**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1), when facility had knowledge of Resident 1's preference to sit outside, had a history of falls, and required assistance with personal care. Facility staff did not provide supervision while Resident 1 was outside and were unaware Resident 1 left the facility's premises on 10/1/24 unsupervised. These failures resulted in Resident wandering unsafely in the streets around the facility and suffering an avoidable auto versus pedestrian accident. Resident 1 sustained injuries which included injury to the right femur shaft fracture (break in the thigh bone between the hip and knee), closed inferior pubic rami fractures (break in one of the bones in part of the pelvis), traumatic pneumothorax (air leaks from the lung and fills the space between the lung and chest wall), closed fracture of multiple ribs, right phalanx fracture (a break in one or more of the small bones in right finger), L1 vertebra compression fracture (injury that occurs when too much pressure is applied to the spine), closed fracture of transverse process of lumbar vertebra (injury caused by high amount of force on a bone in the lower back). As a result, Resident 1 was hospitalized in the trauma unit with injuries that caused pain, suffering and mobility deficits. During an interview on 10/3/24 at 10:00 a.m. with the administrator (ADM), the ADM stated that on 10/1/24 at approximately 8:00 a.m., he was alerted by a facility staff member that a man, resembling Resident 1, was being transported by emergency medical services (EMS) two to three blocks away from the facility. The ADM stated when he arrived at the incident site, law enforcement was at the scene. The facility staff checked the facility to account for all residents and concluded Resident 1 was missing. The ADM stated Resident 1 was his own representative and made decisions for himself and had no prior history of leaving the facility premises. The ADM stated Resident 1 was considered an independent resident and did not require constant monitoring while being outside for daily exercises around the facility perimeter or sitting in the courtyard. During a review of Resident 1's admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Hypertensive heart and kidney disease (condition that damages the heart and kidneys), peripheral vascular disease (circulation disorder), end stage renal disease (terminal illness when kidneys can no longer function), Chronic Kidney Disease (CKD- kidneys are damaged and don't filter blood properly), Alcohol abuse, hyperlipidemia, Anxiety disorder (feeling of worry, unease and nervous), Polyneuropathy (nerve damage), muscle weakness, dysphagia (difficulty swallowing), need for assistance in personal care, other abnormalities of gait and mobility, cognitive communication deficit, heart failure, cardiomegaly (heart is larger than normal), constipation, pain, acquired absence of the left leg, history of falling, edema (swelling caused by too much fluid). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 8/29/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 13 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a review of Resident 1's ADL care plan, dated 3/21/23, the care plan indicated, . The resident has an activities of daily living (ADL) self-care performance and resident is at risk for declining in ADL self-performance . interventions . toilet use . the resident requires supervision/touching assistance by 1 staff for toileting. Transfer the resident requires supervision/touching assistance (requiring person to observe transfers) by 1 staff for to move between surfaces . During a review of Resident 1's Falls care plan, dated 3/22/23, the care plan indicated, . The resident at risk for falls related to gait (manner of walking)/balance problems . interventions anticipate and meet the residents' needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . During an interview on 10/3/24 at 10:15 a.m. with the Receptionist, the receptionist stated the process for a leave of absence (LOA) included signing out the resident at the nurse's station on the floor they were located. The receptionist stated it was her responsibility to ask any resident who was exiting the facility through the lobby doors, where they were going. The receptionist stated it was also her responsibility to identify elopement (when a patient incapable of protecting themselves departs unsupervised and undetected) risk residents when they are near the exit doors in the lobby. The receptionist stated on the morning of 10/1/24, she was told Resident 1 had left the facility premises before her start of shift at 8:00 a.m. The receptionist stated there was no facility staff positioned to monitor the exit doors in the lobby before she arrived. The receptionist stated she was not responsible for monitoring residents when they were outside but was responsible for alerting staff when residents exited the facility. The receptionist stated it was important to monitor all residents and know where they are at all times to ensure their safety. During an interview on 10/3/24 at 10:35 a.m. with Resident 2, Resident 2 stated he had been in the facility for two and half years. Resident 2 stated he understood the facility process to sign himself out but would exit the facility and return without any issues of signing out. Resident 2 stated he knew Resident 1 and would often see him sitting outside. Resident 2 stated there were no employees seen outside when he would sit outside with Resident 1. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis for polyneuropathy, type 2 diabetes mellitus (body doesn't regulate insulin and causes high blood sugar), osteoarthritis (cartilage and bone break down over time), seizures (uncontrolled activities in the brain that cause changes in behavior, movement and awareness), major depressive disorder (mental illness that causes low mood and loss of interest in activity), alcohol abuse, lack of coordination, abnormalities of gait and mobility, muscle weakness, heart failure (heart is unable to pump enough blood and oxygen in the body), opioid (medication used to reduce moderate to severe pain) abuse. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 14 out of 15 which indicated Resident 2 was cognitively intact. During a record review of Resident 1's Physician Order dated 10/18/23, the Physician Order indicated, May go out on pass. During a record review of Resident 1's Physician Order dated 10/1/24, the Physician Order indicated, May go out on pass independently. During a concurrent interview and record review on 10/3/24 at 10:46 a.m. with LVN 1, Resident 1's Physician Order dated 10/18/23 and Leave of Absence Binder dated 2024 were reviewed. The Physician Order indicated, May go out on pass. LVN 1 stated the order indicated Resident 1 could have left the faciity on his own as long as he signed out in the LOA binder. The LOA binder indicated Resident 1 had not signed himself out of the facility on 10/1/24. LVN 1 stated she was the nurse in charge of Resident 1's care on 10/1/24. LVN 1 stated she knocked on Resident 1's bathroom door at approximately 7:15 a.m. as he was not in bed, and Resident 1 had verbally responded from the bathroom indicating he was there. LVN 1 stated she left the room and returned at approximately 7:45 a.m. to check Resident 1's blood pressure, but noted he was not in his room. LVN 1 stated she knew Resident 1 had a daily routine to wheel himself to the elevator of the third floor, wheel himself outside and sit in the facility front courtyard or wheel himself around the facility perimeter for exercise. LVN 1 stated she was not alarmed by Resident 1's absence from his room as the certified nursing assistant (CNA) caring for Resident 1 would have gone downstairs to alert Resident 1 that breakfast was being served or Resident 1 would have gone up to the third floor on his own by breakfast time served at around 7:55 a.m. to 8:00 a.m. LVN 1 stated usually Resident 1 would have been monitored by the facility receptionist while he was outside because there was no staff assigned to monitor residents while they are outside or surrounding the perimeter of the facility. LVN 1 stated, generally there were a lot of residents who sat outside at a time, and it would have been beneficial to assign a staff member to monitor them. LVN 1 stated it was important to monitor Resident 1 and all other residents for their safety. During an interview on 10/3/24 at 11:16 a.m. with CNA 1, CNA 1 stated the facility process was for all residents to sign out in the LOA binder prior to leaving the facility premises. CNA 1 stated when Resident 1 left the facility to sit in the courtyard or exercise around the facility premises, Resident 1 was not required to sign out because he was still on the facility premises. CNA 1 stated when Resident 1 was outside there was no one specifically assigned to monitor. CNA 1 stated when Resident 1 was sitting outside it was the CNA assigned to Resident 1's responsibility to monitor resident every hour. CNA 1 stated it would have been beneficial to have staff assigned to monitor residents who were sitting outside for their safety. During an interview on 10/3/24 at 11:50 a.m. with the social services director (SSD), the SSD stated it was all staff responsibility to monitor residents while they were sitting outside of the facility. The SSD stated when the residents were sitting outside the facility, staff kind of kept an eye on them. The SSD stated it was all facility staff's responsibility to monitor the residents who were outside. The SSD stated she was not aware of who would monitor residents in the early morning before the receptionist arrived at 8:00 am. During a concurrent interview and record review on 10/3/24 at 1:15 p.m. with the assistant director of nurses (ADON), Resident 1's Physician Order dated 10/1/24 and Physician Order dated 10/18/23 were reviewed. The physician order dated 10/1/24 indicated, . May go out on pass independently. The physician order dated 10/18/23 indicated, May go out on pass. The ADON stated Resident 1 was permitted to leave the facility independently without supervision but had not followed the LOA process in place when he was outside for his exercises. The ADON stated Resident 1 was independent and his own representative and did not require constant monitoring when he was outside. The ADON stated the two physician orders were the same and Resident 1 could have signed himself independently. The ADON stated the reason for the change in the orders specifically on 10/1/24 was because the facility was working on changing the orders not because they meant different things. During an interview on 10/3/24 at 1:24 p.m. with the administrator (ADM), the ADM stated Resident 1 was non-compliant with the facility policies. The ADM stated that during his investigation, the LOA binder located at the nurse's station on the third floor was reviewed. The ADM stated it was determined, Resident 1 had not signed himself out of the facility on 10/1/24. The ADM stated independent residents including Resident 1, were not monitored as they would go outside complete their daily routines and go back into the facility. The ADM stated that prior to the receptionist arrival, residents who were sitting outside were monitored by staff that were in and out of the facility, but no one was specifically assigned to monitor the residents. During a phone interview on 10/3/24 at 2:47 p.m. with CNA 2, CNA 2 stated she was assigned to Resident 1 on 10/1/24 the day of incident. CNA 2 stated that on the day of the incident she had arrived late to her shift at around 7:40 a.m. and did not receive report as night shift CNA had ended her shift prior to CNA 2's arrival. CNA 2 stated she went to Resident 1's room and noted Resident 1 was not in his room. CNA 2 stated she was not alarmed with Resident 1's absence as Resident 1 was assumed to be downstairs in the courtyard or facility premises as per his routine. CNA 2 stated she was assisting other residents on the third floor when she was notified that something had happened to Resident 1. CNA 1 stated the facility process was for all residents leaving the facility premises to sign out at the nurse's station and alert staff. CNA 2 stated Resident 1 required set up help with dressing & toileting and required 1 person supervision assistance for transfers. CNA 2 stated when Resident 1 was outside it was assumed all staff was monitoring all residents and stated she would monitor Resident 1 every 30 minutes to an hour. CNA 2 stated it was important to monitor all residents when they were outside for safety and to know where they were at all times. During a review of electronic mail (Email) correspondence from the facility ADM titled Out on Pass Clarification dated 10/3/24, the email was regarding Resident 1's Physician Order dated 10/18/23, the Physician Order indicated, May go out on pass. The email was also regarding Resident 1's Physician Order dated 10/1/24, the Physician Order indicated, May go out on pass independently. The email indicated .I talked to director of nursing (DON) about the difference between out on pass and out on pass independently. The difference between the two is that both residents are able to go out on pass but one will require assistance to go out, while the Independent is able to go without the need of assistance . Review of the email from the ADM indicated Resident 1 required assistance when leaving the facility. During a concurrent observation and interview on 10/4/24 at 9:50 a.m. with Resident 1 at the acute care hospital room, Resident 1 was observed lying in bed eating breakfast, Resident 1 was observed smiling and talking. Resident 1 was observed with abrasion (rub or wearing off of the skin) to the right side of face, bilateral (both) bruising to upper extremities and bandage wrapped around his right thigh extending below the knee. Resident 1 stated he did not recall what had occurred during the accident and could not recall where he was located at the time of the interview. Resident 1 stated he recalled being at the facility for a few days not years. Resident 1 stated he recalled riding his bike and then suddenly being transported by EMS. Resident 1 was not able to state the year, location or situation but could recall his name. Resident 1 stated he had lost his legs in the acute hospital when they were cut by a laser. Resident 1 repeatedly asked if it was ok for him to stay in the acute hospital because he could not walk. Resident 1 appeared confused. During a record review of emergency medical services (EMS) report, dated 10/1/24, the EMS report stated, . EMS arrived on scene patient laying supine (lying on back) in middle of road, Glasgow Coma Scale (GCS- 13 a clinical scale used to measure a person's level of consciousness after a brain injury. Score levels 3-8 are sever traumatic brain injury [TBI], 9-12 moderate TBI, and 13-25 mild TBI) patient was involved in a vehicle versus pedestrian accident where he was struck by a vehicle, traveling approximately 25 miles per hour per driver of vehicle while crossing the road in his wheelchair. It's estimated that the patient was approximately six feet from his wheelchair patient presents with altered mental status, combativeness. Physical exam revealed a hematoma (blood collection under the skin) to the right side of forehead, abrasions to upper back, possible deformity to the right femur, and appeared to have vomited at least once . During a review of Resident 1's Intensive Care Unit Progress Note dated 10/4/24, the progress note indicated, . patient who presented to the emergency department after pedestrian versus auto. Patient was in middle of street in wheelchair when he got hit by car going 25 miles per hour. Was ejected off of wheelchair, positive head trauma, loss of consciousness. GCS 13 . injuries right femur shaft fracture, closed inferior pubic rami fractures, traumatic pneumothorax, closed fracture of multiple ribs, right phalanx fracture), L1 vertebra compression fracture, closed fracture of transverse process of lumbar vertebra Procedures right femur open reduction and internal fixation (ORIF- surgical procedure that realigns and stabilizes the bone), right foot nail avulsion (removal of a toenail or fingernail due to injury) and nailbed repair . During a review of the facility's policy and procedure (P&P) titled, Out on Pass, dated 1/11/2016, the P&P indicated, . it is the policy of the facility to meet residents' physical and psychosocial needs when going out on pass. The facility will make reasonable efforts to ensure the resident safety and uphold resident rights . the attending physician will write/give an order for a resident to go out on pass on the physician order sheet. The attending physician should include whether the resident should be accompanied by a responsible person while out on pass or may leave the facility unaccompanied . in the absence of a specific order that indicates the resident may go out on pass unaccompanied, the resident must be accompanied by a responsible person. If the resident is receiving skilled service, the resident may go out on pass for a therapeutic purpose (preventing, diagnosing, monitoring, treating for a disease or injury) only . During a review of the facility's policy and procedure titled, Elopement Risk Reduction Approaches, dated 11/2012, the P&P indicated, . ensure that residents are able to move about freely, are monitored and remain safe . During a review of the facility's P&P titled, Resident Safety, dated 4/15/21, the P&P indicated, . to provide a safe and hazard free environment . the interdisciplinary team (IDT- team that consists of various staff that are involved with resident's care) will establish a person-centered observation or monitoring systems for the resident to address the identified risk factors identified. To observe the safety and wellbeing of the residents, a resident check will be made at least every two hours around the clock by nursing service personnel. The person-centered care plan may require more frequent safety checks .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure an environment free of accident hazards for one of three sampled residents (Resident 1), when on 7/12/24 Resident 1 removed the window screw, opened the window, and jumped from the facility's second story. Certified Nursing Assistant (CNA) 1 noted a change in Resident 1's demeanor and heard Resident 1 stating she is done and did not report to licensed staff. This failure resulted in Resident 1 sustaining a fracture (broken bone) of multiple ribs on the right side, laceration (bleeding or tearing) of the liver, fracture of the right femur (bone of the thigh articulating at the hip and the knee), and right pneumothorax (when air builds up in the space between the chest wall and lung and puts pressure on the lung causing it to collapse). Findings: During an interview on 7/12/24 at 8:45 a.m., with the administrator (ADM). The ADM stated Resident 1 had opened the window in her room located on the second floor and jumped off to the ground on the first floor. The ADM stated Resident 1 was found by facility staff outside by the sidewalk. The ADM stated it appeared Resident 1 removed the protective screw from the window and pushed the window screen out to exit the window. The ADM stated he thought Resident 1 could have used a kitchen butter knife or utensil to unscrew the window screw as the window screws should have been tightly screwed in place. The ADM stated Resident 1 was transferred to the acute hospital for further evaluation. During a review of Resident 1's admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis, systemic lupus erythematosus (long lasting disease that affects many parts of the body), hereditary and idiopathic neuropathy (nerve problem that causes pain, numbness, tingling, swelling or muscle weakness), spinal stenosis (causes pressure on the spinal cord or nerves), Major Depressive Disorder (mental health disorder causes persistent low or depressed mood), Borderline Personality Disorder (mental illness that causes loss of emotional control), anorexia (eating disorder that causes low body weight and intense fear of gaining weight), muscle weakness, post-traumatic stress disorder(disorder that develops when a person has experienced a scary, shocking, terrifying, or dangerous event), adult failure to thrive, homelessness, and patient noncompliance with other medical treatment and regimen due to unspecified reason. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/6/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 14 out of 15 (0 -7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 -12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an observation on 7/12/24 at 9:16 a.m., in Resident 1's room, the window was observed to have a broken window screen and a removed screw was located near the window seal. The window was observed through the glass and the window screen was noted to be out of place, bent and pushed outward. A dining table was observed against the wall under the window border. There was a window screw positioned by the window seal next to the screw hole on the window base. When the window was pulled open to the left, it was noted to open all the way through. The screen was observed outward, bent and broken. Outside the window the rooftop to the first-floor dining room was located extended out about 10 feet outward allowing a walking distance. No footprints or drag marks noted were observed on the first-floor rooftop. During a concurrent observation and interview on 7/12/24 at 9:22 a.m., with Resident 2 in Resident 2's room, Resident 2 was observed lying in bed dressed, cleaned and groomed. Resident 2 stated she was moved to Resident 1's room the day prior and was recently residing in another room of the facility. Resident 2 stated she was asleep when Resident 1 left the facility and had not heard anything from Resident 1. Resident 2 stated that the prior day CNA 1 was heard communicating with Resident 1 when she heard Resident 1 say I'm done, it's over, this is the end. Resident 2 stated CNA 1 continued speaking with Resident 1 and then CNA 1 left for the night. Resident 2 stated the last thing she remembered was Resident 1 asking to close her privacy curtain and then going into the restroom using her wheelchair. Resident 2 sated Resident 1 remained in the restroom for a long period of time and could not recall when she exited the restroom. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis major depressive disorder, anxiety disorder (mental health disorder characterized by feeling of worry), insomnia and repeated falls. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 7 out of 15, which indicated Resident 2 was had severe cognitive impairment. During an interview on 7/12/24 at 12:23 p.m., with CNA 1, CNA 1 stated he worked with Resident 1 often and was familiar with her care. CNA 1 stated he was assigned to care for Resident 1 the day prior and recalled talking with Resident 1 regarding her financial issues and how she needed to pay her cellphone bill and remove her car from the acute hospital parking lot. CNA 1 stated before dinner Resident 2 was moved into Resident 1's room. CNA 1 stated that following the roommate's arrival, Resident 1's demeanor changed appearing different and acting different. CNA 1 stated she began saying she is done. CNA 1 stated he asked Resident 1 what she meant and Resident 1 stated I am done with everything. CNA 1 stated he spoke with Resident 1 religiously and stated, only god decides when we leave this earth. CNA 1 stated he left Resident 1 after calming her and returned to Resident 1's room prior to the end of the shift. CNA 1 stated prior to the end of shift he asked Resident 1 if she needed anything, in which Resident 1 responded I don't need anything I am done with everything and CNA 1 proceeded to leave. CNA 1 stated during the last encounter with Resident 1 she was observed looking at her phone and writing on paper. CNA 1 stated he had not reported the change in Resident 1's behavior to the charge nurse and did not report it to the oncoming staff because he believed she was getting ready to leave the facility to retrieve her car as mentioned in a prior conversation. CNA 1 stated the screws on the windows were checked by the maintenance department and should have been screwed in place tightly and not removed easily. During an interview on 7/12/24 at 2:21 p.m., with RN 1, RN 1 stated she was in charge of Resident 1 on 7/11/24. RN 1 stated Resident 1's demeanor was not changed, and she had not noticed a difference with her care. RN 1 stated she was made aware that Resident 1 jumped from the second story through her room window. RN 1 stated the facility process was for CNA 1 to have notified the charge nurse to ensure Resident 1 was properly assessed and monitored for suicidal ideations. RN 1 stated all windows should have had a screw to lock them in place and keep them from opening more than 3-4 inches. RN 1 stated it was the maintenance department's responsibility to check all windows and screws were in place and secured. During an interview on 7/12/24 at 2:30 p.m., with the Nurse supervisor (NS), the NS stated the expectation was for CNAs to report any change in residents to the charge nurse immediately. NS stated it was important for CNA 1 to have notified the charge nurse for proper assessment, monitoring and proper care for Resident 1. During an interview on 7/12/24 at 2:43 p.m., with RN 2, RN 2 stated the facility expectation was for all CNAs to report any change in residents which included resident behavior. RN 2 stated the charge nurse should have been notified right away to assess the resident and ensure safety. RN 2 stated the facility windows should have a screw in place to securely keep the windows from opening all the way. RN 2 stated the maintenance department checked the windows to ensure they were secured. During an interview on 7/12/24 at 2:51 pm with CNA 2, CNA 2 stated it was the facility expectation for CNAs to report all changes including behavioral changes to the charge nurse immediately. CNA 2 stated if the resident was experiencing suicidal ideations, it was not appropriate for the CNA who was present to leave the resident. CNA 2 stated the facility maintenance department was in charge of ensuring windows were properly secured in all resident rooms. During a concurrent interview and record review on 7/12/24 at 3:01 p.m., with the Maintenance supervisor (MS), the facility's Maintenance Daily log dated 7/8/24-7/12/24 was reviewed. The log indicated the MS was checking doors, locks & alarms, and conducting test operations for doors and locks but there was no documentation of the MS checking the windows or window screws. The MS stated the log did not indicate windows locks or security, but it was implied that they were checked daily during rounds when the facility doors were checked. The MS stated the window screws were approved by the fire marshal as appropriate for the facility. The MS stated the window screws were checked every morning during daily maintenance rounds but could not provide documentation. The MS stated all the window screws were secured in the facility and Resident 1 was able to open the window because she was actively having suicidal ideations. The MS stated that if a resident was experiencing suicidal ideations, they would find a way. During a telephone interview on 7/12/24 at 3:24 p.m., with Licensed Vocational Nurse (LVN) 1, the LVN stated she was in the facility assigned to work on Resident 1's floor. LVN 1 stated that on 7/12/24 at around 1:16 am she received a call from the nurse's station on the first floor alerting her that there was a person lying on the sidewalk outside. LVN 1 stated she proceeded to notify all staff including CNAs and nurses present to check all resident rooms on the floor to account for all residents. LVN 2 stated she went to the first floor and walked outside to find an ambulance and noted Resident 1 was lying on the sidewalk. LVN 1 stated Resident 1 was awake and talking stating that her chest was in pain. LVN 1 stated the emergency medical technicians (EMT) assessed Resident 1 and immediately transferred her onto the ambulance to the acute care hospital. LVN 1 stated she had not observed any belongings or items around Resident 1 or in the area where Resident 1 was lying. LVN 1 stated when Resident 1 was transferred she proceeded to go back to the second floor where Resident 1's room was located. LVN 1 stated she entered Resident 1's room and observed three piles of letters which indicated Resident 1 was experiencing suicidal ideations and attempted jump out of the second story. LVN 2 stated Resident 1's room window was closed but observed the window screen was broken and Resident 1's wheelchair was positioned by the room window. LVN 1 stated she spoke with the CNA 3 who was in charge of Resident 1. LVN 1 stated CNA 2 last observed Resident 1 on 7/12/24 at 12:40 am, according to CNA 3 Resident 1 was in the restroom. LVN 1 stated it was the facility expectation for any CNA or staff member present when any resident is expressing behavioral/emotional changes to notify the charge nurse immediately to ensure safety and proper assessment. During a telephone interview on 7/12/24 at 3:38 p.m. with CNA 3, CNA 3 stated she was assigned to Resident 1 on 7/12/24. CNA 3 stated Resident 1 had requested to use the wheelchair to go to the restroom during the night. CNA 3 stated that at approximately 11:45 pm, she observed Resident 1 still in the restroom when assisting Resident 2. CNA 3 stated she did not return to Resident 1's room until she was alerted by facility staff that a resident was found outside by the sidewalk and was identified as Resident 1. CNA 3 stated that when she entered Resident 1's room, she noted Resident 1's privacy curtains were closed, wheelchair was positioned by the window and when Resident 1's bed was observed there were letters indicating Resident 1 was experiencing suicidal ideations. CNA 3 stated she had received change of shift report from CNA 1 at the start of the shift. CNA 3 stated that CNA 1 reported that Resident 1 was upset because she did not want a roommate in the room but made no indication that Resident 1 was experiencing suicidal ideations. CNA 3 stated that if Resident 1 was expressing feelings of suicidal ideations, the charge nurse should have been alerted immediately. CNA 3 stated the facility process was for the CNA to alert the charge nurse, complete a stop and watch form (form that alerts facility staff that there was a change in resident during the shift) and remain with resident until safe. CNA 3 stated it was not an acceptable practice for CNA 1 to walk away from Resident 1 if Resident 1 was expressing her feelings because there was a potential for harm. During a review of the facility's document titled, Stop and Watch Early Warning Tool, dated 2014, the document indicated, . if you have identified a change while caring for or observing a resident/patient, please circle the change and notify the nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. Seems different than usual, talks or communicates less, overall needs more help . agitated or nervous more than usual, tired weak, confused or drowsy . During an observation on 7/15/24 at 3:24 p.m., Resident 1 was observed in the general acute care hospital (GACH). Resident 1 was observed lying in bed, asleep and difficult to arouse opening eyes when spoken to and then would close eyes to sleep. Resident 1 was observed to have bruising to the right arm, right hand, left hand and swelling. Resident 1's right hip and right lower extremity were wrapped with bandage. During an interview on 7/15/24 at 3:35 p.m., with the GACH RN 4, RN 4 stated Resident 1 had been experiencing drowsiness and drops in oxygen saturations. RN 4 stated that during Resident 1's stay, Resident 1 had been banging on the bed frame and throwing objects. RN 4 stated that Resident 1 had made comments stating she wished her head would have hit the floor but denied she was experiencing suicidal ideations (define). RN 4 stated Resident 1 had sustained a right femur fracture, open reduction and internal fixation (ORIF- surgery used to stabilize and heal a broken bone) of the right hip and stated Resident 1's whole right side of body was injured. RN 1 stated Resident had a diagnosis of depression with history of suicide attempts. During an interview on 7/15/24 at 3:47 p.m., with Resident 1, Resident 1 stated she was admitted into the emergency room after she had jumped out of her window on the second floor of the facility where she resided. Resident 1 stated she had attempted to land on her head to kill herself. Resident 1 stated the suicidal ideations were a result of staff treatment in the facility where she resided but could not state the treatment she was referring to. Resident 1 stated she had thoughts of suicide previously during a stay in the GACH. Resident 1 stated that on 7/12/24 she had requested the wheelchair from the charge nurse to use the restroom, then the charge nurse proceeded to exit her room. Resident 1 stated she had observed one screw on the room window that was easily removable, removed the screw to open the window, pushed the window screen, and stood up from the wheelchair and jumped off the window. During a record review of Resident 1's, Emergency Department (ED) trauma Timeline Report, dated 7/12/24, the report indicated, . Per emergency medical services (EMS) report, patient was trying to commit suicide and jumped from the second-floor balcony of her room . patient was found by a bystander who called EMS . patient endorses pain to both hips, abdomen and right lower extremity . mechanism of injury . fall from second story building. She states she wanted to commit suicide . she crawled out of her window and fell around 30 feet with loss of consciousness. Complains of abdominal and hip pain. clinical impression, closed fracture of multiple ribs of right side, laceration of liver, closed displaced subtrochanteric fracture of right femur, closed displaced intertrochanteric (the bumpy parts at the top of the thigh bone) fracture of right femur and right pneumothorax . During a record review of Resident 1's document from GACH titled, Post-Op Check, dated 7/12/2024, the document indicated, the patient stated, .I jumped out of the nursing facility that I came from because they were abusing me. They were not giving me my medicine. I begged them to give it to me, and they would not listen. So, I climbed on top of the building and jumped to try and kill myself . During a record review of document titled, History of Present Illness, dated 7/12/2024, the record indicated the patient reported, .She was able to crawl to the window and then fell out of the window in an attempt to kill herself . On arrival to the ED, she complained of pain in her right left, lower back and abdomen During an interview on 7/15/24 at 4:15 p.m., with the facility's administrator (ADM), the ADM stated the maintenance department had verified all windows had tightly placed screws in every window of the facility. The ADM stated the facility windows should only open 2-3 inches and screws should not have been easily removable. During an observation on 7/15/24 at 4:45 p.m., the facility window screws for the second and third floor windows were observed. There were fourteen room with windows observed to have loose window screws. During an interview on 7/15/24 at 6:21 p.m., with the ADM, the ADM stated the facility's department managers and supervisors should have checked the window screws during the daily room rounds. The ADM stated it was the facility's expectation for staff to notify the maintenance department if any loose screws were observed. During a telephone interview on 7/16/24 at 11:15 a.m., with the director of staff development (DSD), the DSD stated she had provided the facility CNAs with a verbal in service regarding the use of the stop and watch and how it should have been utilized. The DSD stated she was unable to provide documentation to confirm in-service was completed. The DSD stated the facility expectation with a change of condition that included suicidal ideations was for the staff to take every statement seriously even if they are thinking in the back of their minds that the resident would not say or do something that involved suicide. The DSD stated the facility process was for the CNA who identified the change, to ensure resident safety and notify the nurse immediately for a resident assessment. The DSD stated it was not appropriate for CNA 1 to leave Resident 1 after Resident 1 was expressing thoughts of feeling like she was done. During a review of the facility's job description titled Director of Plant Maintenance, undated. The job description indicated, . principal responsibilities . ensures a safe, comfortable, sanitary environment for residents, staff, and visitors in accordance with federal, state, and corporate requirements. Performs preventative maintenance procedures . maintains equipment necessary to meet center needs . maintains written records and documents of services performed . During a record review of the facility's policy and procedure (P&P) titled Maintenance Service, dated 01/01/2012, the P&P indicated, . purpose to protect the health and safety of residents, visitors, and facility staff. Policy the maintenance department maintains all areas of the building, grounds, and equipment. Procedure, the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . maintaining the building in compliance with current federal, state and local laws, regulations, and guidelines . maintaining the building in good repair and free from hazards, providing routinely scheduled maintenance service to all areas . the director of maintenance is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds and equipment are maintained in a safe and operable manner . the director of maintenance is responsible for maintaining the following records/reports: inspection of building . maintenance staff follow established safety regulations to ensure the safety and well-being of all concerned .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one of five sampled residents (Resident 1) when Resident 1 fell out of bed during provision of care by Certified Nurse Assistant (CNA) without assistance from another staff member in accordance with the Comprehensive Assessment and needs of the resident. This failure resulted in Resident 1 having an avoidable fall, sustaining injuries of a Fractured Occipital Condyle (break at the base where skull meets spine), laceration (cut) to her nose, bruising, swelling to her left eye and experienced pain. Findings: During a review of Resident 1's admission Record (AR), dated 11/29/23, the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included, Dementia (loss of cognitive functioning, thinking remembering, and reasoning), Muscle Weakness, Difficulty in Walking and Other Specified Disorders of Bone Density and Structure (disease of the bone). During a review of Resident 1's Minimum Data Set (MDS) assessment (assessment of functional and cognitive abilities), dated 11/09/23, the MDS Section C indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) of 4 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15-cognitively intact). During a review of Resident 1's MDS assessment, dated 11/09/23, the MDS Section GG (Functional Abilities and Goals) indicated, Resident 1 was dependent (requiring assistance from staff) to roll from left and right, for a Tub/shower Transfer, completion of Oral Hygiene, upper and lower body dressing, personal hygiene and eating. During a concurrent observation and interview on 11/29/23 at 9:45 a.m. in Resident 1's room, Resident 1 was lying in bed awake. Resident 1 had an [brand name] Collar (device used to prevent movement of head and neck) around her neck. Resident 1 stated she was having difficulty speaking due to the presence of the device. Resident 1 stated she was having pain. During an interview on 11/29/23 at 11:20 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1 required extensive assistance by two staff members at all times. CNA 2 stated prior to Resident 1's fall on 11/6/23 Resident 1 was able to feed herself and brush her teeth. During a concurrent interview and record review on 11/29/23 at 12:10 p.m. with the Assistant Director of Nursing (ADON), Resident 1's Care Plan (CP) dated 6/22/23 was reviewed. The CP indicated, .provide assistance and care to resident with two staff members . The ADON stated CNA 1 was changing Resident 1's brief on 11/6/23 when Resident 1 was rolled out of bed and onto the floor. The ADON stated Resident 1 sustained injuries from the fall. The ADON stated he spoke with CNA 1 after the fall and CNA 1 was aware Resident 1 required the assistance of two staff members to assist when care was being provided. During a record review on 11/29/23 of untitled undated document, signed by CNA 1, document indicated, at 5:44 a.m., .when doing my last round, I knocked on resident door and asked to come into complete my last round, as I was changing resident I pulled the draw (half) sheet toward me so I can turn resident on side to change her brief, but she continued to roll and fell off bed . During an observation on 11/29/2023 at 12:50 p.m. outside of Resident 1's room with the ADON. In the doorway of the room, there was a picture of two hand shaking. The ADON stated the meaning of this picture was to alert staff that resident was two-person care. ADON stated there should be two persons providing care for Resident 1. ADON stated the picture of two hands shaking was outside of Resident 1's room since the care plan was implemented on 6/22/2023. During a concurrent observation and interview on 11/29/23 at 12:55 p.m. with CNA 2, outside of Resident 1's room, CNA 2 stated there was a picture of a handshake by Resident 1's name outside the doorway of her room. CNA 2 stated, the picture of the handshake had been there for a long time. CNA 2 stated the picture indicated Resident 1 required two persons to assist with Resident 1's care in order to meet any of her needs. During an interview on 11/29/23 at 1:00 p.m. with CNA 4, CNA 4 stated she was aware Resident 1 required the assistance of two staff members when providing care. CNA 4 stated the picture of the handshake was there for staff to provide two-person care at all times. CNA 4 stated when staff provided care without following the two-person assistance, it placed Resident 1 at risk for falls and injuries. During an interview on 11/29/23 at 1:10 p.m. with CNA 3, CNA 3 stated Resident 1 was unable to feed herself or brush her teeth due to the supportive device around her neck. CNA 3 stated Resident1's care and needs had changed because of the injuries from the fall. During an interview on 11/29/23 at 1:30 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated Resident 1 required the assistance of two staff when care was provided. LVN 2 stated Resident 1 was at risk for falls, injuries, or death when care was not provided according to the care plan interventions in place. LVN 2 stated prior to the fall, Resident 1 was able to feed herself, and was currently unable to feed herself because of the injuries. LVN 2 stated Resident 1 fell off her bed and sustained injuries that were life threatening. During an interview on 11/29/23 at 1:45 p.m. with the Director of Nursing (DON), the DON stated Resident 1 needed assistance and care for brief changes, showers, repositioning. The DON stated, CNA 1 did not follow protocol for a two person assist when care was provided. DON stated, the outcome resulted in Resident 1 falling out of bed and sustaining major injuries. DON stated, the fall and injuries could have been prevented. DON stated the intervention in the care plan were put in place to keep Resident 1 from harm. DON stated CNA 1 did not follow the care plan. During an interview on 11/29/23 at 2:10 p.m. with Administrator (ADM), ADM stated, Resident 1's fall was avoidable. The facility Administrator (ADM) stated CNA 1 did not follow the facility policy and care plan that were in place for Resident 1. The ADM stated during the investigation, CNA 1 admitted she provided care to Resident 1 by herself. The ADM stated CNA 1 admitted it was wrong to provide care for Resident 1 without assistance from a second staff member. During a telephone interview on 11/30/23 at 12:15 p.m. with LVN 3, LVN 3 stated he was assigned to Resident 1 during his shift on 11/06/23. LVN 3 stated he noticed the door to Resident 1's room was closed and thought staff were providing care to the resident. LVN 3 stated CNA 1 came out of Resident 1's room and alerted him that Resident 1 had fallen out of bed. LVN 3 stated when he immediately went into the room CNA 1 was alone in the room with Resident 1. LVN 3 stated he saw Resident 1 lying on the floor next to her bed face down. LVN 3 stated there was blood on the floor around Resided 1's face and she was moaning in pain. LVN 3 stated he then assisted Resident 1 back into bed and performed an assessment. LVN 3 stated Resident 1 was bleeding from her nose and there was a laceration across her nose and swelling to her left eye. LVN 3 stated Resident 1 was moaning in pain during the physical assessment. LVN 3 stated prior to the fall Resident 1 was able to feed herself and brush her teeth. LVN 3 stated Resident 1 was now unable to feed herself and needed feeding assistance. LVN 3 stated Resident 1 was now unable to brush her teeth and had limited movement of her head and neck. LVN 3 stated Resident 1's fall could have been prevented if CNA 1 had provided care assisted by with another staff person. During a review of Resident 1's general acute hospital record, titled, AFTER VISIT SUMMARY, dated 11/6/2023, the AFTER VISIT SUMMARY indicated Resident 1 received an x-ray of the cervical spine (neck region of your spinal column or backbone) due to a fall. The X-Ray indicated Resident 1 was found to have an occipital condyle fracture. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program undated, the P&P indicated, .To provide residents a safe environment that minimizes complications associated with fall .the facility will implement a Fall Management Program that supports providing an environment free from fall hazards .staff will develop a care plan according to the identified risk factors and root causes . During a review of the facility's P&P titled, Resident Safety, undated, the P&P indicated, .To provide a safe and hazard free environment .Residents will be evaluated to identify circumstances that pose a risk for the safety and wellbeing of the Resident .After a risk evaluation is completed .a Resident-centered care plan will be developed to mitigate safety risk factors . During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning undated, the P&P indicated, .It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain their highest physical, mental and psychosocial well-being .