Pennsylvania Department of Health
FOULKEWAYS AT GWYNEDD
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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FOULKEWAYS AT GWYNEDD - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a State Licensure Survey and Civil Rights Compliance Survey on November 7, 2025, it was determined that Foulkeways at Gwynedd was not in compliance with the following requirements of 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 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of facility policy, facility documents, resident clinical records, and staff interviews, it was determined that the facility failed to ensure adequate supervision and the proper functioning of elopement prevention systems for one of 15 residents reviewed. (Resident R15)
Findings:
Review of the facility policy titled "Elopement Prevention and Assessment " revised July 20, 2024 defines elopement as a situation in which a resident with impaired cognition, lack of safety awareness, or poor judgment successfully leaves the facility or a secured area. This policy requires an individualized care plan to reduce allotment risk, including interventions such as a wander alert bracelet, redirection, validation therapy, and one to one supervision as indicated.
Review of Resident R15's clinical record revealed that resident was admitted into the facility on July 20, 2025, with a diagnosis of Alzheimer's disease (progressive neurological disorder that affects memory thinking and behavior) and hearing loss. The resident was cognitively impaired, oriented to self only and exhibited confusion and expressed a desire to leave the facility.

Continued review of Resident R15's clinical record revealed the resident elopement risk assessment dated July 23, 2025, and reassessments on September 3, 2025, and September 30, 2025, identifying the resident as a high risk for elopement due to dementia, impaired decision making, independent ambulation, and express desire to "go home."

Review of Resident R15' s care plan dated July 23, 2025, revealed that resident has exhibited wandering behaviors related to Alzheimer 's disease with interventions to anticipate and meet needs, to attempt and determine cause of wandering, elopement bracelet and mark door room with name and familiar items. Updated to this care plan on September 5, 2025, revealed that if the resident expresses to go to the mailroom staff was to walk with him. An additional intervention was added to the resident ' s care plan on September 30, 2025, to offer walks as needed. Continued review of resident 's care plan that the resident was at risk of falls. Resident R15 had an ADL (activities of daily living) deficit and ambulated with one assist (indicating resident needs assistance to walk).
Review of Resident R15 ' s October 2025 behavior intervention monthly flow record revealed that from October 5, 2025 through 31, 2025 there were multiple days and shifts with no documentation related to monitoring and assessing the resident for wandering.
Review of the documentation reported to the State Survey Agency dated September 2, 2025, revealed that Resident R15 exited the building when the Wander Guard (bracelet place on the resident that activities a door locking mechanism) failed to send an alert to staff mobile devices. The resident was found by the Spiritual Care Coordinator in the community center parking lot, walking toward his prior residence.
Investigation findings indicated that the staff on duty did not receive alarm notifications, post-incident testing showed the system functioned properly when retested, and the resident was able to exit when another resident opened the door before the alarm triggered.

Review of the documentation reported to the State Survey Agency dated September 29, 2025, revealed that Resident R15 again exited the facility unsupervised at approximately 10:15 a.m. Security footage confirmed the exit door magnetic lock malfunctioned, allowing the door to open despite the elopement alarm sounding. The resident was found outside on the paved walkway near the cafAlthough the alarm vendor had inspected the system on September 5, 2025, and reported "no abnormalities, " the locking mechanism was later found to be defective.
Interview with Licensed nurse, Employee E7 on November 6, 2025, at 9:20 a.m., revealed that instructions to check the residents' Wanderguard bracelet were included in the medication administration system but was unaware of where the bracelet was located. She stated, "It ' s on his wrist" though the bracelet was not observed in place. When asked how bracelets were tested, she replied that "when residents walk through the doors, the alarm will go off and all nurses will be notified."
Interview with Licensed Nurse, Employee E10 on November 7, 2025, at 8:36 AM, she reported that
"nurses and supervisors usually check [the bracelets] weekly. " When asked how checks were performed, she admitted she had not checked them herself and "assumed if a resident walks past the sensor, it will go off."
Interview with Licensed nurse, Employee E3 on November 7, 2025, at 9:10 a.m., revealed that during an elopement, alerts are sent to nurses ' phones showing which door was accessed. She stated that bracelets are checked daily as part of the medication pass and that the red blinking light indicates proper function.
Interview with Employee E2, Director of Nursing (DON) on November 8, 2025, at 10:10 a.m. revealed that nurses only monitor if a resident behavior is exhibited. When asked about unrecorded days on the October 2025 behavior flow record, the DON stated she would " look into it " but provided no explanation prior to survey exit.
Interview with Employee E1 Nursing Home Administrator (NHA on November 8, 2025, at 10:10 a.m. confirmed "there was a break in the system, " but stated it " has been fixed" and that "ongoing testing and monitoring" of all resident elopement systems is occurring.

28 Pa. Code 201.14 (a) Responsibility of Licensee

28 Pa. Code 210.18 (1) Management

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 01/02/2026

The facility will ensure adequate supervision and the proper functioning of the elopement prevention system. The DON or designee will educate all nursing staff on the proper function checks for the elopement tags. The placement and function checks will be completed every shift to ensure the elopement tag is working properly. The DON or designee will audit the TARS of residents who have been identified as elopement risk weekly for four weeks then monthly for 3 months, and random checks quarterly.
The facility will audit all doors with the elopement mechanism every week on an ongoing basis. When completing the door audits, the facility will ensure the doors lock, and the notifications are transmitted through the system properly. The NHA or designee will review the audits weekly for accuracy for one month and then monthly on an ongoing basis. The result of the audit will be reviewed at the Quality Assurance Performance Improvement meeting.

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

§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 observation, review of facility policy and procedure, interviews with staff, and clinical record reviews, it was determined the facility failed to ensure Resident R34 received proper supervision after attending an activity on another nursing floor. This failure resulted in actual harm to Resident R34 who exited the nursing facility, sustained a fall, and diagnosed with a fracture of the left clavicle for one of 15 residents reviewed. (Resident R34)
Findings include:
Review of the facility policy titled "comprehensive resident assessment and care plan" dated November 26, 2019 revealed the interdisciplinary care team was responsible for completing and implementing a care plan for each resident within 48 hours of admission. The facility policy further indicated assessments were to be completed of each resident by the interdisciplinary care team members (nurses, physician, activities staff, dietitian, social worker and rehabilitation staff). The facility policy indicated the interdisciplinary care team was responsible for implementing the person center care plan for each resident on a daily basis.
Review of Resident R34's clinical record revealed the resident was admitted to the facility on August 23, 2025, with the diagnosis of Subdural Hematoma (collection of blood outside of the brain) and Subarachnoid (bleeding in the space below one of the thin layers that cover and protect the brain) Hematoma after a fall.
Review of Resident R34's care plan dated August 23, 2025, indicated "I have an ADL (Activities of Daily Living) and/or functional status deficit related to weakness." Interventions included for the resident to receive assistance of one staff member for transfers, ambulation, and toileting.
Review of Resident R34's physician notes dated August 25, 2025 revealed the resident was assessed with mental status of disorientation.
Review of Resident R34's August 2025 physician orders revealed a physician order for Occupational and Physical Therapy.
Review of Occupational and Physical Therapy evaluation dated August 26, 2025, revealed the resident was identified as dependent with ambulation. The assessment also indicated Resident R34 was at high risk of falls. The therapy department directed the care plan of Resident R34 for one-person physical assist and use of the roller walker for safe ambulation to prevent falls.
Review of the Occupational Therapist evaluation of Resident R34 dated September 16, 2025, indicated the resident required partial/moderate assistance of one staff member for all mobility activities.
Review of Resident R34's nursing notes revealed, September 23, 2025, Licensed nurse, Employee E3 assisted Resident R34 ambulating to the first-floor activities room. Licensed nurse, Employee E3 documented the activities staff were informed to notify the nursing staff when Resident R34 was ready to return to the nursing unit.
Review of facility incident documentation dated September 23, 2025 revealed at 2:36 p.m. "Nurse escorted Resident to the scheduled 2pm activity in activities room and informed activities staff to notify Nurse when the resident is ready to leave so that [he/she] can be escorted back to [his/her] room. At 2:33pm Nurses was contacted by Activities staff and informed that the Resident left the room unaccompanied. Nurse (Licensed nurse, Employee E3) proceeded to search for resident and located [her/him] outside, lying on the grass at 2:36." License nurse, Employee E3 and Administrative Assistant, Employee E12 assisted Resident R34 to [her/his] feet and walked back into the building. The nurse assessed Resident R34 revealed an abrasion of the left knee. Resident R34 was complaining to the nurse that (she/he) had mid-back pain. The nurse documented that she provided the resident with pain medication. The nurse placed an alarming device on the resident's left ankle.
Continued review of the incident documentation revealed the physician ordered an x-ray of Resident R34's left shoulder which was positive for fracture.
Review of radiology report dated September 24, 2025, revealed the resident was diagnosed with a distal left clavicle (collar bone between the sternum and shoulder blade) fracture.
Review of the documented witness statement for the incident on September 23, 2025 revealed Licensed nurse, Employee E3 found Resident R34 outside the main entrance of the skilled nursing building, positioned supine in the grass.
Interview with Licensed nurse, Employee E3 at 10:30 a.m., on November 7, 2025, confirmed that Resident R34 was fifty feet away from the entrance to the skilled nursing unit. Upon assessment the licensed nurse found that Resident R34 was complaining of mid-back pain and had a left knee abrasion. Licensed nurse, Employee E3 asked the resident at the time of the fall to describe how she fell and the resident was not able to answer the nurse.
Interview with the activities staff, Employee E5 at 11:00 a.m., on November 7, 2025, confirmed Resident R34 ambulated out of the activities room using a rolling walker without staff assistance on September 23, 2025.
Review of Resident R34's orthopedic physician's report dated October 1, 2025 revealed Resident R34 had a left clavicle fracture. The physician indicated Resident R34's family chose conservative treatment for the resident with immobilation, a sling, and pain medication.
The facility failed to ensure Resident R34 received proper supervision after attending an activity on another nursing floor of the facility. This failure resulted in actual harm to Resident R34 who exited the nursing facility, sustained a fall, and diagnosed with a fracture of the left clavicle.
28 PA. Code 211.10(a)(b)(c)(d) Resident care policies
28 PA. Code 211.12(d)(1)(2)(3)(5) Nursing services
28 PA. Code 204.14(a) Responsibility of licensee
28 PA. Code 201.18(b)(1)(3)(e)(1)(1)(3) Management

Plan of Correction - To be completed: 01/02/2026

The activity staff will be educated on alerting the nursing staff when a resident is ready to come back to the nursing floor so residents who need assistance can be assisted and have the proper supervision after attending an activity on another nursing floor. If a resident wants to leave the activity room, the activities staff will contact a staff member to assist the resident back to the nursing floor. NHA, DON or designee will complete random checks to ensure activity staff help transport and call for assistance when activities are occurring and to ensure residents who need supervision are supervised. This plan of correction will be reviewed at the Quality Assurance Performance Improvement meeting.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Observations:

Based on review of facility policy, review of clinical records, interview with residents and staff, it was determined that the facility failed to offer and educate all residents on the prevention of pneumococcal disease and failed to offer the pneumococcal vaccine to residents for five of five residents reviewed for immunizations. (Residents R12, R13, R14, R15, and R16)
Findings include:
Review of the facility policy titled " Pneumococcal Vaccination of Residents " revealed that according to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination is recommended for adults 65 years of age and older and for younger adults with certain underlying health conditions. The policy states that:
-All residents aged 65 and older, or younger residents with qualifying medical conditions, should receive the pneumococcal vaccine.
-Revaccination may be necessary as indicated.
-Vaccines are to be administered by appropriately qualified personnel following facility procedures, with a physician's order required.
-Immunization status is to be determined by reviewing available medical records.
-Residents with undocumented or unknown pneumococcal vaccination status are to be offered the vaccine after informed consent and education regarding risks and benefits.
-Vaccine administration is to be documented in the clinical record.
A review of the CDC ' s Pneumococcal Vaccine Recommendations for Adults (updated October 26, 2024) indicated that adults aged 65 years and older have the option to receive PCV20 or PCV21, or to forego additional pneumococcal vaccines if previously immunized. Pneumococcal disease is caused by bacteria that commonly reside in the nose and throat and can lead to illnesses ranging from mild ear infections to serious infections such as pneumonia. The disease is spread through direct contact with respiratory secretions. Adults aged 65 years and older are at increased risk for pneumococcal disease.
Review of Residents R12, R13, R14, R15, and R16 reviewed revealed no documentation of pneumococcal vaccination or evidence that the vaccine had been offered or discussed with the residents.
Interview with Employee E11, Infection Preventionist, on November 7, 2025 at 10:00 am confirmed that pneumococcal vaccines have not yet been offered to any residents in the facility. Employee E11 stated she began her position in infection prevention and control in March 2025 and has not yet addressed the pneumococcal vaccination program for residents.

28 Pa. Code 211.2 (d)(3)(5) Medical Director

28 Pa. Code 211.12(d)(3)(5) Nursing Services

Plan of Correction - To be completed: 01/02/2026

The facility will offer and educate all residents on the prevention of pneumococcal disease. The IP or designee will review the immunization records of the five residents and all current residents for their pneumococcal vaccine. All residents who are not up to date will be educated on the prevention of pneumococcal disease and will be offered the vaccine. The IP or designee will review the immunization records of all new admissions and will educate and offer the pneumococcal vaccine to the residents who are not up to date. The DON or designee will complete an audit all current residents to ensure their pneumococcal vaccine status is up to date and all residents have been educated and offered the pneumococcal vaccine. The DON or designee will complete audits on all new admissions pneumococcal vaccine status including education and offering of the pneumococcal vaccine weekly x 4 weeks then monthly x 3 months, and random checks quarterly. Results will be reported to QAPI.

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