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F0835
F

Failure to Prevent and Identify Resident Elopement Risk

Harmony, Pennsylvania Survey Completed on 05-09-2025

Penalty

Fine: $42,530
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of a resident and the failure to properly identify another resident's risk for elopement. The job descriptions for both the NHA and DON require them to ensure compliance with federal, state, and local regulations and to maintain the highest degree of quality care for residents. Despite these responsibilities, the facility did not prevent a resident from eloping and did not adequately assess another resident's risk for elopement. These failures were confirmed during staff interviews, where both the NHA and DON acknowledged their inability to manage the facility effectively in these instances. The deficiencies created an Immediate Jeopardy situation for two residents, as the facility did not follow established guidelines and regulations to protect residents from harm related to elopement.

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