Health inspection·September 18, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of Emergency Medical Service (EMS) records, hospital record review, review of the facility Elopement and Secure Unit policy and procedures and interviews, the facility failed to provide adequate supervision and individualized interventions to prevent Resident #87 from eloping from the third floor secured behavioral unit. This resulted in Immediate Jeopardy on 09/02/23 at approximately 9:00 P.M. when Resident #87, with a known history of elopement and poor judgement and insight, was last seen by facility staff before eloping from the facility third floor secure behavioral unit without staff knowledge. Actual serious harm/injury occurred when Resident #87 exited the window of his third story room and either jumped/fell to the ground or descended via a ledge to a first story rooftop before jumping/falling to the ground. Resident #87 was not identified as missing from the facility until 09/03/23 at approximately 6:00 A.M. when he was observed outside the facility covered in blood and feces by Dietary Aide #805. The resident was subsequently transported to the hospital where he was diagnosed with a right acetabular non-weight bearing fracture (socket of hip bone), left distal radial (wrist) fracture, right fifth rib fracture, comminuted fracture (bone fractured into more than three separate pieces) of the lateral right orbital wall (eye socket), right parietal bone (part of skull) fracture, right temporal bone (part of skull) fracture, and sphenoid (sinus) fracture. This affected one resident (#87) of three residents reviewed for elopement. The facility census at the time of the survey was 101. On 09/12/23 at 1:42 P.M. the Administrator was notified that Immediate Jeopardy began on 09/02/23 at approximately 9:00 P.M. when Resident #87 lacked sufficient supervision, exited the facility unsupervised from the secured care unit without staff knowledge, resulting in serious bodily injury/hospitalization. The Immediate Jeopardy was removed on 09/05/23 when the facility implemented the following corrective action: • On 09/03/23 at 6:00 A.M. Resident #87 returned to the facility and was assessed to have swelling to his head and eye. Licensed Practical Nurse (LPN) #803 notified the Director of Nursing (DON), Administrator, Nurse Practitioner (NP) and on-call NP. On-call NP indicated they would contact the resident's guardian and give report to hospital. Staff performed a head count to ensure all residents were accounted for. Emergency Medical Services (EMS) arrived to the facility at approximately 8:00 A.M. and transferred Resident #87 to hospital. Upon the resident's return, an STNA was assigned to remain in the room until the window was secured. The STNA remained in Resident #87's room from 7:00 A.M. until secured by Maintenance at 10:40 A.M. Page 1 of 10 365879 365879 09/18/2023 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 • Level of Harm - Immediate jeopardy to resident health or safety On 09/03/23 the Maintenance Director verified all windows on the 100, 200, 300, and 400 units were secured and unable to be opened enough to prevent a resident from exiting. • Residents Affected - Few On 09/03/23 the Maintenance Director verified all exits on the secured behavior unit were functioning. • On 09/03/23 the facility completed a re-assessment of Resident #87's elopement risk. The resident was assessed to be at risk of elopement. • On 09/03/23 the Director of Nursing (DON) completed an elopement assessment for all residents. There were no new interventions or changes to any other residents' care plans as a result of the assessments. • On 09/03/23 the DON/designee educated all shift nurses (Licensed Practical Nurses (LPNs) and Registered Nurses (RNs)), on all floors to complete a head count at the start of each shift. Any variances were to be reported daily to the DON and Administrator. Results would be shared with the Quality Assessment Performance Improvement (QAPI) committee as needed. • On 09/03/23 the DON educated the secured behavior unit staff on duty, to complete a head count each hour. At the time of the head count, environmental observations (for safety) were also to be completed until further notice. Any variances were to be reported to the DON and Administrator. There were no variances reported as all residents were accounted for. The DON/designee used the OnShift messaging system to educate all staff on the head count requirement at the start of each shift, and the third floor every hour requirement. The DON/designee also educated all facility staff on the facility elopement process and procedures. • On 09/03/23 the DON and Administrator completed a QAPI plan. • Beginning 09/04/23 the Administrator/designee implemented a plan to complete weekly random audits of 10 resident rooms for four weeks to ensure the resident room windows were secure. • 365879 Page 2 of 10 365879 09/18/2023 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Beginning 09/04/23 the facility implemented a plan for the Maintenance Director/designee to verify all resident room windows on the secured behavior unit were secure daily for four weeks. Variances would be reported to the Administrator/designee immediately. • Beginning 09/04/23 the facility implemented a plan for the Maintenance Director/designee to check the 100, 200, and 400 resident room windows once a week to ensure the windows were secure. Variances would be reported to the Administrator/designee immediately. • On 09/05/23 the QAPI plan was reviewed by the IDT committee including the DON, Administrator, and Medical Director. • On 09/05/23 the DON and Administrator reviewed the facility head count process. The results would be shared with the QAPI committee as needed. • On 09/05/23 the Administrator/designee conducted an elopement drill. • On 09/05/23 the Administrator contacted Resident #87's guardian to discuss the elopement incident and interventions in place. • On 09/08/23 Resident #87 returned to the facility from the hospital and an admission assessment was completed. A head-to-toe assessment was also completed. Resident #87 was scheduled for a follow up appointment with the vascular surgeon for his left distal radius fracture. • On 09/11/23 the facility completed a social services review and evaluation for Resident #87. The facility identified continued support and opportunities to discuss feelings would be provided. • On 09/12/23 the facility completed a psychological evaluation for Resident #87 with new physician orders for medications, including Zoloft for depression and Risperdal for paranoid schizophrenia. • On 09/13/23 Resident #87's care plan was reviewed with revisions and new interventions related to Resident #87's elopement risk, actual elopement, and sustained injuries. 365879 Page 3 of 10 365879 09/18/2023 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 • Level of Harm - Immediate jeopardy to resident health or safety The facility provided information that by 09/22/23 the Maintenance Director would replace all 100, 200, 300, and 400 unit window screws with self-tapping hex washer head screws for added security. Residents Affected - Few Although the Immediate Jeopardy was removed on 09/05/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of a Care Coordination Note dated 08/04/21 revealed the probate court had issued an order of detention for psychiatric admission for Resident #87. Resident #87 once stabilized would be referred to Cityview Healthcare and Rehabilitation. Review of an Emergency Department Biopsychosocial Assessment Note dated 08/04/21 revealed Resident #87 presented via Sheriff's Department and was on a probate order. Resident #87 was noted to have a long history of schizophrenia. Resident #87 was a patient at a skilled nursing facility (SNF) and had eloped by climbing over a fence. Resident #87 refused to answer questions and had no understanding of the need for medications to maintain his life. Resident #87 was admitted for inpatient psychiatric stay. Review of a Behavioral Health Institute admission Note dated 08/05/21 revealed Resident #87 had a tendency to isolate self, had difficulty with relationships, poor social skills, and generalized negative attitude about future/recovery. Resident #87 was noted to have poor judgement and insight. Review of the medical record for Resident #87 revealed an admission date to the facility on [DATE] with diagnoses including paranoid schizophrenia, major depressive disorder, insomnia, brief psychotic disorder, schizoaffective disorder, and mental disorder due to known physiological condition. Resident #87 was identified to have a legal guardian. Review of medical record revealed Resident #87 was admitted to the facility third floor secured behavioral unit. Review of an Elopement Evaluation dated 08/11/21 revealed Resident #87 had history of attempting to leave the facility without informing staff and was recently admitted without accepting situation. Staff were notified of Resident #87's wandering risk. Review of the plan of care dated 08/30/21 revealed Resident #87 required a room on the secure unit related to unawareness of safety needs and to promote psycho-social well-being due to mental illness. Interventions included encourage the resident to participate in activities of choice and provide distraction with diverse activities throughout the day. Review of the plan of care dated 08/30/21 revealed Resident #87 was at risk for elopement due to history of eloping. Interventions included apply wander guard (a monitoring device that activates audible alarm if an individual approaches a set boundary), check function of wander guard every shift, change battery monthly of wander guard, and complete elopement risk assessment upon admission/quarterly/and as needed. Review of a social service note, dated 10/13/21 revealed Resident #87 was asking to go home and had 365879 Page 4 of 10 365879 09/18/2023 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few no understanding of his reason for placement. Resident #87 had a guardian. The guardian explained Resident #87 had required adult protective services (APS) assistance while in community and had eloped from last skilled nursing facility he had resided in. Resident #87 had many behaviors requiring attention and would need to stay long term care (LTC) for the foreseeable future. Review of a physician's order dated 04/15/22 revealed Resident #87 was in the least restrictive environment possible and needed a secure unit due to behaviors related to paranoid schizophrenia. Review of facility Consent to Resident on the Connections Unit dated 10/13/22 revealed Resident #87's guardian signed consent for him to reside on the Connections secured unit. The consent gave description of the Connections secured unit: a secure unit which provided a living environment, supportive for those with mental health diagnosis and supports a need for increased safety and supervision. The unit was a locked unit with coded keypads to unlock the doors. The form noted Resident #87 was admitted for reason of: chooses to be on the unit because of personal preference such as a specific room, smaller physical environment, and comfort in a focused daily routine. Review of the plan of care note dated 11/29/22 revealed Resident #87 continued to require long term care (LTC) per guardian due to inability to care for self in community. Review of an Interdisciplinary Care Conference Summary dated 05/08/23 revealed Resident #87 was requesting to go home to live with his sister. Resident #87 was noted to have cognitive loss. Placement on secured unit was reviewed and remained appropriate. Review of an Interdisciplinary Team (IDT) Note dated 05/11/23 revealed Resident #87's guardian continued to recommend placement at Cityview Healthcare and Rehabilitation for mental health and medical care. Guardian indicated Resident #87 was a danger to himself and others. Review of the plan of care dated 05/12/23 revealed Resident #87 had the need to reside in the Connections Community due to behavior of physical aggression with others. Interventions included encourage daily routine to stay as independent as possible, encourage outlets of behaviors, review for potential contracts to motivate the resident, reinforce with positive rewards when positive behavior displayed, utilization of behavior modification, and when positive behavior is noted address immediately with a compliment. Review of physician's order dated 05/30/23 revealed Resident #87 required room on secured unit to promote psychosocial well-being and interaction with peers. Review of a Bi-Annual Comprehensive Visit note, dated 06/26/23 revealed Resident #87 was assessed by a Nurse Practitioner (NP). Resident #87 was assessed to be alert and oriented to person and place. The NP noted Resident #87 was forgetful and difficult to understand. The NP questioned Resident #87's ability to provide accurate answers to questions. The NP assessed Resident #87 to have memory loss and cognitive impairment of intellectual disabilities. The NP noted Resident #87 had paranoid schizophrenia which was managed by a psychologist. Review of an Elopement Evaluation dated 07/14/23 revealed Resident #87 was assessed to be not at risk for elopement. Review of annual Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #87 had unclear speech, a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact), and 365879 Page 5 of 10 365879 09/18/2023 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few no wandering behaviors. Resident #87 required staff supervision with set up assistance for transfers, toileting, and bathing, and was independent with no set up for walking in room/corridor. Resident #87 was noted to be occasionally incontinent of bowel and bladder. The assessment indicated there were no wandering or elopement alarms used. Review of a PsychoTherapies Skilled Nursing Facility Encounter note, dated 08/08/23 revealed Resident #87 was seen for follow up management of chronic mental health and psychiatry conditions. Staff and Resident #87 reported no concerns or behaviors. On Mental Status Examination, Resident #87 was assessed to have poor judgement and insight, poor attention and concentration, and poor fund of knowledge. The facility was to continue to provide Invega medication for schizophrenia and Trazodone medication for insomnia as ordered. Review of a quarterly social service [NAME] dated 08/14/23 revealed Resident #87 resided on a secured behavior unit and placement was appropriate due to need for monitoring for safety. Resident #87 was noted to have paranoid schizophrenia and indicated the resident was well adjusted to unit with no behaviors. Review of a Secured Unit assessment dated [DATE] revealed Resident #87 was assessed for Connections behavioral community. Continued placement was recommended due to Resident #87 liked the unit and preferred to stay on unit. Review of the facility Behavior Monitoring Response History revealed on 08/31/23 Resident #87 had an episode of wandering. Review of Medication Administration Record (MAR) for September 2023 revealed the last confirmed time Resident #87 was seen by a nurse on 09/02/23 was at 9:00 P.M. when he was administered Trazodone for insomnia, Atorvastatin Calcium for hyperlipidemia, and insulin for diabetes mellitus. Review of an electronic medical record entry (General Note) dated 09/03/23 and entered as a late entry on 09/05/23 by LPN #803 revealed Resident #87 exited the elevator to third floor secure behavioral unit at approximately 6:00 A.M. on 09/03/23. Resident #87 was noted to be covered in feces and blood. Resident #87's head and eye were swollen. The nurse attempted to assess Resident #87; however, the resident was insistent on going to his bedroom. Nurse and nurse's aide followed Resident #87 to his bedroom and observed him immediately go over to bedroom window to close it. Nurse assessed window and noticed it was able to open and close fully. Resident #87 indicated a staff member with blonde and silver hair had taken him outside and left him outside. Resident #87 indicated he slept across the street. Resident #87 then indicated he may have gone out the window but was unsure. Nurse again attempted to assess Resident #87 and vital signs were stable. The nurse notified the DON, Administrator, NP and on-call NP. The on-call NP indicated they would contact resident's guardian and give report to hospital. Staff performed a head count to ensure all residents were accounted for. Emergency Medical Services (EMS) arrived to the facility at approximately 8:00 A.M. and transferred Resident #87 to hospital. EMS indicated they were unsure which hospital Resident #87 was being taken to as it appeared he fell from a third story window. Review of Transfer Form dated 09/03/23 revealed Resident #87 was transferred to the hospital from the facility for trauma related to fall or other. The transfer was unplanned and Resident #87's guardian was notified. Review of an Elopement Evaluation dated 09/03/23 revealed Resident #87 was at risk for elopement 365879 Page 6 of 10 365879 09/18/2023 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few due to history of elopement or attempted leaving the facility without informing staff, resident wanders, wandering behaviors was a pattern and goal directed. Review of the Cleveland Emergency Medical Services (EMS) Patient Care Report dated 09/03/23 revealed a call was placed for services at 7:32 A.M. on 09/03/23. EMS arrived on scene at 7:47 A.M. however were unable to reach Resident #87 until 8:00 A.M. due to the resident residing on a locked unit. Resident #87's chief complaint was a fall victim. Resident #87 reported pain to his face with noted abrasions and swelling to right eye. Resident #87's right eye was noted to be swollen shut. Resident #87 also reported pain in his neck. Resident #87 reported to EMS approximately 12 hours prior he had jumped from third floor window and landed on face. Resident #87 stated he crawled back into the nursing home and staff put him back to bed. Staff confirmed Resident #87 had jumped from the window. Resident #87 reported no suicidal ideations and indicated he had jumped to escape from nursing home staff. Resident #87 was transported to hospital without incident. Review of the hospital History and Physical dated 09/03/23 revealed Resident #87 was admitted to the emergency department status post fall from three stories. Resident #87 was noted to be agitated and perseverating on making sure his money was safe. Resident #87 complained of pain around his neck due to cervical collar and pain to left wrist. Resident #87 was noted to have right frontal cephalohematoma (an accumulation of blood under the scalp), scattered abrasions over right side of face, and right periorbital edema (swelling around eye) and ecchymosis (discoloration around eye). The hospital staff were unable to obtain a past history due to the resident's mental status. Resident #87 was sent for radiology services including computerized tomography (CT) scan of chest, abdomen, pelvis, facial bones/head and x-ray of wrist. Resident #87 was found to have right acetabular fracture, left distal radial fracture, right fifth rib fracture, comminuted fracture of lateral right orbital wall, right parietal bone fracture, right temporal bone fracture, and sphenoid fracture. It was recommended to admit Resident #87 to trauma intensive care unit (TICU) and consult with neurosurgery, orthopedics, plastic surgeon, and ophthalmology. Resident #87 required Haldol for agitation. Review of a hospital daily progress note dated 09/03/23 revealed no acute surgery per plastic surgeon was needed however the resident should remain on sinus precautions. Ophthalmology suggested to avoid blowing nose, use ice packs, and administer nasal decongestant. Orthopedics recommended no acute surgery for right acetabular fracture, right fifth rib or left distal radial fracture. Orthopedics recommended to allow weight bearing to right hip, start therapy, splint left upper extremity and pad pressure points. Review of hospital Clinical Event Note dated 09/04/23 revealed neurosurgery reviewed follow up imagining and Resident #87 was stable. Neurosurgery suggested follow up in two weeks for repeated scan. Review of a hospital daily progress note dated 09/05/23 revealed Resident #87 continued to have agitation. Resident #87 was given dose of Haldol and started on Risperidone. Review of a social services note dated 09/06/23 revealed Resident #87 had called the facility social worker and asked to be picked up so he could return to facility. Resident #87 was asked what had happened and Resident #87 indicated he wanted to go back to Austintown, but his guardian would not let him. Resident #87 was informed they could discuss further with guardian upon return to facility from hospital. Resident #87 was noted to become delusional and spoke of playing professional football. Review of a hospital Gold Form: Provider Orders dated 09/08/23 revealed Resident #87 was accepted 365879 Page 7 of 10 365879 09/18/2023 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few for return to Cityview Healthcare and Rehabilitation. Resident #87 was provided with orders for sinus precautions, ice packs and nasal decongestant as needed, to follow up with outpatient services for right temporal bone fracture, sphenoid fracture, right parietal bone fracture, right acetabular fracture and left distal radial fracture, and follow up with primary care provider for rib fracture. Resident #87 was also provided with medication orders for Risperidone one milligram (mg) oral tablet twice per day, Sertraline 25 mg oral tablet once per day, Trazodone 50 mg oral tablet once per day at bedtime, Melatonin 5 mg oral tablet as needed daily, and Haloperidol 2 mg oral tablet every eight hours as needed. Review of a general note dated 09/08/23 revealed Resident #87 returned to the facility from the hospital. Resident #87 was assessed to be alert and oriented to person, place, and time and able to make his needs known. Resident #87's vital signs, bowel sounds, lung sounds, and skin were assessed with no abnormal findings. Resident #87 was able to ambulate with stand by assist and was non-weight bearing to left arm. Resident #87 was noted to have dark discoloration to the right side of face and soft cast on left arm. Resident #87 had a scheduled follow up appointment with vascular surgeon for left distal radius fracture. Orders were verified with NP and faxed to the pharmacy. Review of a head-to-toe assessment dated [DATE] revealed Resident #87's skin integrity was assessed with noted bruising to face. Review of a social service note, dated 09/11/23 revealed Resident #87 was seen for return from hospital. The Social Worker assessed Resident #87 as alert and oriented to person, place, and time with BIMS score of 15. Resident #87 was asked about the (elopement) incident, and he stated he did not remember. It was noted Resident #87 had rib fracture, orbital fracture, and radius fracture. Social Services would continue to provide opportunities to express feelings about desire to go to Austintown. Social Services noted Resident #87's guardian requested continued placement at Cityview Healthcare and Rehabilitation related to past failures in group homes and other SNFs. Interview upon entrance conference on 09/11/23 at 8:51 A.M. with the Administrator and Director of Nursing (DON) confirmed there had been an elopement involving Resident #87. On 09/11/23 at 9:31 A.M. Resident #87 was observed lying in his bed in his room on the third floor secured behavioral unit. Interview on 09/11/23 at 12:12 P.M. with Maintenance Supervisor #802 revealed he received a phone call on 09/03/23 and was notified Resident #87 was found outside of the building. Maintenance Supervisor #802 reported he was asked to come to the facility and check all windows for security. Maintenance Supervisor #802 indicated windows were secured using screws in the window tracks. Maintenance Supervisor #802 indicated the window in Resident #87 was found to be tampered with upon inspection. Observation on 09/11/23 at 12:16 P.M. with Maintenance Supervisor #802 of Resident #87's bedroom window revealed the screw in window track had been replaced and the window was secure when pushed on. Maintenance Supervisor #802 indicated he planned to replace all screws in windows with a flat head screw that required a special tool to remove. Maintenance Supervisor #802 indicated with the current screws a resident could use a flat object to loosen/remove it over time. Observation on 09/11/23 at 12:23 P.M. with Maintenance Supervisor #802 of Resident #87's bedroom window from outside the facility revealed the building consisted of four floors with a basement. Below Resident #87's window was access to the basement level via stairway. Below windows on each floor 365879 Page 8 of 10 365879 09/18/2023 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was a ledge that ran the length of the building. Branching off on first floor level was a roof top identified on map as boiler room. Maintenance Supervisor #802 indicated each floor was approximately 10 to 12 feet tall. There was chain-link fence surrounding the facility parking lot with gate. Maintenance Supervisor #802 indicated the gate does not get closed at night. Telephone interview on 09/11/23 at 12:46 P.M. with Licensed Practical Nurse (LPN) #803 revealed he was the nurse from 11:00 P.M. on 09/02/23 to 7:00 A.M. on 09/03/23. LPN #803 indicated he came in and completed initial rounding at 11:00 P.M. LPN #803 noted Resident #87 appeared to be in bed with covers over his head. However, LPN #803 was unable to verify if Resident #87 was actually in bed at time of observation. LPN #803 revealed he normally checked on residents every two hours but could not confirm if he did this for Resident #87 as he was assisting another resident with behaviors that night. LPN #803 indicated he started morning medication pass at 5:00 A.M. LPN #803 indicated he went to nurses' station to get a glucometer and saw Resident #87 get off elevator. LPN #803 indicated Resident #87 returned to the third floor secured behavioral unit via elevator at approximately 6:00 A.M. LPN #803 indicated Resident #87 was not accompanied by any staff members. LPN #803 reported he was unaware Resident #87 was out of the facility until his return at approximately 6:00 A.M. on 09/03/23. LPN #803 indicated Resident #87 was covered in blood and feces. LPN #803 indicated he began questioning Resident #87 who brushed past him and walked down to his bedroom. LPN #803 indicated he followed Resident #87 to room and observed Resident #87 closing his bedroom window. LPN #803 indicated that was unusual and he went to the window to inspect. LPN #803 noted the window was able to fully open and close. LPN #803 indicated Resident #87 reported pain in arm and noted swelling on head during assessment. LPN #803 questioned Resident #87 again on what had happened. Resident #87 initially reported a nursing assistant with blonde or silver hair took him outside and he slept across street. LPN #803 questioned how the wounds were inflicted and Resident #87 later indicated he may have gone out the window. LPN #803 indicated he then contacted the DON and Administrator. LPN #803 indicated he was instructed to contact the nurse practitioner. LPN #803 indicated he was advised to send Resident #87 to hospital via EMS. LPN #803 noted it took about 30 minutes until Resident #87 left with EMS services. Telephone interview on 09/11/23 at 12:56 P.M. with State Tested Nursing Assistant (STNA) #804 revealed she was working from 11:00 P. M on 09/02/23 to 7:00 A.M. on 00/03/23. STNA #804 indicated she usually sits within view of the elevator on her break in case a resident tried to get on elevator. STNA #804 indicated on 09/03/23 she observed Resident #87 exit the elevator. STNA #804 indicated she followed Resident #87 to his room and observed Resident #87 close the window in his bedroom. STNA #804 indicated she was unaware Resident #87 was not in his room until he exited the elevator. STNA #804 indicated Resident #87 appeared dirty upon his return. STNA #804 indicated she does rounds every two hours, however she was not supposed to wake the residents if they were sleeping. STNA #804 indicated Resident #87 appeared to be in bed with covers over his head during her rounds but was unable to verify if Resident #87 was actually in bed at time of observations. The resident's medical record documentation included an entry in the Walk In Room Response History section on 09/02/23 at 11:24 P.M. However, the interview with STNA #804 on 09/11/23 at 12:56 P.M. verified she did not physically see Resident #87 at this time, but rather thought the resident was in bed with covers over his head. Interview on 09/11/23 at 1:35 P.M. with Resident #87 confirmed he had gone out the window of his bedroom on the secured behavioral unit. Resident #87 indicated he walked along the ledge under window and jumped down to first floor roof then jumped again to the ground. Resident #87 indicated he went across the street to an open area, but stated he came back after an hour. Resident #87 indicated the 365879 Page 9 of 10 365879 09/18/2023 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few hospital tried to put casts on his legs and arms, but he stated he didn't get hurt. Resident #87 was unable to provide any additional details involving the incident. Interview on 09/11/23 at 1:50 P.M. with the DON revealed the facility had security cameras located on the back of building but they were not in working order. The DON indicated an interview was not completed with Resident #87 at the time of the incident as he appeared to have a head injury and was not coherent at that time. The DON indicated she had attempted follow up interviews with Resident #87, however he had reported he does not remember the situation. The DON indicated the facility was working with resident's guardian to move Resident #87 off the secured unit prior to the incident, but Resident #87 did not want to move from secure unit. The DON indicated, prior to the incident, Resident #87 had been provided with the access codes to the elevator as Resident #87. The DON indicated the nurse aide had reported Resident #87's bed was arranged that night with a pillow and blanket as if he was in bed (resulting in an inability to determine exactly when Resident #87 left the facility or was not in his bed). The DON verified Resident #87 returned to the third floor via elevator at 6:15 A.M. on 09/03/23. The DON reported the resident had been let back into the facility by Dietary Aide #805. Interview on 09/11/23 at 2:15 P.M. with STNA #807 revealed she started her shift on 09/03/23 at 7:00 A.M. and was responsible for monitoring unsecured window in Resident #87's room until it could be secured. STNA #807 indicated she asked Resident #87 what he was trying to do by going out window and he responded I want to go home. STNA #807 noted Resident #87 appeared injured and she let him rest until EMS services arrived. Telephone interview on 09/11/23 at 3:39 P.M. with Guardian #809 verified he was Resident #87's guardian. Guardian #809 revealed the resident was an elopement risk, however Resident #87 had initially been compliant since arriving to facility. Guardian #809 indicated Resident #87 had a challenging mental health history and was found in unsafe living conditions prior to admission. Guardian #809 indicated Resident #87 was originally placed in a group home, however due to non-compliance was discharged . Guardian #809 [TRUNCATED] 365879 Page 10 of 10