**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of or has the potential to experience heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. (State Operations Manual appendix pp Long Term Care Facilities.) A Wander guard bracelet is used to keep residents at risk of wandering/elopement comfortable and protected. It is discreet yet powerful, it triggers alarms and can lock monitored doors to prevent the resident leaving unattended. A review of the facility incident investigation record for MD00173383, was conducted on [DATE] at 8:35 AM. The report stated that staff on [NAME] View observed Resident #17 walking in the common area and hallway then at approximately 9:17 AM on [DATE] they noticed that resident #39 wasn't there. At about 9:35 AM, Resident #17 was located at the top of the back staircase of [NAME] view hall. The report added that the resident was standing with walker in the stairwell, pants were down around lower leg, and wearing a wander guard on left wrist. The resident was described as oriented to person, confused and with impaired memory. Further review of the report revealed staff written statements that indicated the alarm did not go off. Review of the medical record on [DATE] at 10:30 AM, revealed Resident #17 was admitted in [DATE] with diagnoses that included Dementia, Anxiety, Depression, Insomnia, Hyperlipidemia, Macular degeneration, Glaucoma, Diabetes, Osteoarthritis, Hypertension, history of falling. On [DATE] at 1:45 PM, Resident # 17 was observed sitting in a wheelchair in the common area. Resident was alert and oriented to person only. He could say his/her first name but was not interviewable. Surveyor observed resident wearing a left wrist wander guard bracelet. On [DATE] at 11:40 AM, in an interview with the Maintenance Technician (Staff #22), he/she stated they conducted weekly maintenance checks on all the facility alarm doors. Staff #22 further stated that the Wander guard bracelet prevents the door from opening. When the alarm goes off it rings on all the pagers and alerts staff to the specific location of the door/stairwell. Pagers are specific to each floor and assigned to the nursing staff. The alarm will not go off if there was a problem with the system or if the wander bracelet battery died. Staff #22 added that the system was installed a couple of years ago and was working properly. On [DATE] at 12:10 PM, interview with Licensed Practical Nurse (LPN # 7). LPN # 7 stated she was working on the day Resident #17 was found in the long hallway stairwell of the second-floor unit. LPN #7 stated that the alarm did not go off even though the resident was wearing a wander guard bracelet. She/he further stated that they checked the resident ' s transmitter was checked and it was functional, and maintenance checked all the doors, and they were functioning properly. LPN #7 added that the nurses and the GNAs (Geriatric Nursing Assistant) all carry pagers that will ring when a resident with a wander guard bracelet went close to any of exit doors. When asked how the resident got into the stairwell, LPN #7 stated they were told by maintenance that if the alarmed door was pushed hard enough, the door will open, so the resident might have pushed the door open. On [DATE] at 8:39 AM, in an interview with the Assistant Director of Nursing (ADON), she stated that immediately following the incident, all the doors and the wander guard system including the resident ' s bracelet were checked and found to be functioning properly. When asked how the resident got into the stairwell, the ADON stated she was going to look into the report and come back with information. On [DATE] at 9:10 AM, the Administrator, the DON, and ADON respond to the question of how the resident got into the stairwell undetected. The Administrator stated that they could not determine how Resident #17 got in there because the wander guard alarm did not go off. He further stated that the fire alarm did not go off as well (that would have released the doors). He said they immediately brought in a company to check the Willow View Long Hall doors and the wander guard system on [DATE], all functioned without fail. Additionally, the resident ' s transmitter was checked and was functional, however, the transmitter was changed to a new wander guard transmitter to ensure no interruption in service. He advised staff education on door alarms, door checks, stairway checks, pagers, elopement precautions, resident engagement/diversional activities was completed. The resident ' s care plan was reviewed and updated. When asked if the alarm door could be pushed opened, the Administrator stated the door could be pushed opened if force is applied on it for 15 to 30 seconds. However, the Administrator stated that the alarm would go off if the door was forced open, which was not what happened in the above incident. On [DATE] at 2:25 PM, the monitoring log for the facility elopement deterrent system from [DATE], through [DATE], was requested and reviewed. Surveyor noted the following activity on the [NAME] View (WV) Long Hall Fire Stairwell on [DATE]; door open, door alarm signal was noted at 9:16 AM and shortly after that another signal picked up the resident at 9:17 AM and 9:19 AM respectively. There was a door access, no description, noted at 9:19 AM and 9:32 AM through 9:35 AM. On [DATE] at 4:20 PM, in an interview with one of the surveyors, the Administrator stated that door access, no description, noted on the monitoring log for the facility elopement deterrent system meant a staff member accessed the door. On [DATE], surveyors were able to verify that example #2 for Resident #17 was corrected prior to the survey start date. On [DATE] at 5:00 PM, all concerns were addressed with the Administrator, the Director of Nursing, and the Assistant Director of Nursing prior and during the survey exit. Based on a facility reported incident, reviews of a medical record, and staff interview, it was determined that the facility staff failed to: 1) follow Resident #15's plan of care and prevent injury to a resident during incontinence care. This resulted in harm to Resident #15; 2) provide adequate supervision of Resident #17 to prevent unsafe wandering/elopement. Although this noncompliance resulted in no actual harm Resident #17, it has a potential for more than minimal harm if the practice is not corrected. This occurred for 2 of 8 residents reviewed during a Long-Term Care Survey Process annual recertification survey. The findings include: A review of facility-reported incident MD00175591 on [DATE] revealed that Resident #15 while being cared for on [DATE] at 1:20 AM, rolled out of bed onto the floor. X-rays were obtained and confirmed a right arm fracture and pelvic fracture. Review of the medical record on [DATE] revealed Resident #15 was admitted to the facility in [DATE] with diagnoses that included a stroke with left-sided weakness, morbid obesity, chronic kidney disease, and hypothyroidism. A review of Resident #15's ADL self-performance care plan on [DATE] revealed that Resident #15 was assessed by the staff on [DATE] and noted to require total assistance by 2 staff members to turn and reposition in bed and 2 staff members for toileting/incontinence care. The interventions were added to Resident #15's care plan. A review of the facility policy, Lifting/Transferring/Repositioning, L-05, Resident Safety, on [DATE], revealed that the purpose of the policy is: To strive to establish the requirements for safe resident lifting, transferring and repositioning techniques, reduce ergonomic hazards, help prevent injuries to employees, and to promote safe work practices. The policy indicates: Each employee will utilize a mechanical lift device when lifting or transferring a resident who has limited ability to assist. The determination is made by nursing or therapy staff who will determine the percentage of assistance each resident requires. Staff will not lift anything heavier than thirty-five (35) pounds without using the assistance of some lifting device. In an interview with Geriatric Nursing Assistant (GNA) #37 on [DATE] at 4:40 PM, GNA #37 stated that s/he was alerted to Resident #15 on [DATE] at 1:20 AM, by Resident #15 calling GNA #37 on the telephone to report that s/he needed help. GNA #37 then stated that s/he went to Resident #15 ' s room and raised the head of the bed that is when Resident #15 asked for his/her incontinence brief to be checked. GNA #37 stated that Resident #15 indicated that no other staff member had been in his/her room since 12 noon on [DATE]. GNA #37 stated that Resident #15 ' s brief was soaked with urine and that s/he had a bowel movement. GNA #37 stated that s/he lowered Resident #15 ' s head of the bed and raised the entire bed as high as it could be raised into the air. GNA #37 stated that s/he then positioned Resident #15 to perform incontinence care. GNA #37 stated that s/he was cleaning Resident #15 with one hand and holding onto Resident #15 with the other hand. GNA #37 stated this is when Resident #15 started to slide out of the bed. GNA #37 stated that s/he could not hold onto Resident #15. GNA #37 stated that s/he was never shown, during new employee training in [DATE], how to look up a resident ' s care guide on the IPAD. The staff care guide/IPAD is where staff can review every resident care plan and what individualized nursing interventions, like the number of staff members needed for resident transfer/care. In an interview with the facility director of nurses (DON) on [DATE] at 11:45 AM, the facility DON stated that s/he was unable to locate any of GNA #37 ' s checklists that indicated GNA #37 had received training on the use of the IPAD/Care tracker and how to access all residents care plans since being hired in [DATE]. The DON stated that GNA #37 did receive one on one education with the staff education nurse on [DATE], including, reviews of the orientation checklist for a nursing assistant, charting in the electronic health record, and how to look up all residents ' care plans on the electronic health record. In an interview with Resident #15 on [DATE] at 12:51 PM, Resident #15 stated that s/he recalled falling out of bed in February 2022 and having a fractured right arm. Resident #15 stated that ' s/he called GNA #37 to provide incontinence care. Resident #15 stated that GNA #37 is six foot 7 inches tall, so GNA #37 did have to raise my bed into the air. Resident #15 stated that s/he slide out of bed onto the floor and that GNA #37 was alone when providing care on [DATE] at 1:20 AM. Resident #15 stated that 2 staff members come in now to provide any type of care for me. Resident #15 stated that his/her right arm is his/her functioning arm and that the left arm is weak.