Pennsylvania Department of Health
AMBLER EXTENDED CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

AMBLER EXTENDED CARE CENTER
Inspection Results For:

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AMBLER EXTENDED CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated survey completed on August 20, 2026,it was determined that Ambler Extended Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:
Based on facility policy review, clinical record review, review of facility documentation, observation, and staff interviews, it was determined that the facility failed to provide necessary 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. The incident has been identified as past non-compliance.

Findings include:

Review of the facility policy entitled, "Elopement Unauthorized Absence Policy," dated July 2, 2025, revealed that staff were to protect residents from elopement.

Clinical record review revealed that Resident 1 was admitted to the facility on July 15, 2026, and had diagnoses that included vascular dementia. According to the Minimum Data Set assessment (a periodic evaluation of resident care needs), dated July 21, 2026, the resident had a BIMS (Brief Interview for Mental Status - a quick, structured test to assess a person's attention, orientation, and short-term memory) score of four (ranges from zero to 15, with zero to seven indicating severe problems with thinking and memory) and ambulated (walked) without assistance. According to the nurses' notes, the resident was able to walk the hallways independently (without assistance). On August 13, 2026, a nurse noted that Resident 1 left the building at 4:15 p.m. and was located a block away at 4:48 p.m.

In an interview on August 20, 2026, at 11:46 a.m. the Licensed Practical Nurse (LPN) 1 stated that Resident 1 frequently walked back and forth in the hallways all shift.

Review of facility documentation dated August 13, 2026, revealed that staff was alerted to Resident 1 leaving the facility by another resident. The facility was not aware of Resident 1's whereabouts or that she had left the facility unauthorized and unsupervised until the other resident notified facility staff.

In an interview on August 20, 2026, at 11:07 a.m. the Administrator stated that the receptionist had mistaken the resident for a visitor, unlocked the front door without verifying who Resident 1 was or asking her to sign the in/out visitor log, and allowed Resident 1 to exit through the facility's main entrance. The Administrator stated that the resident was located along Bethlehem Pike, a major roadway adjacent to the facility. The Administrator further stated that the receptionist should not have allowed any residents to exit the front door without staff accompanying them, and that the receptionist should have verified who she was allowing to exit the facility while utilizing the visitor sign in/out log.

On August 20, 2026, at 1:05 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 identified the jeopardy at the time of the incident, August 13, 2026, at 4:15 p.m., and implemented the following corrective action plan:

1. Resident 1 was assessed by a licensed nurse on August 13, 2026, and found to have no injuries.

2. A wander guard (electronic monitoring device that alarms/locks exit doors) was placed on Resident 1 on August 13, 2026.

3. All exit doors were checked and were locked and functioning correctly on August 13, 2026.

4. New orders were obtained for a psychology evaluation and frequent monitoring for Resident 1.

5. New elopement assessments were completed for Resident 1 and all other residents in the facility on August 13, 2026. Care plans were updated as needed to reflect the assessments. Elopement assessments will continue to be completed by licensed nurses according to the facility policy.

6. Seven days of nurse's notes were reviewed for facility residents to identify any wandering or exit-seeking behaviors on August 13, 2026.

7. All residents with wander guards were checked for function and placement on August 13, 2026. Wander guard placement and function will continue to be checked by nursing staff according to facility policy.

8. An elopement drill was conducted on August 13, 2026.

9. All staff were educated on the elopement policy on August 13, 2026.

10. Pictures of any at risk residents were placed at the front desk on August 13, 2026.

11. All receptionists were educated on the new picture identification process, maintaining visualization of the front door, and who to allow/verify entrance/exit to the facility on August 13, 2026, at 8:30 p.m.

12. The Director of Nursing would monitor the front desk procedure, including picture identification, weekly for two weeks.

13. All information will be reviewed at the facility's Quality Assurance and Performance Improvement meetings.

On August 20, 2026, a review was conducted to verify the complete implementation of the facility's corrective action plan. All staff interviewed confirmed that they received the training described in the facility action plan. All nursing staff were aware of the requirements for supervising residents who were at risk for elopement. All facility doors and safety devices (wander guards) were in place and were functioning properly. The receptionist was observed monitoring the exit doorway and was aware of the new and existing procedures. All sampled residents were being supervised by staff as needed. All training was completed by August 13, 2026, at 8:30 p.m.

The Immediate Jeopardy existed on August 13, 2026, from 4:15 p.m. until August 13, 2026, at 8:30 p.m.

Verification of all elements of the action plan was completed on August 20, 2026, at 2:30 p.m., and the Immediate Jeopardy was officially lifted, effective August 20, 2026. The Nursing Home Administrator and the Director of Nursing were informed that residents were no longer considered to be in 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 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 09/03/2026

Past noncompliance: no plan of correction required.

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