F-F689 included Immediate Actions Taken:

1. Implemented 1:1 supervision for this resident when he is not in group settings. Implemented upon his return to the facility on Tuesday, 05/20/25 and will remain for this resident for the duration of his stay at [the facility]. Compliance will monitored by Department Heads along with the Administrator and Director of Nursing.

2. Installed a double lock/window stop system on his patient room window to increase safety. The system was installed at 8:10 AM on 05/20/25 (prior to the resident returning to the facility). Window lock/stops will be checked for proper operation twice daily for the duration of Resident R2's stay at the facility. The lock/stop system has been installed on all patient room windows and will be monitored quarterly. Compliance will be monitored by

the Director of Plant Maintenance.

3. Reeducated the staff on the facility's Emergency Procedure for a Missing Resident. education began

during and immediately after the search on 05/20/25 and concluded on 05/23/25. Education will continue for all employees quarterly on each shift. Compliance will be monitored by the Department Heads along with the Administrator and Director of Nursing.

4. A Quality Assurance Performance Improvement (QAPI) was initiated on 05/20/25 to ensure that Resident R2 and other facility resident have appropriate supervision and assuasive devices in place to prevent accidents, especially those with exit seeking behaviors. Compliance will be monitored by Department Heads along with Administrator and Director of Nursing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 425054