Pennsylvania Department of Health
LAUREL RIDGE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LAUREL RIDGE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to an incident, completed on August 20,2025, it was determined that Laurel Ridge Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

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 review of facility policy, clinical record review, incident reports, facility documents, employee statements, and staff interview it was determined that the facility failed to ensure that a resident received adequate supervision which resulted in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). for one resident (Resident R1). This failure created an immediate jeopardy situation for one of 14 ambulatory residents. This was identified for past non-compliance for Resident R1.

Findings include:

Review of facility policy "Elopement of Patient" defined elopement as any situation in which a patient leaves the premises or a safe area without the facilitys knowledge and supervision, if necessary.

The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:
13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment

Review of the clinical record indicated Resident R1 was admitted to the facility on 7/18/25, with diagnoses that included sequelae of cerebral infarction (long-term effects and complications that occur after a stroke), high blood pressure, and difficulty walking.

Review of Resident R1's Minimum Data Set (MDS- a periodic review of resident needs) dated 7/25/25, indicated the diagnoses were current. Further review of the MDS Section C: Cognitive Patterns; Brief Interview for Mental Status; Question C0500 indicated a BIMS score of 15.

Review of facility submitted documentation indicated the following: On 8/2/25, the Director of Nursing (DON) was notified of patient missing. At 12:21 a.m. a facility-wide search revealed Resident R1 was not able to be located in or around the facility. DON directed staff in the facility to notify the police department. The police spotted his car on a traffic camera on 8/2/25, at 11:15 a.m. The police located Resident R1 on 8/2/25, at approximately 5:55 p.m.

Review of a physician order dated 7/18/25, indicated resident may leave the facility unaccompanied utilizing transportation arranged by the facility.

Review of an Elopement Evaluation assessment completed on 7/18/25, indicated Question 5 Does the resident wander? was answered No. Question 13 Risk for Wandering/Elopement identified indicated a Risk for Wandering/Elopement Identified was checked and initiated a risk for wandering/elopement care plan.

Review of the care plan dated 7/18/25, indicated the following:
Identify if there is a certain time of day wandering / elopement attempts occur
Ensure the safety of resident and others.
Evaluate elopement risk.
Evaluate medication schedule and possible pharmacological causes of wandering
Initiate visual supervision during acute episodes.
Provide emotional support regarding new onset wandering.

Review of Nurse Aide (NA) Employee E1 undated witness statement indicated after dinner when they picked up Resident R1s meal tray he was lying in bed. Around 6:30 p.m. on 8/1/25, they were at the nurses station and saw Resident R1 walked past them going towards the dining room. They did rounds around 9:15-9:30 p.m. and noticed Resident R1 was still not in bed so they asked NA Employee E5 where he was, and she stated Resident R1 was probably still in the dining room. It was normal behavior for Resident R1, so they continued with their rounds.

Review of NA Employee E2s undated witness statement indicated they saw Resident R1 at the front desk on 8/1/25, between 5:30-6:15 p.m. asking for the code to the front door, but they did not hear anyone respond.

Review of Licensed Practical Nurse (LPN) Employee E3s witness statement dated 8/2/25, indicated they last saw Resident R1 on 8/1/25, between 4-5:00 p.m. at the nurse's station.

Review of NA Employee E4s undated witness statement indicated they last saw Resident R1 walking down the hall on 8/1/25, between 4-4:30 p.m. with a family member.

Review of NA Employee E5s witness statement dated 8/2/25, indicated they saw Resident R1 with his mother and the Physician Assistant (PA) before dinner around 5:00 p.m. on 8/1/25. He rang for a blanket around 7:00 p.m. and was given a snack around 7:45-8:00 p.m. They did not see him after that but didnt think anything about it because Resident R1 goes all over the building and outside.

Review of LPN Employee E6 witness statement dated 8/2/25, indicated they arrived at work at 11:00 p.m. on 8/1/25. They were alerted by NA Employee E8 that a resident was missing at 12:15 a.m. on 8/2/25. They checked the inside and outside of the facility with other staff members.

Review of LPN Employee E7s witness statement dated 8/2/25, indicated when the NA did 12:00 a.m. rounds, Resident R1 was not found in his room or anywhere in the building. They provided Resident R1 with his medication around 7:00 p.m. on 8/1/25. All responsible parties notified of Resident R1 leaving the facility.

Review of NA Employee E8s witness statement dated 8/3/25, indicated when they arrived on shift 8/1/25 (11:00 p.m. 7:00 a.m.), they walked down the hall to check on the residents, Resident R1s bed was empty. They thought Resident R1 was in the bathroom. When they did another check down the hall Resident R1s bed was still empty, so they looked in the bathroom and Resident R1 was not in there.

Review of Registered Nurse (RN) Employee E9's undated witness statement indicated Resident R1 was observed walking up and down the hallway with his walker on 8/1/25, at approximately 8-9:00 p.m. Resident R1 stated he was trying to strengthen his legs. He did not have any belongings with him at the time. He was alert and displaying no unusual behaviors. He was observed joking and laughing with staff. RN Employee E9 did not witness Resident R1 leave the building.

A telephone interview was attempted with Resident R1 on 8/20/25, at 10:10 a.m., the call went straight to voicemail. A return call was not received.

During a telephone interview on 8/20/25, at 10:15 a.m. Resident R1s mother stated she did not know where Resident R1 went when he left the facility but thought he might have called someone to pick him up, she was unsure how he left the facility. She stated that Resident R1 had mental health issues and his roommate yelled mom repeatedly all night and there was another incident that occurred at the facility on 8/1/25, that might have stressed Resident R1 to much so he decided to leave.

Review of the clinical record did not include any mental health diagnoses.

During an interview on 8/20/25, at 10:53 a.m. the DON stated Resident R1 picked his car up from the hospital where he left it when admitted to the facility. The police finally caught Resident R1 on 8/2/25, at 6:15 p.m. approximately 22 hours after he left the facility. She stated that staff do not complete every two-hour checks on all residents, just the incontinent residents. She confirmed staff should have realized Resident R1 was not in the facility sooner than three or four hours.

During an interview on 8/20/25, at 1:15 p.m. NA Employee E1 stated they gave Resident R1 dinner between 4:45-5:00 p.m., between 5:15-6:00 p.m. they passed meal trays and assisted the residents who needed fed. They picked up Resident R1s tray between 5:45-6:00 p.m. and he was in his room. Around 6:00 p.m. they were at the nurses' station assisting another resident with a concern and Resident R1 walked past them. NA Employee E1 stated Resident R1 never really sat down, he was always walking. The last time they observed Resident R1 was around 8-8:30 pm when he was given a snack and then he walked to the dining room. When they did rounds, they got to Resident R1s room approximately 9:00 p.m. and noticed he was not there. They asked NA employee E5 where he was and was told he was probably still sitting in the dining room. They did not go check; they took their co-workers word he was still there. NA Employee E1 stated that when they did rounds, they usually by-passed Resident R1s room becauseNA Employee E1 stated Resident R1 was always walking in the hallways, he never sat down and was always on the move. The staff only do two-hour rounds on incontinent residents.

During an interview on 8/20/25, at 1:45 p.m. RN Employee E9 stated she saw Resident R1 walking in the hallway with his walker between 8-9:00 p.m. he spoke to another nurse about trying to strengthen his legs. He did not have anything except his phone with him. She stated that she checked the doors every time they alarmed, and it was not due to any residents exiting the building. It was family/visitors leaving the facility. She stated it was possible that Resident R1 had the door codes. RN Employee E9 stated she had to pull two NAs to a resident room due to an incident regarding a different resident. She conducted the whole house audit on 8/2/25, when Resident R1 was noted to be missing.

During an interview on 8/20/25, at 10:20 a.m. NHA (Nursing Home Administrator) and DON confirmed that the facility failed to ensure that a resident received adequate supervision which resulted in an elopement for one of three residents (Resident R1). They do not know how or where Resident R1 left the facility. They do not know an exact time Resident R1 left the facility but gave a time frame from 8-9:00 p.m. This was identified for past non-compliance for Resident R1 with a compliance date of 8/2/25.

On 8/20/25, at 2:03 p.m. the NHA and the DON were notified that Immediate Jeopardy was called due to inadequate supervision of a resident that resulted in an elopement on 8/1/25, and facility staff were provided an Immediate Jeopardy template at that time, and a corrective action plan was requested.

On 8/20/25, at 3:47 p.m. an immediate action plan was received and accepted which included the following interventions:

Immediate Action:

Upon identifying Resident R1 was not able to be located, the facility initiated a facility wide search. Midnight census sheet printed, whole house audit completed, all residents located except for Resident R1.
Facility Door codes were changed by the maintenance director on 8/2/25: all facility entry locations checked, and alarms and wander guard system determined to be functioning as desired without any concerns.
Resident council meeting held on 8/2/25, residents made aware that they must notify staff prior to leaving the facility for ANY reason and that a Release of Responsibility form must be signed for any LOA from the facility.
Elopement drill completed by the DON on 8/2/25.
An elopement audit was conducted on all residents in the facility. The residents that continued to be an elopement risk had care plans reviewed and updated accordingly to show new elopement assessments were completed.
Facility elopement assessment updated for current residents on 8/2/25. Care plan verified to reflect elopement status as applicable. Elopement binder verified to be accurate with current identified elopement risk residents and their photos and binder is present at the nurses station. Completed 8/2/25.

Systemic Changes:

Facility staff educated on Elopement policy as well as educated on the facility elopement assessment and staff educated on the facility door entry code and that no staff are permitted to release the code to any resident, family members, or visitors.

Monitoring:

The facility DON and/or designee will ensure that Elopement Drills will be completed on every shift for 72 hours, then three times a week for eight weeks, then weekly for four weeks, then monthly for three months. Nursing supervisor and/or designee will ensure that there is a head in bed/resident accountability check at every shift change. Initiated on 8/2/25, ongoing audits for three months.
The results of the audits will be reviewed at the monthly Quality Improvement Committee for evaluation, recommendations, and interventions as deemed appropriate.

Review of facility documentation included the following:
Education for all employees in all departments on elopement policy and procedure.
Facility Elopement Drills were being completed as stated above.

During interviews eight staff to include nurses, nurse aides, maintenance, activities, dietary, and business office confirmed they received education on elopements, they understood the education, and feel they know what to do in case of another elopement.

The facility has demonstrated compliance with the above since 8/2/25. Information was reviewed via Plan of Correction documentation. This IJ started on 8/1/25 and completion was demonstrated by 8/2/25.

During an interview on 8/20/25, at 3:47 p.m. NHA and DON and review of the facility's immediate actions, education and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance on 8/2/25, ensuring residents are provided adequate supervision to ensure their safety.

Plan of Correction - To be completed: 08/28/2025

Past noncompliance: no plan of correction required.

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