**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to notify one Resident's (#172) physician and legal guardian of a change in condition out of a total sample of 27 residents. Specifically, the facility failed to notify the physician of Resident #172's refusing medication, exit seeking behavior, an elopement from the facility and multiple other attempts of elopements from the facility, including through a second story window, resulting in Resident #172 from falling out of a second-floor window and requiring acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs. Findings include: Review of the facility policy titled, Notification of Changes, dated 2024, indicated the following: -The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. -The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. -Circumstances requiring notification include: 1. Accidents a. resulting in injury b. potential to require physician intervention 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. 3. A change of room or roommate assignment. 4. Notice of Rome changes. Resident #172 was admitted to the facility in June 2025 with diagnoses including dementia with behavioral disturbances and unsteadiness on feet. Review of the Brief Interview for Mental Status (BIMS) assessment completed on 6/6/25 indicated Resident #172 scored a 6 out of a possible 15, which indicated he/she had severe cognitive impairment. Review of the initial nursing assessment completed on 6/4/25 indicated the Resident required supervision for all mobility tasks. On 6/8/25 at 6:47 A.M., the surveyors observed Resident #172 lying on the ground on the outside of the building below a second-floor open window. A window screen was observed hanging from the side of the building. Resident #172 had significant lacerations to his/her left arm and face, and blood was visible on the Resident's bilateral arms, face and chest. The Resident was screaming and when approached by the surveyor the Resident said he/she went out the window because he/she was trying to get out of the building. The facility nursing staff called 911 and the Resident was taken to the hospital. During an interview on 6/8/25 at 6:52 A.M., Certified Nursing Assistant (CNA) #1 said she worked the overnight shift and Resident #172 was wandering up and down the hallways since 5:00 A.M., and at one point was attempting to go near the dining room window. CNA #1 said she had been told by other staff that the Resident had attempted to jump out of the dining room window previously and the staff had to barricade the window with tables and chairs to prevent access to the window. CNA #1 said at approximately 6:30 a.m., she left the Resident alone so she could go into the hallway and complete her paperwork. CNA #1 said it was at this point the Resident must have walked down to his/her bedroom and jumped out the window. On 6/8/25 at 6:56 A.M., the surveyor observed Resident #172's bedroom window. The window was open, with the opening measuring 24.5 inches wide and 4 feet 2 inches high. The surveyor observed nothing in the window to secure the opening of the window to prevent it from opening to that distance. Review of Resident #172's admission paperwork included the following: -A hospital psychiatric consultation dated 4/22/25, that indicated History of present illness. This is a (male/female) who was referred for admission because of increased agitation. Patient does have a history of dementia as well as depression and is a long-term nursing home resident. While there, (he/she) apparently was trying to get out a window on the third floor. (He/she has no recollection of this event and denies that it was a suicide attempt. (He/she) was subsequently referred for inpatient psychiatric treatment. -A Discharge summary, dated the day of admission to the facility, that indicated admitted (from another facility) for agitation and elopement behaviors. While admitted pt (patient) initially was exit seeking but redirectable, with medication adjustment improvement in exit seeking behaviors. Pt wanders at times but is easily redirectable and pleasant with redirection. -From (another facility), BIBA (brought in by ambulance), patient trying to get out 3rd floor window. Baseline confusion, alert to name only, secondary to dementia. Review of the elopement assessment dated [DATE] indicated Resident #172 was wandering and that his/her wandering was both goal-directed and aimless and not goal-oriented. Review of the nursing note dated 6/5/25 and written by the Director of Nursing indicated the following: -At 0845 writer and the Administrator were called to the second floor. The resident was observed using a very loud tone of voice and swearing at staff members. The Director of Nursing (writer) was able to escalate (sic) the resident's behavior and redirect the resident. The resident responded very well to the Director of Nursing, with a calm, soft voice, and apologized for yelling. While the writer was assessing the resident, it was noted that the resident was very confused, did not know where they were, and was using word salad when speaking. The writer was able to calm the resident to the point that they were able to leave the resident safely with the nursing staff. Nursing staff will continue to monitor the resident for the remainder of the shift. The medical record failed to indicate the medical provider or guardian was notified of these escalating behaviors. Review of the social services note dated 6/5/25 indicated the following: -Resident was transferred from (first-floor room) to (second-floor room) for safety reasons with prior authorization from Guardian and the agreement of roommate. Social worker will continue to monitor for changes in mood and behavior. Social services continues to remain available as needed for ongoing psychological support and reassurance. The medical record failed to indicate the medical provider was notified of the room change. Review of the nursing note dated 6/7/25 and time stamped 7:11 A.M., indicated the following: -Resident attempt (sic) to elope twice by opening the window in the dinner room. Cont. (continue) to monitor for safety. The medical record failed to indicate the medical provider or guardian was notified of the attempts of elopement. Review of the nursing note dated 6/7/25 and time stamped 12:53 P.M., indicated the following: -Pt. (patient) is alert, oriented and confused at baseline. Refused all am (morning) scheduled medications, ate 50% of breakfast and 100% of lunch. The medical record failed to indicate the medical provider or guardian was notified of the Resident's refusal of medications. Review of Resident #172's mood care plan created on 6/4/25, indicated the following intervention: -Monitor/document/report any risk for harm to self: suicidal plan, past attempted suicide, risky actions (stocking pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med (medications) or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. During interviews on 6/8/25 at 6:56 A.M., and 6/10/25 at 6:52 A.M., Nurse #1 said he was aware Resident #172 had a history of attempting to jump out windows and while at this facility, the Resident had attempted to open and exit the second-floor dining room window on 6/6/25 and 6/7/25. Nurse #1 said the Resident had also opened the balcony door off the dining room on 6/6/25 and had gone over to the edge of the balcony and needed to be pulled from the edge. Nurse #1 said he did not notify the provider or management of these behaviors and incidents. During an interview on 6/8/25 at 6:59 A.M., CNA #1 said the staff were aware that Resident #172 had been attempting to exit seek through windows and was unaware if anyone contacted administration or the medical providers to report this. During an interview on 6/11/25 at 8:38 A.M., Nurse #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on the second floor on the day of Resident #172's admission. Nurse #6 said the Resident was opening windows and looking outside. Nurse #6 said prior to the Resident moving to the second floor, he/she had been admitted to the first floor and had eloped out of the building, and as a result he/she was moved to the second floor. Nurse #6 said once the Resident was on the second floor, he/she was constantly trying to elope from the building by pushing on doors, elevators and windows. Nurse #6 said she did not bother to call down to tell the management that Resident #172 was exit seeking because they already knew and that is why he/she was transferred to the second floor. Nurse #6 said she did not notify the physician or nurse practitioner of the wandering and exit seeking behavior. During an interview on 6/9/25 at 10:12 A.M., CNA #5 said Resident #172 eloped from the building when he/she was first admitted and made it two miles down the road. CNA #5 said on the second day at the facility, Resident #172 attempted to jump off the second-floor balcony. CNA #5 said the administration blamed the nurse for agitating the Resident and said the nurse was overreacting to the situation. CNA #5 was unaware if the physician was notified after these two events. On 6/8/25 at 9:09 A.M., the surveyor interviewed the Administrator and Director of Nursing. During the interview, the Administrator said he received a call at 7:00 A.M. that Resident #172 had fallen out of his/her bedroom window. The Administrator said Resident #172 was a new admit to the facility and had dementia and was confused with a history of behaviors. The Administrator said the Resident recently displayed behaviors of yelling, swinging arms and banging on the walls and said the Resident wanted out and was assessed as being high risk for elopement. The Administrator said he was unaware of Resident #172's previous elopement history, including his/her attempt to elope from a third-floor window at a previous facility as he did not read the Resident's pre-admission paperwork. The Administrator said that the Resident did elope from the first floor on 6/4/25 and made it around the building to the back parking lot and was then moved to the second floor. He said he was also aware that on 6/6/25, Resident #172 was able to exit the second-floor dining room onto the balcony through a door that is supposed to be always locked. The Administrator said he had not received any calls over the weekend regarding Resident #172's increased behavior and attempt to elope from the second-floor dining room windows twice on 6/7/25. The Administrator said he was unaware if the physician was notified regarding Resident #172's elopement, elopement attempts, increased behaviors or history of elopement. During an interview on 6/9/25 at 2:03 P.M., the Director of Nursing said he read the nursing note dated 6/4/24 indicating Resident #172 was attempting to open windows, was aware he/she eloped out the front door on 6/4/25, and attempted to go out a window on 6/6/25 but was unaware the Resident had refused medications and did not notify the physician of any of these incidents. During an interview on 6/9/25 at 9:54 A.M., Resident #172's Guardian said she was never notified of the Resident's escalating behaviors, elopement, refusal of medications and attempted elopements out a window. The Guardian said she would have expected to be notified of all of these. During an interview on 6/9/25 at 8:44 A.M., Physician #1 said he had not yet assessed Resident #172 since his/her admission into the facility. Physician #1 said he was unaware of Resident #172's elopement history and the facility did not notify him or his nurse practitioner of Resident #172's behaviors, refusal of medications, room change, elopement and elopement attempts and that all of those examples are indicative of a call to the provider. Physician #1 said he is also the medical director of the facility and would have expected the facility to have a plan to ensure safety for residents admitted with a high risk and history of elopement. During an interview on 6/9/25 at 8:49 A.M., Nurse Practitioner (NP) #1 said she completed Resident #172's admission assessment. NP #1 said Resident #1 was wandering when she met him/her and was incoherent. NP #1 said she was unaware of Resident #172's elopement history and the facility did not make her aware of this on the day she was in the building. NP #1 said she expects the facility to notify her if a resident refuses medication, has escalating behaviors, attempts to elope and actually elopes from the facility. NP#1 said she was never notified with any of these when they occurred with Resident #172. NP#1 then checked the call log for the medical office and said no phone calls were made over the weekend on 6/7/25 to notify the physician's group that Resident #172 had attempted to elope out the window twice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to keep three Residents (#172, #56 and #35 free from accidents while at the facility. Specifically, 1. For Resident #172, with a known history of elopement from a window, the facility failed to ensure it provided appropriate supervision and safety resulting in the Resident falling from his/her second-floor bedroom window during an elopement attempt, resulting in an acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs; 2. For Resident #56, the facility failed to ensure supervision was provided during a trialing of an upgraded diet texture resulting in a choking episode requiring the Heimlich Maneuver; and 3. For Resident #35, the facility failed to ensure smoking materials were not left unsupervised in the Resident's room. Findings include: Review of the facility policy titled, Elopement Prevention, dated 12/27/24, indicated the following: -The facility maintains a process to assess all residents for risk of elopement, implement prevention strategies for those identified as elopement risk, institute measures for resident identification at the time of admission. -The physical plant is secured to minimize the risk of elopement, such as: c. safety locks or keypad entry that restrict access to dangerous areas, d. restricted window openings 1. Resident #172 was admitted to the facility in June 2025 with diagnoses including dementia with behavioral disturbances and unsteadiness on feet. Review of the Brief Interview for Mental Status (BIMS) completed on 6/6/25 indicated Resident #172 scored a 6 out of a possible 15, which indicated he/she had severe cognitive impairment. Review of the initial nursing admission assessment completed on 6/4/25 indicated the Resident required supervision for all mobility tasks. On 6/8/25 at 6:47 A.M., the surveyors observed Resident #172 lying on the ground on the outside of the building below a second-floor open window. A window screen was observed hanging from the side of the building. Resident #172 had significant lacerations to his/her left arm and face, and blood was visible on his/her bilateral arms, face and chest. The Resident was screaming and when approached by the surveyor he/she said he/she went out the window because he/she was trying to get out of the building. The facility nursing staff called 911 and the Resident was taken to the hospital. During an interview on 6/8/25 at 6:52 A.M., Certified Nursing Assistant (CNA) #1 said she worked the overnight shift and Resident #172 was wandering up and down the hallways since 5:00 A.M., and at one point was attempting to go near the dining room window. CNA #1 said she had been told by other staff that the Resident had attempted to jump out of the dining room window previously and the staff had to barricade the window with tables and chairs to prevent access to the window. CNA #1 said at approximately 6:30 a.m., she left the Resident alone so she could go into the hallway and complete her paperwork. CNA #1 said it was at this point the Resident must have walked down to his/her bedroom and jumped out the window. On 6/8/25 at 6:56 A.M., the surveyor observed Resident #172's bedroom window. The window was open, with the opening measuring 24.5 inches wide and 4 feet 2 inches high. There was nothing in the window to secure the opening of the window to prevent it from opening to that distance. On 6/8/25 at approximately 7:00 A.M., the surveyor observed the second-floor dining room window that CNA #1 said Resident #172 had been repeatedly approaching. The window was able to open from the left side with an opening measuring 22.5 inches wide and 4 feet 7 inches high. There was nothing in the window to secure the opening of the window to prevent it from opening to that distance. The right side of the window was secured with a device in the window ledge to prevent it from opening. Review of Resident #172's admission paperwork included the following: -A hospital psychiatric consultation dated 4/22/25, that indicated History of present illness. This is a (male/female) who was referred for admission because of increased agitation. Patient does have a history of dementia as well as depression and is a long-term nursing home resident. While there, (he/she) apparently was trying to get a window on the third floor. (He/she has no recollection of this event and denies that it was a suicide attempt. (He/she) was subsequently referred for inpatient psychiatric treatment. -A Discharge summary, dated the day of admission to the facility, that indicated admitted (from another facility) for agitation and elopement behaviors. While admitted pt (patient) initially was exit seeking but redirectable, with medication adjustment improvement in exit seeking behaviors. Pt wanders at times but is easily redirectable and pleasant with redirection. -From (another facility), BIBA (brought in by ambulance), patient trying to get out 3rd floor window. Baseline confusion, alert to name only, secondary to dementia. Review of the elopement assessment dated [DATE] indicated Resident #172 was wandering and that his/her wandering was both goal-directed and aimless and not goal-oriented. Review of the nursing note dated 6/5/25 and written by the Director of Nursing indicated the following: -At 0845 writer and the Administrator were called to the second floor. The resident was observed using a very loud tone of voice and swearing at staff members. The Director of Nursing (writer) was able to escalate (sic) the resident's behavior and redirect the resident. The resident responded very well to the Director of Nursing, with a calm, soft voice, and apologized for yelling. While the writer was assessing the resident, it was noted that the resident was very confused, did not know where they were, and was using word salad when speaking. The writer was able to calm the resident to the point that they were able to leave the resident safely with the nursing staff. Nursing staff will continue to monitor the resident for the remainder of the shift. Review of the social services note dated 6/5/25 indicated the following: -Resident was transferred from (first-floor room) to (second-floor room) for safety reasons with prior authorization from Guardian and the agreement of roommate. Social worker will continue to monitor for changes in mood and behavior. Social services continues to remain available as needed for ongoing psychological support and reassurance. Review of the nursing note dated 6/7/25 and time stamped 7:11 A.M., indicated the following: -Resident attempt to elope twice by opening the window in the dinner room. Cont. (continue) to monitor for safety. Review of the nursing note dated 6/7/25 and time stamped 12:53 P.M., indicated the following: -Pt. (patient) is alert, oriented and confused at baseline. Refused all am (morning) scheduled medications, at 50% of breakfast and 100% of lunch. Review of Resident #172's elopement and wandering care plan created on 6/4/25, failed to indicate an individualized care plan for Resident #172's history of elopement through windows. Interventions that were included on the care plan, all initiated on 6/4/25, were: -Clearly identify Resident's room and bathroom. -Engage Resident in purposeful activity. -Identify if there are triggers for wandering/eloping. -Identify if there is a certain time of day wandering/elopement attempts occur. -Identify if there is a pattern and purpose of wandering. -Provide care in a calm and reassuring manner. -Provide clear, simple instructions. -Provide reorientation to surroundings. -Wander guard (a bracelet worn to activate an alarm if exiting through the doors or elevator of the unit) placed to left ankle. The care plan failed to include any interventions after actual elopement attempts by the Resident. Review of Resident #172's mood care plan created on 6/4/25, indicated the following intervention: -Monitor/document/report any risk for harm to self: suicidal plan, past attempted suicide, risky actions (stocking pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med (medications) or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. During interviews on 6/8/25 at 6:56 A.M., and 6/10/25 at 6:52 A.M., Nurse #1 said he was aware Resident #172 had a history of attempting to jump out windows and while at this facility, the Resident had attempted to open and exit the second-floor dining room window on 6/6/25 and 6/7/25. Nurse #1 said the Resident had also opened the balcony door off the dining room on 6/6/25 and had gone over to the edge of the balcony and needed to be pulled from the edge. Nurse #1 said he did not notify the provider or management of these behaviors and incidents. During an interview on 6/8/25 at 6:59 A.M., CNA #1 said the staff were aware that Resident #172 had been attempting to exit seek through windows and was unaware if anyone contacted administration or the medical providers to report this. During an interview on 6/11/25 at 8:38 A.M., Nurse #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on the second floor on the day of Resident #172's admission. Nurse #6 said the Resident was opening windows and looking outside. Nurse #6 said prior to the Resident moving to the second floor, he/she had been admitted to the first floor and had eloped out of the building, and as a result he/she was moved to the second floor. Nurse #6 said once the Resident was on the second floor, he/she was constantly trying to elope from the building by pushing on doors, elevators and windows. Nurse #6 said she did not bother to call down to tell the management that Resident #172 was exit seeking because they already knew and that is why he/she was transferred to the second floor. Nurse #6 said she did not notify the physician or nurse practitioner of the wandering and exit seeking behavior. During an interview on 6/9/25 at 10:12 A.M., CNA #5 said Resident #172 eloped from the building when he/she was first admitted and made it two miles down the road. CNA #5 said on the second day at the facility, Resident #172 attempted to jump off the second-floor balcony. CNA #5 said the administration blamed the nurse for agitating the Resident and said the nurse was overreacting to the situation. CNA #5 was unaware if the physician was notified after these two events. On 6/8/25 at 9:09 A.M., the surveyor interviewed the Administrator and Director of Nursing. During the interview, the Administrator said he received a call at 7:00 A.M. that Resident #172 had fallen out of his/her bedroom window. The Administrator said Resident #172 was a new admit to the facility and had dementia and was confused with a history of behaviors. Both the Administrator and Director of Nursing said they had not read Resident #172's admission paperwork and were unaware of his/her behaviors, elopement risk and previous attempt to elope out a third-floor window. The Administrator said that the Resident did elope from the first floor on 6/4/25 and made it around the building to the back parking lot and was then moved to the second floor. He said he was also aware that on 6/6/25, Resident #172 was able to exit the second-floor dining room onto the balcony through a door that is supposed to be always locked. The Administrator and Director of Nursing said they were aware Resident #172 displayed behaviors of yelling, swinging arms and banging on the walls and said the Resident wanted out and was assessed as being high risk for elopement. The Director of Nursing said he needed to be called to Resident #172's floor when his/her behavior escalated and needed to provide support to the Resident in order to deescalate the behaviors. The Administrator said he had not received any calls over the weekend regarding Resident #172's increased behavior and attempt to elope from the second-floor dining room windows twice on 6/7/25. The Administrator said he was unaware if the physician was notified regarding Resident #172's elopement, elopement attempts, increased behaviors or history of elopement. During an interview on 6/9/25 at 2:03 P.M., the Director of Nursing said he read the nursing note dated 6/4/24 indicating Resident #172 was attempting to open windows, was aware he/she eloped out the front door on 6/4/25, and attempted to go out a window on 6/6/25 but was unaware the Resident had refused medications and did not notify the physician of any of these incidents. The Director of Nursing said he attempted to secure the second-floor dining room window, and was successful in doing so on the right side of the window, but because I am not a carpenter he was unable to secure the left side. The Director of Nursing said after not being able to secure the left side of the window, he did not come up with a plan to secure that window further. During an interview on 6/9/25 at 9:54 A.M., Resident #172's Guardian said she was never notified of the Resident's escalating behaviors, elopement, refusal of medications and attempted elopements out a window. The Guardian said she would have expected to be notified of all of these. During an interview on 6/9/25 at 8:44 A.M., Physician #1 said as the medical director of the facility and would have expected the facility to have a plan to ensure safety for residents admitted with a high risk and history of elopement. During an interview on 6/9/25 at 8:49 A.M., Nurse Practitioner (NP) #1 said she completed Resident #172's admission assessment. NP #1 said Resident #1 was wandering when she met him/her and was incoherent. NP #1 said she was unaware of Resident #172's elopement history and the facility did not make her aware of this on the day she was in the building. NP #1 said she was unaware of Resident #172's actual elopement and elopement attempts at the facility. During an interview on 6/9/25 at 1:33 P.M., the Administrator said the clinical liaison who interacts with the hospital does the initial admission screening, then speaks with the admission coordinator at the facility. The Administrator said this screening process is in place to ensure the facility can clinically and safely take care of the residents. The Administrator says he has little involvement in looking at the preadmission screens as he trusts the Director of Nursing to do this. The Administrator said elopements are not something he has had a great deal of experience with as it has been many years since he has had a building with a locked unit. He said he believed the facility would be able to clinically care for Resident #172 at the time of his/her admission, however, he was not aware of the Resident's prior elopement attempts. The Administrator said he was aware Resident #172 had eloped from the building, had gotten out onto the second-floor balcony and had banged on windows; however, he said he was unaware the Resident had attempted to open and climb out a second-floor window on two other occasions. The Administrator said he would have expected any elopement attempts or safety concerns to be reported to him as it is his responsibility for all residents' safety. When asked about his system for ensuring the windows of the facility are secure, the Administrator said he had asked his maintenance director to complete an audit in March 2025 to check all windows and ensure they could not open more than four inches. The Administrator said he did not receive a formal audit from the maintenance director and took his word that it had been completed. During an interview on 6/10/25 at 7:35 A.M., the Case Manager in charge of admissions from the hospital was interviewed. The Case Manager said she helps coordinate Resident #172's admission to the facility and was aware that the Resident was in the hospital for psychiatric concerns and had attempted to elope from a window at a previous facility. The Case Manager said she sent all of the preadmission paperwork and the Resident's clinical history/information to the facility to ensure the facility would be able to handle the patient. During an interview on 6/10/25 at 9:01 A.M., the Admissions Coordinator said she was aware of Resident #172's prior attempt to elope from a window prior to his/her admission to the facility and did not tell the Administrator and did not have a conversation with anyone in the building to ensure the windows were secure. During an interview on 6/11/25 at 8:17 A.M., the Maintenance Director said he was asked to complete a window audit in March 2025, and he delegated his task to his assistant, asking him to ensure the windows could not open more than 4 inches. The Maintenance Director said he was never given a formal audit showing that his assistant completed this task, but he took his word for it. The Maintenance Director said he was never told to check the second-floor dining room door to the outside balcony, and he had never been told to add that door to his daily safety check. During an interview on 6/11/25 at 8:29 A.M., the Maintenance Assistant said he was assigned the task to audit all windows in March 2025, and he did this task but did not write down the results on a formal audit form. The Maintenance Assistant said he was aware that the window in Resident #172's room could open all the way, and he did not go back to ensure that it was secure. The Maintenance Assistant said the door to the second-floor dining room is not on a daily safety check list and he was never told to check the door after the fact. During an interview on 6/11/25 at 11:18 A.M., the Administrator said he was unaware the window in Resident #172's bedroom was able to open all the way and that the maintenance assistant was aware of this. 2. Resident #56 was admitted to the facility in April 2024 with diagnoses that included dysphagia, Huntington's Disease, adult failure to thrive, and severe protein-calorie malnutrition. Review of Resident #56's Minimum Data Set (MDS) assessment, Dated 7/27/24, indicated require change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of Resident #56's Minimum Data Set (MDS) assessment, dated 4/2/25, indicated he/she scored an 8 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive deficits. Further review of the MDS indicated mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of Resident #56's diet order from 8/4/24 to 1/14/25 indicated Regular diet, Liquid / No Texture texture, Nectar consistency. Review of Resident #56's Speech Evaluation, dated 8/2/24, indicated baseline mechanical soft nectar liquids. Swallowing abilities= Severe, Oral phase= Moderate. Diet Recs - Solids = Mechanical Soft Textures, Mechanical Soft/Ground Textures. Supervision for Oral Intake = Close supervision. Review of Resident #56's Speech Therapy note, dated 8/6/24, indicated Pt (patient) was trialed on soft meatballs during noon meal. Pt took an entire meatball and place in her mouth. SLP directed pt to take food out of her mouth. Review of Resident #56's Speech Therapy note, dated 8/29/24, indicated Pt presented with mechanical soft food. Review of Resident #56's nursing progress note, dated 9/3/24, indicated During the lunch service, the dietician provided a chicken sandwich to the patient. While eating, the patient began to choke. The nurse on duty quickly intervened by performing the Heimlich maneuver. It was successful, and patient expelled the pieces of the sandwich that were obstructing her airway. After the incident, the patient was assessed and found to be in stable condition. Review of Resident #56's Nurse Practitioner progress note, dated 9/5/24, indicated Patient seen today following an episode of choking on 9/3/2024. Patient was eating a sandwich and choked requiring the Heimlich maneuver, article fluid was expelled. Due to this episode patient continues to have nectar consistent, puréed texture. (sic) During an interview on 6/10/25 at 10:55 A.M., the Speech Therapist said she was working with Resident #56 on 9/3/25, gave the Resident a chicken salad sandwich and then left the Resident with the nurse to be supervised. The Speech Therapist said at that time there was not an order in place for the Resident to have mechanically altered foods with nursing staff but she was working with the Resident to try and upgrade his/her diet. The Speech Therapist said he/she was a puree diet at the time of the trial and was discharged to stay on a puree with thickened liquid diet. During an interview on 6/10/25 at 1:46 P.M., Nurse #3 said she is familiar with Resident #56 and the choking incident that happened on 9/3/24. Nurse # 3 said that speech should not have left the nurse alone with the Resident while trialing new food textures until a doctors order is in place for that food texture. Nurse #3 said the diet order at the time should have said puree texture and not no texture texture. During an interview on 6/12/25 at 10:24 A.M., the Director of Nursing (DON) said when a Resident is working with speech on trialing different foods the expectation is that the speech therapist stay for the whole duration of that meal. The DON said the speech therapist should have never left the nurse with the Resident with the chicken salad sandwich because there was not a doctors order in place for that texture of food and could be dangerous. The DON said he expects the Residents plan of care to be followed and the diet texture should have been clear in the order. During an interview on 6/12/25 at 10:28 A.M., Nurse Practitioner (NP) #1 said she knows Resident #56 well and he/she does have a history of choking at the facility. The NP said she would expect the speech therapist to have stayed until the Resident was done with that session of trialing the mechanically altered food as it is their job. The NP said the texture should have been clear in the doctors orders at that time as the Resident was on a puree diet and still is. 3. Review of the facility policy titled Smoking Policy, undated, indicated the following: - Each Resident should be individually assessed to determine whether he/she can safely smoke without supervision. The Facility shall conduct an assessment to determine whether the resident requires any safety devices such as a smoking apron and shall document this in the resident's care plan. - Supervised smokers are not permitted to have any smoking paraphernalia in their room or on their person. Resident #35 was admitted to the facility in May 2025 with diagnoses including muscle wasting, heart disease and nicotine dependence. Review of the Resident's most recent Minimum Data Set assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 11 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated the Resident requires partial/moderate assistance from staff with ADL care and currently uses tobacco. Review of the list of Residents who currently smoke in the facility provided by the facility failed to indicate that Resident #35 smokes. On 6/8/25 at 8:50 A.M., the surveyor observed Resident #35 lying in his/her bed. On Resident #35's bedside table next to his/her bed was one unlit cigarette and one cigarette that had been previously lit and stubbed out (burnt, black markings were on the end of it). Resident #35 told the surveyor that he/she smokes while living in the facility. Review of Resident #35's Nursing admission Evaluation dated 5/9/25, indicated the following under the smoking section: - Smoking: yes - Resident needs for adaptive equipment: supervision - Does the resident need facility to store lighter and cigarettes: yes - Decision: safe to smoke with supervision Review of Resident #35's active care plans failed to indicate that the facility developed a smoking care plan with individualized, resident-specific interventions. During an interview on 6/10/25 at 8:36 A.M., Nurse #5 said there is a lock box downstairs that contains all of the Residents' smoking materials after they finish smoking. Nurse #5 said Residents should not have any cigarettes or smoking material at the bedside. The surveyor showed Nurse #5 the photos of the cigarettes at Resident #35's bedside and he said they should not be there. During an interview on 6/10/25 at 9:19 A.M., Nurse #7 said cigarettes are kept in a lock box and staff who are in charge of supervising smoking ensure Residents put all smoking material back in the box after smoking. Nurse #7 said nursing has complained about this and residents are going outside without supervision and smoking. Nurse #7 said we have lost control of residents going out to smoke. During an observation on 6/10/25 at 9:41 A.M., as the surveyor was interviewing Nurse #7, Resident #35 was walking down the hallway coming from his/her room holding a cigarette in his/her right hand. Resident #35 told Nurse #7 that he/she had the cigarette with him/her and is trying to leave the building to smoke. During an interview on 6/10/25 at 10:33 A.M., the Director of Nursing (DON) said all residents who wish to smoke in the facility must have a smoking assessment and smoking care plan. The DON said if a resident is of sound mind and body then they can have smoking materials with them. During an interview on 6/10/25 at 12:30 P.M., the Administrator said residents who are alert and oriented and are safe smokers who do not need supervision are allowed to have smoking materials with them and he said he refers to the facility policy. The Surveyor reviewed the smoking policy with the Administrator, and he said Resident #35 should not have smoking materials with him/her and he/she should have a smoking care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure licensed nursing staff were trained and competent in managing wandering behavior and elopement, subsequently, one Resident (#172) eloped and fell from a second-floor bedroom window and requiring acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs. Findings include: Review of the Facility Assessment, most recently updated on 4/18/25, indicated the following: -The staff are provided with training/education which includes how to care for residents with a diagnosis of dementia. -The staff are provided with competency training on disaster planning and procedures, which includes competency on elopements. Review of the document titled, Round [NAME]: Annual Education, undated and provided by the Administrator indicated the following: -Round [NAME] Education (group education) is mandatory. -Stations for training included: elopement, dementia, how to deal with difficult behaviors, and safety training. Resident #172 was admitted to the facility in June 2025 with diagnoses including dementia with behavioral disturbances and unsteadiness on feet. Review of the Brief Interview for Mental Status (BIMS) completed on 6/6/25 indicated Resident #172 scored a 6 out of a possible 15, which indicated he/she had severe cognitive impairment. Review of the initial nursing admission assessment completed on 6/4/25 indicated the Resident required supervision for all mobility tasks. On 6/8/25 at 6:47 A.M., the surveyors observed Resident #172 lying on the ground on the outside of the building below a second-floor open window. A window screen was observed hanging from the side of the building. Resident #172 had significant lacerations to his/her left arm and face, and blood was visible on his/her bilateral arms, face and chest. The Resident was screaming and when approached by the surveyor he/she said he/she went out the window because he/she was trying to get out of the building. The Facility nursing staff called 911 and the Resident was taken to the hospital. Review of Resident #172's admission paperwork included the following: -A hospital psychiatric consultation dated 4/22/25, that indicated History of present illness. This is a (male/female) who was referred for admission because of increased agitation. Patient does have a history of dementia as well as depression and is a long-term nursing home resident. While there, (he/she) apparently was trying to get a window on the third floor. (He/she has no recollection of this event and denies that it was a suicide attempt. (He/she) was subsequently referred for inpatient psychiatric treatment. -A Discharge summary, dated [DATE], that indicated admitted (from another facility) for agitation and elopement behaviors. While admitted pt (patient) initially was exit seeking but redirectable, with medication adjustment improvement in exit seeking behaviors. Pt wanders at times but is easily redirectable and pleasant with redirection. -A referral sheet that indicated, From (another facility), BIBA (brought in by ambulance), patient trying to get out 3rd floor window. Baseline confusion, alert to name only, secondary to dementia. Review of Resident #172's medical record indicated the following: -A daily skilled nursing note dated 6/4/25 indicating Resident #172 was attempting to push on doors and open windows. -A nursing note dated 6/7/25 indicating Resident #172 attempted to elope from the facility by the window twice. -Resident #172 was documented as having wandering behaviors on 6/5/25 and 6/7/25. -A social service note dated 6/6/25 indicating Resident #172 was admitted to the facility after a psychiatric hospitalization for irritability and altered mental status. The note failed to include the Resident's history of attempting to elope out of a window. Review of Resident #172's elopement and wandering care plan created on 6/4/25, failed to indicate an individualized care plan for Resident #172's history of elopement through windows. Interventions that were included on the care plan, all initiated on 6/4/25, were: -Clearly identify Resident's room and bathroom. -Engage Resident in purposeful activity. -Identify if there are triggers for wandering/eloping. -Identify if there is a certain time of day wandering/elopement attempts occur. -Identify if there is a pattern and purpose of wandering. -Provide care in a calm and reassuring manner. -Provide clear, simple instructions. -Provide reorientation to surroundings. -Wander guard (a bracelet worn to activate an alarm if exiting through the doors or elevator of the unit) placed to left ankle. The care plan failed to include any revisions/updates to interventions after actual elopement attempts by the Resident. Observations of the facility indicated the wander guard system was only located on the elevators and doors and not any window. During an interview on 6/10/25 6:52 A.M., Nurse #1 said the facility had never given the staff guidance or education on handling residents with a high elopement risk. Nurse #1 said the staff felt stuck because they didn't have guidance on how to manage extreme behaviors, such as residents who are attempting to elope from windows. During an interview on 6/10/25 at 8:02 A.M., Certified Nursing Assistant (CNA) #3 said he works at another facility that does annual competencies and education, so he is not required to do them here. CNA #3 said he was not familiar with Resident #172. During an interview on 6/10/25 at 8:06 A.M., CNA #4 said the staff have not been provided with any in-services or annual education since the new company bought the building in September 2024. CNA #4 said he was not familiar with Resident #172. During an interview on 6/10/25 at 8:14 A.M., Nurse #4 said she has worked at the building for about two and a half months and she had some competencies since starting work but has not finished them. Nurse #4 said she does not remember learning about elopement during her hiring process/orientation. During an interview on 6/10/25 at 8:36 A.M., CNA #9 said he worked over the previous weekend and was aware of Resident #172's attempts to elope from the building, but no one educated him that the Resident was attempting to get out the window. CNA #9 said Resident #172 is not like the typical person the staff had to take care of and the staff had to give him/her special attention. CNA #9 said they were not given any specific education or guidance from management on how to properly take care of Resident #172. During an interview on 6/10/25 at 8:44 A.M., CNA #6 said when she worked over the weekend, Resident #172 was attempting to elope and that the Resident was always in the dining room attempting to go out the window. CNA #6 said no one from the facility talked to her before her shift about the Resident trying to wander and elope and how to manage those behaviors. CNA #6 said she received education from the previous staff educator but cannot remember if managing elopement was part of that education. During an interview on 6/11/25 at 8:38 A.M., Nurse #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on the second floor on the day of Resident #172's admission. Nurse #6 said the Resident was opening windows and looking outside. Nurse #6 said prior to the Resident moving to the second floor, he/she had been admitted to the first floor and had eloped out of the building, and as a result he/she was moved to the second floor. Nurse #6 said once the Resident was on the second floor, he/she was constantly trying to elope from the building by pushing on doors, elevators and windows. Nurse #6 said she did not bother to call down to tell the management that Resident #172 was exit seeking because they already knew and that is why he/she was transferred to the second floor. Nurse #6 said no one from the administration came to the unit to offer her or the other staff guidance or education on how to manage these behaviors and that this would have been very helpful. She said the staff provided constant supervision to the Resident for the entirety of the shift as the intervention of the exit seeking behavior. Review of ten employee records indicated the following: -Eight out of ten employees had no dementia training. Five of these employees were newly hired and did not have the required 8 hours of dementia training. Three out of the five employees had been employed at the facility for over a year and did not have the required four-hour yearly dementia training. -Four out of five employees who had been employed at the facility for more than a year had not completed annual education or competencies for caring for residents with dementia and a risk of elopement. During an interview on 6/8/25 at 9:09 A.M., the Administrator said all staff should have direct knowledge on how to manage residents with dementia who have a risk of elopement. The Administrator said nursing staff are expected to complete education upon hire, annually and as needed. The Administrator said the Assistant Director of Nursing is responsible for staff education. During an interview on 06/09/25 02:03 P.M., the Director of Nursing (DON) said he expects the staff to have education regarding elopement annually and at orientation. The DON said when Resident #172 had escalating behaviors and attempts at elopement, he did not provide staff with on the spot education regarding techniques to prevent elopement. During an interview on 6/10/25 at 11:50 A.M., the Assistant Director of Nursing (ADON) said he was hired within the last 30 days and did not have a chance to meet with the prior staff educator to understand the level of education previously provided to the staff. The ADON said that he is responsible for all new hire education and dementia training. The ADON said he was unaware the staff reviewed did not have annual competencies/education or dementia training. During an interview on 6/12/25 at 10:02 A.M., the Administrator said he was unaware that there was no annual education provided to the nursing staff last year. The Administrator said he had asked the previous nursing leadership to complete education and he had observed some ad hoc education occurring on the floor and assumed all education was being provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure it provided appropriate administrative oversight, specific to clinical management and building safety, when one Resident (#172) fell from his/her second-floor bedroom window during an elopement attempt, resulting in an acute hospitalization with a fracture of the fourth lumbar vertebrae with mild retropulsion into the spinal canal (bone fragments in spinal cord), fractures of the second and third lumbar vertebrae, hematoma of the psoas muscle (lower back muscle), and fractures of the ninth through 12 ribs. Specifically, the facility administration failed to: 1. Ensure the facility's environment was safe for a Resident with a known risk of elopement from a window; 2. Ensure effective systems were in place for education and training for licensed staff to ensure competent, safe, and effective resident care related to residents with dementia and a risk of elopement; 3. Ensure the facility assessment indicated the facility cared for a population with the behaviors of elopement in order to use the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: Review of the facility policy titled, Elopement Prevention, dated 12/27/24, indicated the following: -The facility maintains a process to assess all residents for risk of elopement, implement prevention strategies for those identified as elopement risk, institute measures for resident identification at the time of admission. -The physical plant is secured to minimize the risk of elopement, such as: c. safety locks or keypad entry that restrict access to dangerous areas, d. restricted window openings Review of the facility policy titled, Dementia Treatment Plan, dated 9/2024, indicated the following: -For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. -Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on results of the reviews. -Progressive or persistent worsening of symptoms and increased need for staff support will be reported to the IDT. -The IDT will review the past and current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complication, and functional impairments. -The IDT will adjust interventions and the overall plan depending on he individual's response to those interventions, progression of dementia, development on new acute medical conditions or complications, changes in resident or family wishes, etc. 1. Resident #172 was admitted to the facility in June 2025 with diagnoses including dementia with behavioral disturbances and unsteadiness on feet. Review of the Brief Interview for Mental Status (BIMS) completed on 6/6/25 indicated Resident #172 scored a 6 out of a possible 15, which indicated he/she had severe cognitive impairment. Review of the initial nursing admission assessment completed on 6/4/25 indicated the Resident required supervision for all mobility tasks. On 6/8/25 at 6:47 A.M., the surveyors observed Resident #172 lying on the ground on the outside of the building below a second-floor open window. A window screen was observed hanging from the side of the building. Resident #172 had significant lacerations to his/her left arm and face, and blood was visible on his/her bilateral arms, face and chest. The Resident was screaming and when approached by the surveyor he/she said he/she went out the window because he/she was trying to get out of the building. The facility nursing called 911 and the Resident was taken to the hospital. During an interview on 6/8/25 at 6:52 A.M., Certified Nursing Assistant (CNA) #1 said she worked the overnight shift and Resident #172 was wandering up and down the hallways since 5:00 A.M., and at one point was attempting to go near the dining room window. CNA #1 said she had been told by other staff that the Resident had attempted to jump out of the dining room window previously and the staff had to barricade the window with tables and chairs to prevent access to the window. CNA #1 said at approximately 6:30 a.m., she left the Resident alone so she could go into the hallway and complete her paperwork. CNA #1 said it was at this point the Resident must have walked down to his/her bedroom and jumped out the window. On 6/8/25 at 6:56 A.M., the surveyor observed Resident #172's bedroom window. The window was open, with the opening measuring 24.5 inches wide and 4 feet 2 inches high. There was nothing in the window to secure the opening of the window to prevent it from opening to that distance. Review of Resident #172's admission paperwork included the following: -A hospital psychiatric consultation dated 4/22/25, that indicated History of present illness. This is a (male/female) who was referred for admission because of increased agitation. Patient does have a history of dementia as well as depression and is a long-term nursing home resident. While there, (he/she) apparently was trying to get a window on the third floor. (He/she has no recollection of this event and denies that it was a suicide attempt. (He/she) was subsequently referred for inpatient psychiatric treatment. -A Discharge summary, dated [DATE], that indicated admitted (from another facility) for agitation and elopement behaviors. While admitted pt (patient) initially was exit seeking but redirectable, with medication adjustment improvement in exit seeking behaviors. Pt wanders at times but is easily redirectable and pleasant with redirection. -A referral form that indicated: From (another facility), BIBA (brought in by ambulance), patient trying to get out 3rd floor window. Baseline confusion, alert to name only, secondary to dementia. Review of Resident #172's medical record indicated the following: -A daily skilled nursing note dated 6/4/25 indicating Resident #172 was attempting to push on doors and open windows. -Resident #172 was documented as having wandering behaviors on 6/5/25 and 6/7/25. -A nursing note dated 6/7/25 indicating Resident #172 attempted to elope from the facility by the window twice. -A social service note dated 6/6/25 indicating Resident #172 was admitted to the facility after a psychiatric hospitalization for irritability and altered mental status. The note failed to include the Resident's history of attempting to elope out of a window. Review of Resident #172's elopement and wandering care plan created on 6/4/25, failed to indicate an individualized care plan for Resident #172's history of elopement through windows. Interventions that were included on the care plan, all initiated on 6/4/25, were: -Clearly identify Resident's room and bathroom. -Engage Resident in purposeful activity. -Identify if there are triggers for wandering/eloping. -Identify if there is a certain time of day wandering/elopement attempts occur. -Identify if there is a pattern and purpose of wandering. -Provide care in a calm and reassuring manner. -Provide clear, simple instructions. -Provide reorientation to surroundings. -Wander guard (a bracelet worn to activate an alarm if exiting through the doors or elevator of the unit) placed to left ankle. The care plan failed to include any revisions/updates for interventions after actual elopement attempts by the Resident. Observations of the facility indicated the wander guard system was only placed on doors and elevators and was not on any of the windows in the facility. During interviews on 6/8/25 at 6:56 A.M., and 6/10/25 at 6:52 A.M., Nurse #1 said he was aware Resident #172 had a history of attempting to jump out windows and while at this facility, the Resident had attempted to open and exit the second-floor dining room window on 6/6/25 and 6/7/25. Nurse #1 said the Resident had also opened the balcony door off the dining room on 6/6/25 and had gone over to the edge of the balcony and needed to be pulled from the edge. Nurse #1 said he did not notify the provider or management of these incidents. On 6/8/25 an observation of the second-floor dining room window at 7:50 A.M., the window was observed to be able to open 22.5 inches wide and 4 feet 7 inches high. During an interview on 6/8/25 at 6:59 A.M., CNA #1 said she had noticed that the second-floor dining room window was open from the left side so she barricaded the window with tables and chairs so Resident #172 could not have access to the window. CNA #1 said she did not know how else to secure the window from being able to open to the width a person would be able to get out of. During an interview on 6/8/25 at 7:17 A.M., a resident who was sitting in the second-floor hallway said he/she had witnessed Resident #172 exit the dining room and go onto the outside balcony on 6/6/25 and saw the nurse have to run out onto the balcony to grab the Resident. During an interview on 6/8/25 at 7:35 A.M., Nurse #1 said he was aware the Director of Nursing secured the second-floor window on the right side but failed to secure the left side of the window and that no one assessed Resident #172's window to see if it was secure and unable to open. During an interview on 6/8/25 at 7:32 A.M., when asked about the windows being secure on the second floor, Nurse #2 said there was a dining room window that could open all the way on the left side of the window. Nurse #2 said he was unsure why the full window was not secured. Nurse #2 also said he was unsure why Resident #172's bedroom window was not secured given his/her elopement history. Nurse #2 said he felt the facility was not prepared for this patient due to the high risk of elopement. During an interview on 6/11/25 at 8:38 A.M., Nurse #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on the second floor on the day of Resident #172's admission. Nurse #6 said the Resident was opening windows and looking outside. Nurse #6 said prior to the Resident moving to the second floor, he/she had been admitted to the first floor and had eloped out of the building, and as a result he/she was moved to the second floor. Nurse #6 said once the Resident was on the second floor, he/she was constantly trying to elope from the building by pushing on doors, elevators and windows. Nurse #6 said she did not bother to call down to tell the management that Resident #172 was exit seeking because they already knew and that is why he/she was transferred to the second floor. Nurse #6 said no one from the administration came to the unit to offer her or the other staff guidance or education on how to manage these behaviors and that this would have been very helpful. She said the staff provided constant supervision to the Resident for the entirety of the shift as the intervention of the exit seeking behavior. During an interview on 6/8/25 at 9:09 A.M., the Administrator said he received a call at 7:00 A.M. that Resident #172 had fallen out of his/her bedroom window. The Administrator said Resident #172 was a new admit to the facility and had dementia and was confused with a history of behaviors. The Administrator said the Resident recently displayed behaviors of yelling, swinging arms and banging on the walls and said the Resident wanted out and was assessed as being high risk for elopement. The Administrator said he was unaware of Resident #172's previous elopement history, including his/her attempt to elope from a third-floor window at a previous facility as he did not read the Resident's pre-admission paperwork. The Administrator said that the Resident did elope from the first floor on 6/4/25 and made it around the building to the back parking lot and was then moved to the second floor. He said he was also aware that on 6/6/25, Resident #172 was able to exit the second-floor dining room onto the balcony through a door that is supposed to be always locked. The Administrator said he was unsure how the door was unlocked as that is a safety risk and asked maintenance to immediately lock it. The Administrator said he had not received any calls over the weekend regarding Resident #172's increased behavior and attempt to elope from the second-floor dining room windows twice on 6/7/25. The Administrator said maintenance should check all the windows and doors for safety and he believes there was a specific audit for window safety that had been completed, and he would look for that audit. During an interview on 6/9/25 at 1:33 P.M., the Administrator said the clinical liaison who interacts with the hospital does the initial admission screening, then speaks with the admission coordinator at the facility. The Administrator said this screening process is in place to ensure the facility can clinically and safely take care of the residents. The Administrator says he has little involvement in looking at the preadmission screens as he trusts the Director of Nursing to do this. The Administrator said elopements are not something he has had a great deal of experience with as it has been many years since he has had a building with a locked unit. He said he believed the facility would be able to clinically care for Resident #172 at the time of his/her admission; however, he was not aware of the Resident's prior elopement attempts. The Administrator said he was aware Resident #172 had eloped from the building, had gotten out onto the second-floor balcony and had banged on windows, however, he said he was unaware the Resident had attempted to open and climb out a second floor window on other occasions. The Administrator said he would have expected any elopement attempts or safety concerns to be reported to him as it is his responsibility for all residents' safety. When asked about his system for ensuring the windows of the facility are secure, the Administrator said he had asked his maintenance director to complete an audit in March 2025 to check all windows and ensure they could not open more than four inches. The Administrator said he did not receive a formal audit from the maintenance director and took his word that it had been completed. During an interview on 6/10/25 at 7:35 A.M., the Case Manager in charge of admissions from the hospital was interviewed. The Case Manager said she helps coordinate Resident #172's admission to the facility and was aware that the Resident was in the hospital for psychiatric concerns and had attempted to elope from a window at a previous facility. The Case Manager said she sent all of the preadmission paperwork and the Resident's clinical history/information to the facility to ensure the facility would be able to handle the patient. During an interview on 6/10/25 at 9:01 A.M., the Admissions Coordinator said she was aware of Resident #172's prior attempt to elope from a window prior to his/her admission to the facility and did not tell the Administrator and did not have a conversation with anyone in the building to ensure the windows were secure. During an interview on 6/11/25 at 8:17 A.M., the Maintenance Director said he was asked to complete a window audit in March 2025, and he delegated his task to his assistant, asking him to ensure the windows could not open more than 4 inches. The Maintenance Director said he was never given a formal audit showing that his assistant completed this task, but he took his word for it. The Maintenance Director said he was never told to check the second-floor dining room door to the outside balcony, and he had never been told to add that door to his daily safety check. During an interview on 6/11/25 at 8:29 A.M., the Maintenance Assistant said he was assigned the task to audit all windows in March 2025, and he did this task but did not write down the results on a formal audit form. The Maintenance Assistant said he was aware that the window in Resident #172's room could open all the way, and he did not go back to ensure that it was secure. The Maintenance Assistant said the door to second-floor dining room is not on a daily safety check list and he was never told to check the door after the fact. During an interview on 6/11/25 at 11:18 A.M., the Administrator said he was unaware the window in Resident #172's bedroom was able to open all the way and that the maintenance assistant was aware of this. During an interview on 6/9/25 at 8:44 A.M., Physician #1 said he is the medical director of the facility and would have expected the facility to have a plan to ensure safety for residents admitted with a high risk and history of elopement. 2. Review of ten employee records indicated the following: -Eight out of ten employees had no dementia training. Five of these employees were newly hired and did not have the required 8 hours of dementia training. Three out of the five employees had been employed at the facility for over a year and did not have the required four hour yearly dementia training. -Four out of five employees who had been employed at the facility for more than a year had not completed annual education or competencies for caring for residents with dementia and a risk of elopement. During an interview on 6/10/25 6:52 A.M., Nurse #1 said the facility had never given the staff guidance or education on handling residents with a high elopement risk. Nurse #1 said the staff felt stuck because they didn't have guidance on how to manage extreme behaviors, such as residents who are attempting to elope from windows. During an interview on 6/11/25 at 8:38 A.M., Nurse #6 said she worked the 3:00 P.M. to 11:00 P.M. shift on the day of Resident #172's admission and that the Resident was constantly trying to elope from the building by pushing on door, elevators and windows. Nurse #6 said the Resident was opening windows and looking outside. Nurse #6 said no one from administration came to the unit to offer her or the other staff guidance of education on how to manage these behaviors and that this would have been very helpful. During an interview on 6/8/25 at 9:09 A.M., the Administrator said all staff should have direct knowledge on how to manage residents with dementia who have a risk of elopement. The Administrator said nursing staff are expected to complete education upon hire, annually and as needed. The Administrator said the Assistant Director of Nursing is responsible for staff education. During an interview on 6/10/25 at 11:50 A.M., the Assistant Director of Nursing (ADON) said he was hired within the last 30 days and did not have a chance to meet with the prior staff educator to understand the level of education previously provided to the staff. The ADON said that he is responsible for all new hire education and dementia training. The ADON said he was unaware the staff reviewed did not have annual competencies/education or dementia training. During an interview on 6/12/25 at 10:02 A.M., the Administrator said he was unaware that there was no annual education provided to the nursing staff last year. The Administrator said he had asked the previous nursing leadership to complete education and he had observed some ad hoc education occurring on the floor and assumed all education was being provided. 3. Review of the Facility Assessment, most recently updated on 4/18/25, indicated the following: -The purpose of the assessment is to evaluate the resident population and determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Use this assessment to make decisions about your direct staff needs (including those who provide services under contract and volunteers), as well as your capabilities to provide services to the residents in your facility, at least annually and as necessary, per the above requirement. Using evidence-based, data driven methods focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. - If the facility is less familiar with or has not previously provided care for diagnosis of potential admission, the IDT team will review the details of the referral's requirements for care prior to admission. The review will consist of matching the care needs of the residents to the current skill set of the staff. Any shortfalls in skill and knowledge sets will be identified. Educational opportunities for staff education and training to overcome the skill set lack will be identified and taken advantage of. Training will be provided by nursing management or by vendors of specific medical products the staff are not familiar with. -The facility created a grid of common diagnoses residents are admitted with. The list of diagnoses under the Mental and Behavioral Health sections listed behavior that needs interventions as a diagnosis the facility is able to admit. -The facility created a grid of resident care needs. Under the Mental Health and Behavior care area, the facility lists the following as areas of resident care provided by the facility: manage the medical conditions and medication-relates issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (post traumatic stress disorder), other psychiatric diagnoses, intellectual or developmental disabilities. -The staff are provided with training/education which includes how to care for residents with a diagnosis of dementia. -The staff are provided with competency training on disaster planning and procedures, which includes competency on elopements. The facility assessment failed to indicate the facility cared for a resident population with an increased risk of elopement. The assessment also failed to indicate caring for residents who are at risk for elopement was part of their staff training. During an interview on 6/10/25 at 12:37 P.M., the Administrator said he has written a lot of facility assessments over the years and did not think the elopement risk of the population was something that needed to be included in the assessment. The Administrator said every resident with dementia is at risk for elopement and the facility has a lot of residents with wander guards (a bracelet worn by the resident that triggers an alarm if a resident were to open a door or elevator) so that would indicate there is a risk for elopement. The Administrator said it was his responsibility to ensure the residents of the building were safe, including ensuring the windows are secure as listed in the facility assessment.