, and agitation. According to the Minimum Data Set assessment (a periodic evaluation of resident care needs), dated September 5, 2025, the resident had memory impairment and could walk without assistance. An elopement assessment dated [DATE], revealed Resident 2 was at risk for elopement. Review of Resident 2's care plan revealed he was at risk for elopement with interventions for 1:1 observation and a roam alert bracelet (an electronic device that prevents doors from opening and/or sounds an alarm). On September 17, 2025, the physician ordered for staff to provide 1:1 supervision due to the resident being an elopement risk. On September 2, 2025, social services documented that the resident spends his day wandering around the unit and that his family stated he had a history of elopement and eloped via the window from his previous facility. On September 9, 2025, the physician documented that he discussed his concerns with risk management regarding the resident's high risk for elopement and to consider 1:1 if his behaviors persisted. On September 12, 2025, at 1:49 p.m., a nurse documented that Resident 2 was actively exit seeking, attempting to get on the elevators, and that he was on every 15 minute checks. At 2:49 p.m., it was documented that the resident was able to get on the elevator. On September 13, 2025, staff documented that Resident 2 was continuously standing by the elevator. On September 14, 2025 at 4:15 p.m., the resident was again on the elevator and when staff removed him he punched a window multiple times. At 10:16 p.m., the resident expressed that he needed to leave. On September 15, 2025, the psychology consultant recommended 1:1 supervision instead of every 15 minute checks. On September 16, 2025, Resident 2 was again noted to be hovering around the elevator and needed to be removed from the elevator multiple times by staff. On September 17, 2025, the resident was found with the elevator/door codes written on a piece of paper in his sock. He was then placed on 1:1 observation. On September 19 2025, staff documented that the resident was pacing between stairwells and elevators with the assigned 1:1 staff member following. On September 20, 2025, at 11:21 p.m., the nursing supervisor (RN 4) observed from her office on a different floor that the resident's alert bracelet was alarming and contacted the unit to locate the resident. He could not be located on the unit or on the facility grounds. Resident 2 was located by police on September 21, 2025 at 6:52 a.m., at a convenience store approximately two miles from the facility, and was taken to the emergency room for evaluation. He was returned to the facility at 9:30 a.m. Review of facility documentation, dated September 21, 2025, revealed that the resident's assigned 1:1 staff member left the assignment at 8:00 p.m. on September 20, 2025, and was not replaced. The resident was left unsupervised and did not have 1:1 observation, per his physician's order and care plan, and eloped from nursing unit Tower 3 and the building unwitnessed. Further review of facility documentation revealed that Resident 2 was later observed on camera footage exiting through a stairwell door on Tower 3 after using the code to open the door. There was no documented evidence that the nurse aide (NA 1) and nurse (LPN 1) assigned to Resident 2 on Tower 3 on September 20, 2025, at the time of the elopement, had received the required training prior to the start of their shifts as indicated in the facility's Immediate Jeopardy action plan dated September 19, 2025. Review of additional facility documentation revealed that 29 residents on Tower 3 were assessed to have been at risk for elopement on September 20, 2025. There was no documented evidence that the facility implemented or evaluated the psychology consultant's recommendation for 1:1 supervision until September 17, 2025. There was no documented evidence that the door codes where changed on September 17, 2025, after the resident was found with the codes, or on September 20, 2025, when the resident used the code to exit the facility. In an interview on September 23, 2025, at 11:30 a.m., the Risk Management Nurse confirmed that the door codes were not changed until September 22, 2025. On September 23, 2025, at 11:43 a.m., the Administrator was notified that the failure to provide adequate interventions and supervision to prevent elopement constituted an Immediate Jeopardy situation at F689-K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented the following corrective action plan: 1. Resident 2's room was changed to a secure unit.2. The facility changed all the door and elevator codes on September 22, 2025.3. The facility updated the 1:1 policy to include that staff is never to walk away from the assigned resident until another staff member takes their place.4. The facility educated all staff regarding the new 1:1 policy and not sharing door codes beginning on September 21, 2025. The remainder of staff will be educated by September 24, 2025.5. The facility educated staff that a search should occur immediately if a door alarm is sounding beginning on September 21, 2025. The remainder of staff will be educated by September 24, 2025.6. The facility instructed staff not to utilize fire alarm doors for everyday use to decrease alarm fatigue.7. The facility will continue to assess residents' risk of elopement upon admission, quarterly, and with events. 8. The Nursing Home Administrator will update the pre-admission review of elopement risk by September 24, 2025, to ensure the facility can safely manage a resident at risk of elopement. 9. Monthly department head meetings will be held for the leadership team to discuss elopement events beginning September 25, 2025.10. Staff members observed to be giving out door and elevator codes to visitors or residents will receive disciplinary action. The survey team validated that the Immediate Jeopardy was removed on September 23, 2025, at 4:05 p.m., through review of the facility training, and review of facility procedures following the facility's implementation of the corrective action plan for removal of the Immediate Jeopardy. 483.25(d) Accidents.Previously cited 9/19/25 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 212.12(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) for one of seven sampled residents at risk for elopement. (Resident 1) This failure resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Elopements/Elopement Policy, last reviewed March 25, 2025, revealed that staff were to assure the safety and security of all residents and that facility staff were to list prevention strategies on residents' care plans. The policy further indicated that residents capable of removing their alert bracelets (an electronic device that prevents doors from opening and/or sounds an alarm) were to be issued a stronger tamper resistant band. If the resident was able to remove the stronger band and was independently ambulatory (walked without assistance), the resident would require a one to one (1:1) observation. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia, syncope and collapse (fainting), and cerebral infarction (stroke). According to the Minimum Data Set assessment (a periodic evaluation of resident care needs) dated August 27, 2025, the resident had memory impairment and could walk without assistance. Review of the elopement assessment dated [DATE], revealed the resident wandered and was at risk for elopement. On August 20, 2025, a nurse noted that an alert bracelet was applied to the resident's leg. On September 13, 2025, a nurse noted that he had self-removed his alert bracelet and the nurse questioned if the unlocked unit was appropriate for the resident. On September 17, 2025, at 2:20 p.m., a nurse noted that Resident 1 was observed on the first floor. The resident was returned to the second-floor unit where he resided, and a new alert bracelet was applied. On September 17, 2025, at 2:54 p.m., another nurse noted that Resident 1's alert bracelet could not be located, and another new one was applied. At 4:11 p.m., a nurse noted that the physician group ordered for Resident 1 to be on every 15 minute checks due to wandering and removing his alert bracelet. Review of the facility documentation dated September 17, 2025, revealed that Resident 1 could not be located on the unit at 4:30 p.m., and the facility began a search. When Resident 1 could not be located on the facility grounds, the police were contacted. The police observed the resident walking along a road one mile from the facility. He was returned to the facility by the police on September 17, 2025, at 8:10 p.m. There was no documented evidence that Resident 1 was provided a stronger alert bracelet band or placed on 1:1 observation after removing his alert bracelet on September 13 and 17, 2025, as per facility policy. There was no documented evidence that Resident 1 had care plan interventions developed to address his elopement risk, wandering behavior, and alert bracelet use. In an interview on September 19, 2025, at 11:55 a.m., the Director of Nursing confirmed that there was no documented evidence that Resident 1 was issued a stronger alert bracelet band per policy and that no care plan interventions were developed to address his elopement risk, wandering behavior, and alert bracelet. On September 19, 2025, at 1:28 p.m., the Administrator was notified that the failure to provide adequate supervision to prevent elopement constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented the following corrective action plan: 1. Resident 1's room was changed to a secure unit, and a new alert bracelet was placed on the resident. The resident's care plan was updated to include risk for elopement. Resident 1 was placed on 1:1 observation.2. The facility conducted an immediate audit of all residents with alert bracelets to ensure they were intact and with the appropriate band.3. The facility conducted an audit to ensure all residents with an alert bracelet had an appropriate care plan in place.4. The facility created a log to monitor each alert bracelet and band to ensure the correct band is in place, and that the policy regarding stronger bands is being followed.5. The receptionists will review the binder of at risk residents at the start of their shifts for changes and initial a log.6. The facility will update the template for 1:1 orders in the electronic health record on September 22, 2025.7. The facility educated all staff in the facility on the facility's procedure for alert bracelets, stronger bands, and resident care plans. All staff that were available on September 19, 2025, were immediately educated. Other staff will be re-educated prior to the start of their next shift. 8. Weekly audits of alert bracelets, bands, logs, and care plans will be completed and the results discussed at QAPI (Quality assurance, performance improvement) committee. 9. Signs are posted with instructions to not share door codes and to be aware of residents who may try to exit. The survey team validated that the Immediate Jeopardy was removed on September 19, 2025, at 7:00 p.m., through review of the facility training and review of facility procedures following the facility's implementation of the corrective action plan for removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 212.12(d)(1)(3)(5) Nursing services