**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess each fall and identify causal factors to determine reason for falls, identify potential effective interventions to decrease the risk for falls, failed to comprehensively evaluate and implement fall interventions for 2 of 3 residents (R1, R3) reviewed for falls. The facility's failures resulted in an immediate jeopardy for R1 who sustained a right hip fracture from the 9th fall. The IJ began on 3/28/24, when the facility failed to complete a comprehensive causal analysis, and implement appropriate interventions after R1 self-transferred to the bathroom resulting in his 9th fall from self-transfers which subsequently resulted in, hospitalization, and right hip fracture with surgical repair. The administrator and director of nursing (DON) were notified of the IJ on 4/11/24 at 6:17 p.m. The IJ was removed on 4/12/24 at 5:22 p.m. after it could be verified that the facility had implemented an acceptable removal plan, however, non-compliance remained at D isolated severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's face sheet identified R1 had diagnosis that included, neuropathy (nerve damage that numbness in extremities), vascular dementia, urinary retention, weakness, unsteadiness on feet, muscle wasting and atrophy (wasting or thinning of muscle mass). R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment. R1 had no falls in the past six months. R1 required supervision/touch assist for sit to stand, chair to bed, bed to chair, walking, toileting, and toileting hygiene. R1 required intermittent catheterization and had not done a toileting program. R1's MDS did not identify falls prior to residing at the facility. R1's Fall Risk assessment dated [DATE], identified R1 did not have a history of falls in the past six months, occasional incontinence, required hands on assistance to move from place to place, and used an assistive device. Summary identified that R1 had a score of 16 which placed R1 at a high fall risk, family reported no falls in the last six months and R1 used a walker and assist of one for all transfers with intermittent confusion noted. R1's care plan dated 1/11/24, identified R1 had a risk of falls related to (r/t) dementia, history of falls, and noted self-transferring. Goals included R1 would not experience falls and would be free of injury through review date. R1's care plan dated 1/11/24, identified R1 had altered self-care performance, limited physical mobility r/t dementia, pain, weakness and need for assist. Interventions included: -one-person physical assist with toileting and transferring on/off toilet, use four wheeled walker (4WW). -assistance with adjusting clothing, incontinence care, applying incontinence product, wiping self, and pericare. -encourage to use call light for assistance. Ensure call light is within reach. -one-person physical assist with bed mobility. -one-person assist with transfers and ambulation using gait belt and 4WW. R1's bladder evaluation dated 1/18/24, identified R1 had a history of urinary incontinence and urinary tract infections (UTI). R1 was frequently incontinent. Conditions impacting urinary status included pain, edema, diabetes, and urinary disorders. Voiding status identified R1 had the perception of needing to void, dribbled after void, and urinary retention. R1's usual elimination was upon rising, after breakfast, after lunch, after dinner, at bedtime, during the night, and intermittent cath after voiding. Evaluation for bladder program potential left blank. R1's care plan dated 1/11/24, identified R1 had altered urinary pattern related to functional incontinence, history of urinary tract infection, stress incontinence, urinary retention, neurogenic bladder, and straight cath use. Goals included R1 will show no signs/symptoms of urinary infection, and decrease frequency of urinary incontinence. Interventions included: -catheterize twice per day by staff and as needed (PRN), monitor urine outputs (voided and post cath) -attempt to identify residents individual toileting habits/voiding pattern through observation and interview staff/family Although R1's comprehensive bladder assessment dated [DATE] identified R1's usual toileting routine was prior to facility admission, R1's care plan did not address R1's toileting routine according to the assessment. The falls are identified as follows: R1's progress noted dated 1/12/24 at 4:11 a.m., identified R1 self-transferred into bed from recliner chair and was reminded again to use the call light. At 4:49 a.m., R1 was found taking self back from bathroom without walker and did not use the call light. R1's progress note dated 1/13/24 at 5:26 a.m., identified R1 self-transferred twice to the bathroom, once using his call light and once not using it. R1's Incident Report dated 1/19/24, identified that R1's call light went off around 11:15 p.m. R1 was found laying on the left side by the recliner. Call light was underneath resident and pulled out from wall. R1 stated that his legs gave out on him twice-once in the bathroom and once on his way back from the bathroom. Predisposing factors included R1 did not use the call light consistently, call light in reach, improper footwear, and ambulated without assistance. Intervention included call light clipped to R1's shirt and ice packs applied to back/hip and left side of head, and gripper socks applied. R1's care plan was revised on 1/19/24, to include ensure gripper socks are on. R1's progress note dated 1/20/24 at 9:45 p.m., identified R1 had been self-transferring all afternoon and not using the call light. R1 had been reminded throughout the evening to use the call light and was shown multiple times how to. R1's Incident Report dated 1/21/24, identified R1's call light went off around 2:30 a.m. R1 was found kneeling on floor next to bed holding on to side rail. R1 stated he was coming back from the bathroom and his legs gave out. Added a double touch call light with one call light clipped to R1 and the other call light on outer edge of bed. Predisposing factors included incontinence, gait imbalance, impaired memory, does not use call light consistently, ambulating without assist, used wheeled walker, and call light in reach. Interventions included call light clipped to shirt and gripper socks on. R1's care plan was revised on 1/21/24 to include ensure double touch call light in place, with one call light clipped to shirt and one on outer edge of bed. R1's Fall Risk assessment dated [DATE], identified R1 had a recent fall history of 1-2 times in the past six months, occasional incontinence, required hands on assistance to move from place to place, exhibits loss of balance while standing, uses short discontinuous steps and/or shuffling gait, and used assistive device. Documented date of recent falls on 1/19/24, and 1/21/24. Summary identified R1 now had a score of 20 and placed him at a high fall risk, used walker and assist of 1 for all transfers and R1 noted to often self-transfer despite education and intermittent confusion noted and to see care plan for interventions. R1's care plan was revised on 1/24/24 to include ensure bed alarm is on at all times when resident is in bed. R1's Physical Therapy (PT) discharge date d 1/29/24, identified that R1 required partial to moderate assist with transfers, ambulation, and bed mobility. R1's Occupational Therapy (OT) discharge date d 1/29/24, identified R1 required touching assist with toileting tasks, toilet transfer, and dressing. R1's progress notes reviewed between 1/30/24 to 2/15/24 identified R1 had been found by staff self-transferring 21 times. Thirteen (13) of R1's self-transfers were toileting related and of those 13 self transfers, 10 were between 8:56 p.m. and 6:30 a.m. (the other three did not identify reason for self-transfer) The record identified the self transfers occurred on 1/30/24, 1/31/24, 2/1/24, 2/2/24, 2/4/24, 2/5/24, 2/8/24, 2/9/24, 2/11/24, 2/14/24 and 2/15/24. There was no indications a comprehensive assessment and/or care plan revision was completed that addressed the mitigation of falls related to R1's self transfers to the bathroom. R1's progress note dated 2/15/24 at 12:15 a.m., identified R1 self-transferred throughout shift. R1's Incident Report dated 2/15/24 at 2:40 a.m., identified R1 yelled for help and staff found him resting his head on the foot pedals of the scooter with legs in the doorway of the bathroom and he was lying on his back. R1 was continent, bed alarm was on and blinking but did not go over staff pagers, gripper socks were on. R1 stated he used his walker, and did not use the call light. R1 stated he lost his balance and hit the wall and slid down to the floor because his knees also gave out. Identified an abrasion to upper-mid back, left lower back and bruising to left elbow, right elbow, and left inner wrist. Predisposing factors included drowsy, gait imbalance, impaired memory, weakness/fainted, ambulating without assist, call light in reach, does not use call light consistently, bed alarm, used wheeled walker. Interventions included education to R1 to use his call light, and to sit on the toilet instead of standing in front of it. No revision to the care plan was evident. R1's Fall Risk assessment dated [DATE], identified a score of 22 and placed him at a high fall risk. Risk factors included occasional incontinence, exhibits loss of balance while standing, uses short discontinuous steps and/or shuffling gait, and used assistive device. R1 used walker and assist of 1 for all transfers and R1 noted to often self-transfer despite education and intermittent confusion noted. See care plan for interventions. R1's progress note dated 2/21/24 at 4:16 a.m., identified R1 toileted self. At 8:09 p.m., R1 toileted self. R1's progress note dated 2/23/24 at 2:52 a.m., identified R1 took self to the bathroom. Again, at 3:04 a.m., R1 took self to the toilet. R1's progress note dated 2/26/24 at 3:28 a.m., identified R1 toileted self. At 10:32 p.m., R1 toileted self. R1's progress note dated 2/27/24 at 4:39 a.m., R1 toileted self. R1's progress note dated 2/28/24 at 5:31 a.m., identified R1 toileted self. R1's Incident Report dated 3/1/24 at 10:00 p.m., identified R1 was found lying on his stomach with his head at the end of his bed and feet facing towards his room door. R1 stated he hit the left side of his forehead on the bed, and that his back, head, and ribs hurt and rated the pain 5/10. Staff identified no injuries at this time. R1 stated he was trying to get a shirt out of the closet and his legs slipped. Predisposing factors included gait imbalance, impaired memory, weakness/fainted, ambulating without assist, call light in reach, and does not use call light consistently. Intervention was hourly safety checks. The care plan was revised on 3/1/24 to include the hourly safety checks. R1's Point of Care (POC) hourly safety checks dated 3/12/24 through 4/12/24 identified the hourly safety checks were not consistently completed; checks occurred anywhere between one hour and seven hours apart. R1's Fall Risk assessment dated [DATE], identified a score of 22 and placed him at a high fall risk. There was no change from the previous assessment dated [DATE]. R1's Incident Report dated 3/4/24 at 3:15 a.m., identified R1's bed alarm went off and when staff entered R1's room the walker was seen by the bathroom entrance and R1 was found sitting on buttocks on the floor next to the sink and the wall. Urine was noted to be on the floor next to the toilet and gripper socks were wet with urine. R1 stated he was trying to go to the bathroom and his legs gave out. Predisposing factors included water/urine on floor, gait imbalance, does not use call light consistently, ambulating without assist, using bed alarm, using wheeled walker, and call light within reach. Intervention was R1 was reminded to use the call light and wait for staff to assist. R1's Fall Risk assessment dated [DATE], identified a score of 22 and placed him at a high fall risk and see care plan for interventions. There was no change from the previous assessment dated [DATE]. R1's Incident Report dated 3/11/24 at 11:38 p.m., identified R1 was found laying on the R) side next to the recliner chair. Recliner chair was in sitting position and cushion noted to be moved slightly forward. R1 stated he slid out of the recliner chair and legs wouldn't hold him up/keep him from sliding. Predisposing factors included impaired memory, call light in reach, does not use call light consistently and during transfer. Intervention was to put dysum under and on top of recliner cushion. The care plan was revised on 3/11/24 to include ensure dysum in recliner chair. One under cushion and one on top of cushion. R1's Fall Risk assessment dated [DATE], identified a score of 22 and placed him at a high fall risk and see care plan for interventions. There was no change from the previous assessment dated [DATE]. R1's Incident Report dated 3/27/24, at 11:30 p.m. identified R1 was found sitting on he floor in his bathroom, calling for help. R1's legs were out in front of him with feet under the sink and his back was facing the bathroom door. [NAME] was next to the toilet. R1 did not have grip socks on and had not used his call light to go to the bathroom. R1 stated I was washing my hands and my knees gave out and I went onto my butt. R1 complained of buttock and lower back pain. R1 was transferred to bed via mechanical lift and reminded to use his call light to use the bathroom. Predisposing factors included confused, drowsy, current UTI, gait imbalance, impaired memory, weakness, ambulating without assist, does not use call light consistently, using a bed alarm, using walker. It was not evident the care plan was revised after the fall for new interventions. R1's Incident Report dated 3/28/24 at 3:40 a.m., identified R1 was found lying on the floor next to his bed. Bed alarm was on and R1 had used his walker and had gripper socks on. R1's head was near the side of the bed and legs were stretched out on the floor. R1 stated he was coming back from the bathroom and was going to sit on the bed but wasn't close enough and missed the bed. R1 stated if it takes me longer to get up then maybe you can get here before I start moving. Predisposing factors included confused, drowsy, incontinent, recent illness, current urinary tract infection (UTI), gait imbalance, impaired memory, weakness/fainted, recent change in medications/new, ambulating without assist, call light within reach, does not use call light consistently, side rails up, and using bed alarm. Interventions included staff educated R1 to use the call light and wait for staff, and staff put R1's bed in a lower position. It was not evident the care plan was revised with new interventions. R1's Incident Report dated 3/28/24 at 7:19 p.m., identified R1 was found on the floor laying on the right side with back to the closet door and head towards the room door. R1 stated he was leaving the bathroom and just fell. R1 complained of pain in the right hip and had an abrasion to the right ear with pain rated 2/10 and farther in the report it stated pain was 10/10.Predisposing factors included incontinent, current UTI, gait imbalance, impaired memory, weakness/fainted, ambulating without assist, call light within reach, does not use call light consistently, and used wheeled walker. The bed alarm had been used in the recliner and did not alarm over staff pagers. Intervention included range of motion to hip and ice. On 3/29/24 the report noted that R1 had a right hip fracture. It was not evident new fall interventions were developed and implemented. R1's Hospital summary dated 4/3/24, identified R1 had admitted on [DATE], after sustaining a fall with right hip pain. R1 had multiple falls since moving to Oak Hills Living Center. Computed tomography showed right hip fracture. Right hip surgery completed 4/1/24. The summary further identified R1 had a history of re-current urinary tract infection (UTI); at the time of admission R1 had UTI that was treated with intravenous antibiotics. R1 also had chronic urinary retention and is to be self-cathing. Assessment and plan identified chronic urinary retention a Foley indwelling catheter was placed to decrease risk of recurrent UTI due to inappropriate self-cath due to dementia and no weight baring on the right leg. R1's Fall Risk assessment dated [DATE], identified for a readmission that R1 had multiple falls with documented dates of falls. The assessment identified R1 to be continent with complete control, nothing marked under gait analysis. Summary included a score of 17 that placed R1 at a high risk for falls. R1 was currently a full body mechanical lift and assist of two for all transfers. Intermittent confusion noted and see care plan for interventions. R1's progress note dated 4/9/24 at 9:18 p.m., identified R1's family member called and stated R1 kept calling her and saying he was going to get up and walk. Staff went into R1's room and his legs were hanging out of bed. During an observation and interview on 4/10/24 at 9:11 a.m., R1 was laying in bed, gripper socks on feet. After skin inspection and dressing from OT-A and Registered Nurse (RN)-B, R1 dangled left leg over the edge of the bed. R1 was able to use trapeze to pull himself up in bed. R1 stated I don't know how my hip is, I haven't used it yet. OT-A educated R1 on hip precautions. OT-A placed call light around trapeze above R1's head and lowered bed. OT-A did not attach a call light to R1's shirt or place one on the side of the bed. R1's split call light was attached on the right side of the recliner out of reach of R1 and not in accordance to the care plan. During an observation and interview on 4/10/24 at 10:40 a.m., with NA-A and NA-B, NA-A stated before R1's fall he was pretty mobile. NA-A explained R1 would self-transfer at night they (staff) knew if the bed alarm went off, R1 was up in the bathroom toileting, we would know when he was trying to do things he wasn't supposed to NA-B stated staff knew the fall interventions through staff report and by looking at the Kardex (abbreviated care plan). NA-A and NA-B reviewed the fall preventions in place from the Kardex. At 10:56 a.m., NA-A went to R1's room and moved the call light from the trapeze and clipped it to R1's shirt and moved the call light from the recliner to the side of the bed. During an observation and interview on 4/10/24 at 11:55 a.m., R1 was laying in bed and stated I don't like to stay in bed all the time. I got problems right now that I can't get up. During an interview with R1 and family member (FM)-A on 4/10/24 at 2:04 p.m., R1 was laying in bed. FM-A stated neuropathy was what caused R1's legs to just give out unexpectedly. R1 was falling at home too and required neighbors or emergency services to help him get off the floor. R1 stated he could feel his legs giving out more. R1 talked about wanting to go outside. From his window he could see residents and staff outside. FM-A stated he had to wait for therapy to ok him leaving the bed. During an interview on 4/10/24 at 2:53 p.m., RN-A reviewed R1's falls, RN-A stated the intervention for the double touch call light should probably be worded differently after verification that it was not correctly placed this morning. RN-A stated R1 has not really been in his recliner since hospital return and that intervention should be changed. The fall on 2/15/24, RN-A indicated there was no added intervention and R1 would not go for sitting down to urinate, so staff just gave reminders. Since R1 returned they have not done anything additional for fall prevention. RN-A stated I think if his hip didn't hurt he would be on the move. During an observation on 4/11/24 at 8:20 a.m., R1 was in sleeping in bed. Call light was clipped to the bed by R1's elbow and the other portion of the call light was hanging off the side rail on the outside portion of the bed. R1 would not be able to reach the light. Alarm for recliner was hanging on a lamp by his recliner. During an observation on 4/11/24 at 10:59 a.m., R1 was in the recliner. Call light was hanging off the side table and the other half was hanging on the side rail. R1 was unable to reach the call light on the side rail. Dysum (non-slip rubber-like plastic material used to stabilize surfaces) that would be under his buttocks was on his left arm rest and chair alarm was hanging over his lamp and not underneath his buttocks. During an interview on 4/11/24 at 11:03 a.m., RN-A verified the staff had not put put the call light, Dysum, and chair alarm in place and should have. During an interview on 4/11/24 at 11:44 a.m., R1 was in the recliner. R1 stated his catheter burned. Dysum remained on left arm of recliner and chair alarm hung from the lamp. During an observation on 4/11/24 at 1:27 p.m., R1 was in bed. Call light was clipped to a blanket around groin area and other portion of call light was hanging off the side rail where R1 could not reach it. During an interview on 4/11/24 at 1:15 p.m., RN-B stated [R1] used the toilet whenever. Nursing was to straight cath (intermittently catheterizing to remove urine) in the morning and at bedtime and FM-A would cath R1 during the day. R1 was not good at putting the call light on for toileting, he would sneak in there himself. I hope they keep the cath in because he will end up with UTI's. During an interview on 4/11/24 at 1:24 p.m., NA-D stated prior to R1's right hip fracture they would catch R1 taking himself to the toilet a few times a shift. NA-D thought R1 had a toileting plan from therapy. NA-D stated the nurses monitored output. During an interview on 4/11/24 at 2:22 p.m., with social worker (SW), RN-A, and Director of Nursing (DON) RN-A stated R1 did not have an individualized toileting plan and did not have an answer for why there was not one in place. When R1 was in the hospital an indwelling catheter was placed. RN-A did not believe a toileting program would have prevented the fall. R1 just used the toilet when he wanted to. His right hip pain was the only thing preventing him from moving at the moment. We are going to do a low bed as a prevention, he has a catheter, and maybe start a tracking sheet to track his restlessness. SW stated that one fall intervention in place was the indwelling catheter. During an interview on 4/11/24 at 2:45 p.m., DON did not identify R1's fall pattern; DON stated the team felt satisfied with the interventions in place as they were happening and at the time we felt the interventions were appropriate. Because of his frequenct of falls he will be one of our projects in our new focused risk management meetings. Our expectation was for everyone to be screened for a toileting program. During an observation and interview on 4/11/24 at 3:45 p.m., NA-E was in R1's room. R1 was in bed and sliding toward the end of the bed. R1 stated I had to go to the bathroom, it was burning down there. R1 had pulled on the catheter and again stated it burns. Call light was hanging over the side table and the other one attached to bedding instead of one portion being connected to R1's shirt according to the care plan. NA-E did not acknowledge R1 stating that the catheter burned, instead NA-E explained to R1 that urine went through the tubing to the urinary collection bag. During an interview on 4/11/24 at 3:52 p.m., NA-E indicated he went to R1's room a little bit ago. R1 was not on the floor, he was in bed. R1 had asked to have his catheter checked. NA-E put the call light by his hip side like he wanted and other call light he wanted dangling and he could not reach it. During an observation on 4/12/24 at 8:59 a.m., R1 was in bed wearing grippy socks. NA-F and NA-G were assisting R1 with morning cares. R1 was able to get both legs off the edge of the bed and attempted to get to a seated position. R1 stated his legs hurt like hell. NA-F and NA-G used a full body mechanical lift to transfer R1 from his bed to his recliner. R1's bed alarm did not sound. Pressure chair alarm was hanging over the lamp. The NA's left the room and shortly thereafter a certified occupational therapy assistant (COTA) came into the room and verified the alarm was not under R1. COTA and NA-G put the pressure alarm under R1. During a continuous observation on 4/12/24 that began at 9:55 a.m. and ended at 11:43 a.m. R1 demonstrated restlessness with multiple attempts of self-transfer. -9:55 a.m., R1 was in the recliner with the door 3/4 of the way closed. R1 was leaning forward in the recliner and then sat back several times, in a rocking motion. A visitor entered his room. -10:22 a.m., R1 had attempted to stand up from recliner. An unidentified staff saw R1 from across the hall, walked quickly into the room and redirected R1. -10:24 a.m., R1 shifted his legs to get ready to stand and asked his visitor to help him sit up in the recliner. Visitor gave R1 his hand to support with standing, but then removed his hand and informed R1 he was not supposed to stand. R1 remained seated in the chair. Visitor did not turn on the call light or ask sfaff to assist. -10:28 a.m., R1 was sitting forward in the recliner and continuously shifting his position. -10:46 a.m., unidentified staff answered R1's call light. -10:51 a.m., R1 sat forward in the recliner as he raised the chair up and down; visitor remained in the room. -11:03 a.m., R1 was attempting to stand up, unidentified staff entered the room, R1 denied help. -11:04 a.m., Staff exited room, and R1 had the recliner partially raised and was leaning forward. Staff entered room again with a mug. -11:05 a.m., Staff member exited room and left the door half closed. R1 leaned forward and pointed to the bin with catheter in it. -11:09 a.m., R1 leaned forward and reached down to the floor and pulled on catheter tubing and then fell backwards in the chair, then leaned forward again and back. -11:17 a.m., R1's visitor exited the room, visitor reminded R1 not to get up. -11:19 a.m., R1 leaned forward; staff responded to the activated chair alarm. -11:22 a.m., R1 leaned forward and back in his chair. -11:43 a.m., SW went to room to begin 1:1 observation of R1. During an interview on 4/12/24 at 11:15 a.m. DON was made aware R1 was restless, intermittently trying to stand-up, and pulling at his catheter tubing. DON indicated she would provide 1:1 supervision until a comprehensive causal analysis be completed and appropriate interventions were implemented. DON further indicated she would have nursing assess the issue with the catheter. The immediate jeopardy for R1 was removed 4/12/2024, at 5:22 p.m., when it was verified the facility developed and implemented the following: -Reviewed falls policy and implemented a new process for data collection/analysis. -R1 was provided with 1:1 supervision -Completed comprehensive fall analysis/assessments, reviewed/revised/implemented R1's care plan with appropriate interventions. -Identified like residents who were high risk for falls with falls. Completed a comprehensive analysis and reviewed/revised care plans for appropriate interventions. -All staff were provided education with competency testing on fall program policy and following care plans as it pertained to their scope of practice. R3's MDS dated [DATE], identified an admission date of 5/22. Severe cognitive impairment, required extensive staff assistance. Diagnoses included dementia, abnormalities of gait and mobility, muscle weakness, and difficulty in walking. R3's care plan dated 4/11/24, identified altered self care performance. Goals included maintaining current level of function. Interventions included: -1 person toileting assistance and a high rise toilet seat, prompt/assist with toileting every two hours and PRN during waking hours and once during the night -encourage resident to use call light and that it was within reach -required sit to stand mechanical lift for transfers R3's care plan dated 4/11/24, identified a focus for risk of falls r/t deconditioning, dementia, incontinence, psychoactive drug use, and unaware of safety needs. Goals included R3 would experience no falls and be free of injury. Interventions included: -ensure dysum is underneath allegra in recliner for residents safety 2/22/23 -ensure floor mat is down when resident in recliner chair 2/16/24 -keep bed in lowest position when resident in bed 3/12/24 -place floor mats when resident in bed 3/12/24 R3's fall incident report dated 1/13/24 at 1:15 a.m., identified R3 calling loudly from room. R3 was sitting on the cushion in front of the recliner. R3 stated I was scooting because my butt hurt. Noted incontinence brief was shredded and pulled apart. Predisposing factors included confused, drowsy, incontinent, recent illness, impaired memory, weakness/fainted, call light within reach, does not use call light consistently, and has a foot rest in front of recliner. R3 had intermittent confusion, frequently incontinent, confined to a chair and oriented. Summary score of 19 on the assessment which placed R3 at a high fall risk. Required EZ stand for all transfers and was alert with intermittent confusion. Call light within reach. Dysum in wheelchair. In review of R3's record no new fall interventions were developed or implemented. R3's fall incident report dated 2/16/24 at 3:30 a.m., identified R3 was found laying on right side on floor in front of recliner chair. Incontinence pad had been picked apart by R3 and was all over the floor. R3 did not know she was on the floor or how she got there. R3 had a skin abrasion on right elbow. Predisposing factors included confused, incontinent, impaired memory, call light within reach, and does not use call light properly. R3 scored a 22 on the assessment and was a high fall risk. EZ stand for transfers and alert with intermittent confusion. Call light in place. Intervention was a floor mat. R3's fall incident dated 3/9/24 at 12:50 a.m., identified R3 was on the floor in front of the recliner with half on her foot cushion and the other half on the floor. Asked how she fell and R3 stated I was trying to get these damn things off., pointing to ready wraps that were half off at the time. Predisposing factors included confused, impaired memory, weakness/fainted, call light within reach, does not use call light consistently, using floor mat, and soft foot stool in front of recliner. Frequent safety checks initiated for the remainder of the night. Although R3 had three falls from the recliner, in review of R3's record it was not evident a comprehensive analysis was completed and no new interventions were developed or implemented to prevent or mitigate the risk of re-current falls from recliner. R3's fall incident dated 3/10/24 at 5:30 a.m., identified R3 sitting on the floor in front of the recliner sitting on the floor mat with foot stool under her legs and head leaning up against front of recliner. R3 stated her buttocks hurt from sitting. Noted R3's ready wraps were half off and R3 had started ripping the brief tabs off. Noted that recliner was rocking forward and R3 was leaning forward in it constantly due to the chair leaning. Put in maintenance slip to check over. Predisposing factors included furniture, drowsy, incontinent, impaired memory, weakness/fainted, call light within reach, does not use call light consistently, and using floor mat. During care conference with family discussed sleeping in bed instead of recliner and family to bring in pajama pants as she has been pulling brief apart. R3's care plan was not revised to include R3 to sleep in the bed instead of the recliner. During an interview on 4/1/024 at 1:58 p.m., FM-B stated R3 did f[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review the facility failed to safely use a mechanical lift per manufacture instruction to transfer 1 of 1 residents (R2) who required a mechanical lift for transfers. This resulted in R2 falling from a lift, sustaining major injuries. R2 subsequently died 10 days following the fall. In addition the facility failed to conduct a thorough investigation to determine the cause of the fall from the lift. This resulted in immediate jeopardy (IJ) for R2. The IJ began on [DATE], at approximately 9:30 a.m. when R2 fell from the lift during a transfer sustaining a major head injury and right upper arm fracture after two nursing assistants (NAs) were transferring a resident using the mechanical lift. The facility failed to determine the cause of the incident, continued to use the lift without a thorough inspection of the lift to determine safe for use, failed to contact the manufacturer, and failed to provide retraining and competency for staff using the lift. The administrator, director of nursing (DON), and registered nurse case manager (RN)-A were notified of the immediate jeopardy on [DATE], at 5:20 p.m. The immediate jeopardy was removed on [DATE], at 2:15 p.m. but noncompliance remained at a lower scope and severity of a D with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings Include: R2's Diagnosis Report identified diagnoses of delusional disorders, essential tremors, encephalopathy (any brain disease that alters brain function or structure), and muscle weakness. R2's care plan last revised on, [DATE] identified R2 was not ambulatory and required two staff assist with Hoyer (full body mechanical lift) and medium sling. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment. R2 required total dependence of two staff assist with transfers. R2's Mobility/Transfer Evaluation dated [DATE], indicated R2 required two-person assist with full body mechanical lift with large sling for transfers. R2's care plan dated [DATE], was not revised to reflect the change in sling size. At the time of R2's fall on [DATE] the care plan and mobility evaluation were inconsistent. R2's fall incident report dated [DATE] at 9:52 a.m. indicated R2 was found lying across the legs of the hoyer (mechanical full body lift) on the floor with feet facing the toilet and head by the tub. R2 was noted to have a moderate amount of blood coming from the back of her head. Nursing assistants (NA)s stated that R2 was in mechanical lift sling when a loop came undone and the resident fell to the floor. R2 was unable to describe the incident. R2 was assisted to a sitting position and noted to have some pain to the right upper arm and a large part of scalp reflected (sik) on the right back side of head. R2 was transported by ambulance to the emergency department (ED). R2's nursing progress notes dated [DATE] at 10:10 a.m., indicated registered nurse (RN-B) responded to the fall. R2's progress note included the details as documented in the incident report, adding R2 was transferred to the ED at 9:30 a.m R2's post incident Mobility/Transfer Evaluation dated [DATE] at 4:35 p.m. indicated R2's sling size was changed from a large to medium. R2's ED notes dated [DATE] at 10:15 a.m., indicated R2's injuries from the fall included a fracture of the right humerus (long bone of the upper arm) and traumatic head injury with multiple lacerations. R2's hospice progress note dated [DATE] at 2:53 p.m., indicated R2 was in bed with right arm in a sling, bruising noted on upper arm/shoulder, staples intact on back right side of head, R2 stated she was terrible. R2 wants to get out of bed and reported severe pain when turned. R2's progress note dated [DATE] at 3:45 a.m., indicated R2's time of death was on [DATE], at 1:17 a.m. A typed interview summary dated [DATE] at 12:00 p.m., authored by assistant director of nursing (ADON) indicated upon review of the initial documentation of the incident and interviews with NA-A and NA-B, no apparent root cause could be determined. R2's care plan was identified as being followed. Review of R2's medical record and fall incident report dated [DATE] at 9:52 a.m., did not identify the size of the sling that was used at the time of the fall. Facility's undated investigation documentation and maintenance records did not indicate the lift and lift slings used when the fall occurred, were removed from operation and inspected for safety and malfunction. During a phone interview on [DATE], at 2:25 p.m., NA-C indicated that a few weeks ago R2 fell out of the full body mechanical lift, hit her head, and died days later. Further indicated it was because of a faulty lift but the facility never took the lift out of service. NA-C stated the same lift involved in R2's fall was currently being used to transfer residents. NC-C indicated one other resident used the lift on the unit and the lift would also be used to transfer residents off the floor after a fall. During an interview on [DATE] at 12:20 p.m., NA-B indicated she was one of the two NAs assisting R2 with transferring in and out of the tub on [DATE]. They had transferred R2 into the tub and unhooked the sling for bathing. Once the bath was completed, NA-B was on one side of R2 and NA-A was on the other side of her. They connected both the upper and lower sling loops to the hooks on the lift cross bar on the side that they stood on. They raised R2 over the tub, lifted her feet over the side of the tub, and proceeded to back the lift up to go towards her chair. The left lower loop came off and the right side stayed intact causing R2 to slide out of the sling onto her right side. We were not able to catch her, R2's head bounced off the side of the tub and she fell to the floor. R2 was in shock and pain. They (NA-B and NA-A) did not stop and check loop placement once R2 was suspended in the air. R2 was suspended for about 15 seconds before she fell out. NA-B stated it was a mystery on how it happened. NA-B had to give a statement to nurse as to what happened afterward and thought they were using a medium sling but could not be sure. NA-B verified the lift was never taken out of service and remained in use. During an interview on [DATE] at 12:45 p.m., NA-A indicated she was assisting NA-B with R2's transfer out of the bath when the fall out of the lift sling occurred. She thought they had both checked the strap placement but the incident happened so fast we thought the strap broke. NA-A indicated both her and NA-B met with nurses to walk though it (the incident). NA-A was still not sure what happened to cause R2 to fall out of the lift. During an interview on [DATE] at 3:55 p.m., RN-A stated she was involved in the incident investigation. RN-A indicated after the incident, she went to the tub room, interviewed the NAs involved, looked at the mechanical lift, and sent the information to the administrator. Later that day there was a meeting that included the NA's involved and the ADON. NA's told us what happened and chit chatted about the lift and were not able to determine why the loop fell off of the lift causing the resident to fall out of the sling. RN-A indicated she was not sure if there were any other actions taken except the ADON had assigned a video for staff to watch by the end of September. During an interview on [DATE] at 12:10 p.m., the licensed social worker (LSW) indicated she was involved in the incident investigation. LSW indicated both NAs involved in the transfer reported the sling loops were secure. Both of their statements were consistent with each other. The LSW thought maybe, when moving R2's leg out the tub, the loop may have jolted loose but determined R2's care plan was followed. LSW reported maintenance looked at the mechanical lift and the sling but did not provide any further details of what was looked at. During an interview on [DATE] at 4:10 p.m., Maintenance-A indicated he was not aware of the fall from the mechanical lift until today. He had not removed any mechanical lifts from service or inspected them. He heard that the sling straps may have been put on wrong which caused the fall but was not sure. Maintenance-A indicated the normal process is to have the manufacturer come in every six months to inspect the lifts. Maintenance-A stated the last routine maintenance check on the lifts was completed [DATE]. During an interview on [DATE] at 11:55 a.m., maintenance-B indicated he was notified about the fall and was asked to look at the mechanical lift. He was in the meeting to discuss his findings and stated he drew them a picture of the hooks on the mechanical lift bar. Further explained the lift that was being used when the fall occurred was the only lift in the facility with the extra safety feature of the long hook and if the loops were hooked correctly, it is impossible for it [the sling loop] to fall off, it is against the law of physics. Even if the sling loop was not completely in the notch of the hook, once weight was on it, it would slip on the bar but still would not slip off the hook. Concluded, the only way that [sling loop] could have fallen off is if it was put on the top of the bar, instead of under the safety hook, and if the lift was jolted, then it would slip off. Maintenance-B stated this was explained to the group in the fall follow-up meeting however, there was no facility documentation of his statement. During a phone interview on [DATE] at 10:35 a.m., EZ-Way lift representative (LR)-A indicated she was not aware of any lift related incidents at the facility. The facility will usually call the lift manufacturer if there is an incident related to a lift. The manufacturer right away would send a service technician out to the facility to inspect the lift and set up a staff in-service on proper lift use. Further indicated usually a fall from a lift happens because staff forget to hook a loop up or do not pay attention thinking they had both loops hooked but only had loop attached. LR-A stated, If the sling loops are hooked correctly, gravity should hold the loop in place, it doesn't just fall off. During interview on [DATE] at 1:13 p.m., NA-D indicated they received training on the mechanical lifts during her initial orientation and observed other NAs use the lifts. NA-D denied demonstrating skills or taking a test related to use of body slings and mechanical lifts to a nurse or case manager. During an interview on [DATE] at 11:45 a.m., RN-C stated staff received mechanical lift training from staff development and on the floor training by other [NAs] and I answer questions if they ask. RN-C indicated she had not completed competency testing for the lift with any of the nursing staff. During an interview on [DATE] at 12:05 p.m., RN-D indicated new NAs are trained by the staffing development person. RN-D further indicated she had not completed competency testing for the lift with any of the nursing staff. During an interview on [DATE] at 4:05 p.m., the staffing development coordinator (SDC) indicated following the incident, she assigned all nursing staff a video on how to properly use the mechanical lifts. The video training was to be completed by the end of September. She had planned to schedule a skills fair for this Fall and use of mechanical lifts would be on the agenda. Verified NA-A, NA-B, and any other nursing staff had not received additional training or a competency evaluation after R2's fall from the lift. She Was not sure if they had watched the video as of the time of the interview. SDC indicated the lift would also be used to transfer residents off the floor after a fall. During an interview on [DATE] at 11:10 a.m., DON stated she had just received some new information regarding the [DATE] fall that R2's foot got caught under the tub so they had to lift it over so, maybe that is what happened DON was not sure why that would make the loops fall off. DON stated the facility usually completed at skills fair however, had not completed mechanical lift training for the past few years because of COVID. DON explained a new staff development person was hired three months prior to the incident, but does not know what competencies had been done or where they would be stored if they were done. RN case managers were responsible for making sure the NAs were competent in using the mechanical lifts. On [DATE], the facility was not able to provide any mechanical lift training and competency records for any nursing staff. During an interview on [DATE] at 3:42 p.m., administrator said maintenance looked at the mechanical lift after the fall and was told that there was nothing wrong with the lift. Administrator stated there was no way the sling could have fallen off. The NAs involved were adamant they had hooked the sling up correctly. As a result the facility determined everything was followed and we did not figure out what happened to cause R2's fall out of the lift. No further action was taken. Facility Lifting Machine, Using a Mechanical Policy last reviewed [DATE], directed the following: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. Attach sling straps to sling bar, according to manufacturer's instructions. Make sure the sling is securely attached to the clips and that it is properly balanced. Before resident is lifted, double check the security of the sling attachment. Examine all hooks, clips or fasteners. Check the stability of the straps. Ensure that the sling bar is securely attached and sound. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. Slowly lift the resident. Only lift as high as necessary to complete the transfer. Gently support the resident as he or she is moved, but do NOT support any weight. Manufacturer's recommendations for the full body mechanical lift last reviewed on [DATE], included for safe operation, operators should watch the training video, read through this manual, complete the competency checklist, and practice on fellow staff members before use with patients(residents). When lifting a patient push the UP button on the hand control to initiate the upward motion of the lift. Continue the upward motion until there is tension on the legs of the sling, making sure all loops on the sling are securely hooked on the hanger bars. When transferring the patient, ensure there are no obstructions in the path of travel and pull or push the lift using the operator's handles on the lift mast. Users must accept full responsibility for checking the condition of all slings and harnesses before each and every use on a patient. The IJ that began on [DATE] at 9:30 a.m. was removed on [DATE] at 2:15 p.m. when it could be verified the facility implemented the following actions: the involved mechanical lift was removed from service until the manufacturer inspected and deemed it safe for use; policy was revised to include that any equipment that is involved in an incident will be taken out of service until inspected and deemed safe by the manufacturer; and training with competencies completed with all staff prior to their next shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and document review, the facility failed to provide adequate supervision for 1 of 1 residents (R1) who despite being at risk for elopement and wearing an elopement security band, left the facility unsupervised and without staff knowledge. This resulted in immediate jeopardy when R1 walked 218 yards across uneven terrain into a parking lot of a neighboring apartment complex placing him at risk for serious harm, impairment, or death. The immediate jeopardy began on 5/4/23 at 3:25 p.m., when R1 left the facility unsupervised and was identified on 5/4/23 at 3:55 p.m., when the facility was notified by a tenant at the neighboring apartment complex and the facility arrived to pick up R1. The administrator, director of nursing (DON) and social worker (SW)-A were notified of the immediate jeopardy on 5/18/23 at 11:19 a.m. The facility immediately implemented corrective action and was corrected on 5/5/23 prior to the survey and was issued at Past Noncompliance. Findings include: R1's facesheet printed on 5/17/23, indicated diagnoses of dementia, weakness, unsteadiness of feet and repeated falls. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had moderately impaired cognition, adequate vision and hearing, clear speech, was usually understood and was usually able to understand. R1 required assistance of one staff for transferring between surfaces, walking in his room and around the unit. R1 required extensive assistance of one staff when walking off the unit and used a wander/elopement alarm daily. R1's admission care plan dated 12/30/22, indicated R1 was at high risk for falls. Care plan dated 1/23/23, indicated R1 had cognitive loss with confusion and impaired decision making with a history of elopement, wandering and exit seeking behaviors. Care plan dated 1/30/23, indicated R1 was at high risk for elopement and would be supervised at all times when outside, and a security alarm bracelet or other sensor system to reduce risk of elopement from facility. R1's physician order dated 1/24/23, and again on 3/10/23, indicated: Wanderguard (WG) - Check to ensure functioning properly every day and PRN (as needed). Elopement risk assessments upon admission on [DATE], and on 2/3/23, indicated R1 scored a 12/20 points, which identified he was at risk for elopement. After the elopement incident on 5/4/23, an elopement risk assessment was completed indicating R1 was at risk, scoring 20/20 points. The maximum score was 25, indicating the highest elopement risk. A fall risk assessment dated [DATE], indicated R1 scored 21, indicating high fall risk. The fall risk assessment identified he had eight falls in 2023. R1's treatment administration record (TAR) indicated R1's WG was checked daily by staff starting 1/25/23 through 5/17/23, apart from 3/1/23, when R1 was in the hospital. A progress noted dated 5/4/23 at 4:17 p.m., indicated the facility had been alerted R1 had been outside sitting in front of the next-door apartment complex. Registered nurse (RN)-A and the DON immediately left the facility and went to the apartment building. R1 was found safe and stated he had not fallen and was just sitting enjoying the nice weather. R1 was returned to the facility via facility bus. RN-A and the DON verified R1's WG bracelet was on, however it did not activate the security alarm when R1 was brought back into the facility. A new WG was applied and verified to be in working order. As an intervention to future elopement, RN-A spoke to family member (FM)-C about taking R1 all the way to his room when family and friends brought him back to the facility. During an observation on 5/17/23 at 10:45 a.m., together with SW-A, walked the route R1 took on 5/4/23 when he left the facility with his four-wheeled walker. R1 walked on a paved walking path next to the facility, then across approximately eight feet of a gravel service road used by facility maintence staff, then a distance on sloping grass, then between large decorative rocks to a paved parking lot utilized by tenants and visitors of the apartment complex to a bench at the main entrance of the apartment complex. During an interview on 5/17/23 at 11:23 a.m., maintenance supervisor (MS)-A measured the distance R1 walked with a measuring wheel and reported the distance as 655 feet (218 yards) from the facility entrance to the bench where he was found. During an interview and observation on 5/17/23 at 11:23 p.m., receptionist (R)-D stated she had been working the day R1 left the facility unsupervised. R-D stated R1 had just come back from playing cards at about 3:25 p.m. R1's friend (F)-E walked R1 into the facility and R-D told R1 to have a seat and she would call the nursing unit and have someone escort him back to the second floor. R1 took a seat on a chair in front of door, which was approximately five or six feet directly in front of the automatic sliding glass doors. R-D stated she had been printing checks from her reception desk to a printer in an office behind the reception desk and had been going back and forth between the reception desk and the office to retrieve the checks. According to MS-A on 5/17/23 at 11:41 p.m., the measured distance from the reception desk to the printer was 59 feet. R1 was not visible from the office with the printer. R-D estimated R1 had been out of her sight for about four minutes. When R-D noticed R1 was gone, she assumed nursing staff had picked up R1 to escort him back to his room. At about 3:45 p.m., R-D received a telephone call from someone who recognized R1 and informed the facility he was sitting outside at the neighboring apartment complex. R-D immediately called the nurses station and told them R1 was next door, then called RN-A to inform her. During an interview on 5/17/23 at 12:29 p.m., RN-A stated she had been working the day R1 eloped. RN-A had received a call from R-D at the front desk who informed her R1 was at the neighboring apartment complex. RN-A and the DON immediately went to the apartment complex and found R1 sitting on a bench. When asked what he was doing, R1 stated he was enjoying the day. RN-A stated R1 denied falling and had no apparent injuries. R1 was returned to the facility via the facility bus. On their way back to the facility, RN-A stated both she and the DON wondered if the WG would alarm when they returned to the facility. When R1 went through the entrance door, the alarm did not sound. RN-A confirmed when a resident had a properly functioning WG, a door alarm would activate whether entering or exiting the door. When R1 was returned to the facility a new WG was applied right away. RN-A stated when licensed practical nurse (LPN)-A applied the new WG on 5/4/23, she told RN-A she had to activate it. RN-A stated, That queued us to this [activate] step which may have identified the reason R1 was able to leave the facility without an alarm sounding. RN-A stated R1's first elopement attempt was on 1/24/23 when he had been looking for the elevator and front door multiple times; as a result, a WG was applied on 1/24/23. RN-A was unsure if R1's WG had been activated when applied on 1/24/23. During an interview on 5/17/23 at 12:48 p.m., SW-A stated she had been working the day R1 eloped. Following the incident, she looked at the display phones to determine the sequence of events and stated R1 was unaccounted for for about 20 minutes. The display phone indicated the following: --3:25 p.m., R-D called the nursing unit to escort R1 to his room. --3:45 p.m., R-D received call from apartment complex alerting the facility of R1's whereabouts. --3:48 p.m., R-D called RN-A to notify her of the phone call she received about R1's whereabouts. SW-A stated RN-A and the DON reached R1 at the apartment complex at 3:55 p.m. During a telephone interview on 5/17/23 at 1:30 p.m., F-E stated he was a friend of R1's and had picked up R1 on 5/4/23 between 12:30 p.m. and 1 p.m. to play cards. F-E stated he dropped R1 off at 3 p.m. in the lobby. R1 told F-E he didn't want F-E to walk him to his room. During an interview on 5/17/23 at 2:29 p.m., the DON stated she had been working the day R1 eloped. She was notified immediately when the facility learned R1 was at the neighboring apartment complex. She went with RN-A to assess R1 and return him to the facility. When they returned to the facility, the DON stated R1's WG did not activate the alarm when they brought him through the main entrance door. The DON began their investigation right away by interviewing staff, notifying R1's family and the nurse practitioner (NP). She stated a new WG had been applied to R1 upon return to the facility and staff ensured it was working. The DON stated when a WG was initially activated, the hand-held detector sounded a beep to verify activation. Following the activation step, staff conducted daily checks to ensure proper WG function. The DON stated to do this, staff placed a hand-held detector next to a WG tag and were to visualize two small green lights illuminated on the detector. One green light indicated battery strength and the other verified activation. The DON stated through their investigation, they determined R1's WG had not been activated when applied on 1/24/23. When staff tested R1's WG each day, only one green light illuminated indicating battery strength. According to the DON, staff conducting the daily testing did not know that two green lights needed to illuminate on the detector to ensure proper functioning. According to the DON, following the incident on 5/4/23, the following corrective actions were taken: -- An audit was conducted to ensure two green lights illuminated on the detector for each of the 13 other residents with a WG. No concerns were identified. --1:1 RN, LPN and TMA re-education was initiated on 5/4/23. --Computer desk-top education was added. --Re-education occurred again at a staff meeting on 5/10/23 about ensuring two green lights were present when monitoring WG bands. --The WG instructions were simplified and illustrations added to enhance staff understanding. --Verbiage was added to the TAR for each resident with a WG to check the WG with the detector once daily and ensure two green lights were visible. --Added to a new employee's 14-day check-in meeting, was verify the new employee's understanding of activating and testing WG's. --A new WG policy as created. --WG audits would commence for three months. The DON explained the discrepancy regarding the time F-E stated he returned R1 to the facility on 5/4/23 (F-E stated 3:00 p.m. and interviews specified this time to be 3:25 p.m.). The DON stated according to the paper sign-out log, F-E prefilled the sign-in time on the log with 3:00 p.m. when he picked up R1 between 12:30 p.m. and 1:00 p.m. The sign-in/sign-out sheet was located on the second floor and F-E self-admitted he did not escort R1 back to his room when returning to the facility on 5/4/23 and therefore could not have signed R1 back in. During an interview on 5/17/23 at 3:01 p.m., (LPN)-B stated when R1 went to the hospital on 2/28/23, R1's WG bracelet had been removed and locked in a cupboard in his room. When he returned on 3/2/23, LPN-B obtained the WG from the cupboard, reapplied it, tested it and stated she recalled seeing two green lights illuminate on the detector. RN-A had not been aware R1's WG had been removed and reapplied before and after hospitalization. RN-A stated regardless, the WG should have been activated on 1/24/23, so would not have needed to be activated again on 3/2/23. Manufacturer instructions provided by the DON titled WanderGuard Blue v1.4 - Quick Reference Guide (undated) indicated the following: --ACTIVATING a tag with the detector: 1. Turn on WanderGuard BLUE detector by short-pressing the power button when out of the controller LF (low frequency) range. 2. Place a WanderGuard BLUE tag within the detector's LF range - 12 inches. 3. Activate the tag - press the power button for 1.5 seconds. Detector sends an activation message via LF. It beeps to indicate it is sending an activation message. 4. Upon receiving BLE (Bluetooth low energy) message from the tag, the detectors LF LED (light emitting diode) lights green for two seconds. --CHECKING the tag battery level: 1. Turn on WanderGuard BLUE detector by short-pressing the power button. 2. Place the tag within the LF range of the detector (less than 12 inches). The detector constantly sends LF messages. 3. The detector displays the tag battery level by flashing the tag battery LED and LF LED for two seconds after receiving the BLE message from the tag. 4. When the detector is in proximity to an activated tag, the LED's continue to display green or red depending on the battery level. During a phone interview on 5/17/23 at 3:59 p.m., FM-C stated he had been informed of R1's elopement right away on 5/4/23. FM-C stated R1 had a mind of his own and was determined to do what he wanted. FM-C stated he had picked up R1 for church recently and, Now the bells go off. FM-C did not recall if alarms went off prior to this, stating, I think so, but I can't say for sure. During an interview on 5/17/23 at 5:30 p.m., the DON stated through their investigation, it was concluded R1's WG had not been activated when applied on 1/24/23. The DON did not know how staff had been testing R1's WG daily and documenting proper functioning since 1/24/23 when he was in the facility. when not visualizing two green lights on the detector. The DON stated their previous WG system illuminated with one light indicating proper functioning and thought some staff recalled the old system when conducting testing on current WG's. According to an undated document titled staff interviews conducted by SW-A during the facility investigation, LPN-B reported she had never received education on WG's and checking the batteries. (LPN)-A reported she had never been given education about how to activate or properly check the WG pendants; had only been checking battery life and didn't know to also be checking LF [NAME] light to ensure activation. During an interview on 5/18/23 at 10:29 a.m., office employee (OE)-F whose office was located next to the reception desk, stated through a window, she observed R1 leave with F-E on 5/4/23. OE-F stated she watched R1 get into the car and did not hear the WG alarm go off when he left the building, adding she never heard the alarm go off for R1. OE-F stated at the time, she didn't know R1 wore a WG. OE-F stated that was going to change now, as reception and office staff were going to get a list indicating which residents wore a WG's. During an observation on 5/18/23 from 1:13 p.m. to 1:18 p.m., observed (TMA)-A test WG's for the following residents: R1, R2, R3 and R4. TMA-A demonstrated how the detector was used to test WG's and verbalized two green lights need to been seen. Two green lights illuminated as TMA-A tested WG's for each resident. New policy (according to the DON) titled Wanderguard's - Protocol and Policy, undated, indicated wanderguard's were used for residents at risk of elopement. To obtain a wanderguard, the resident must be care-planned for one. Wandergaurds were dated when activated. Log sheets were filled out with resident information, serial number, and date of activation. Wanderguard bracelets were checked daily on the evening shift primarily by TMA's or nurses and documented in the electronic medical record. Wandergaurds were not removed unless a resident was transferred out of the facility. Facility policy titled Safety and Supervision of Residents, reviewed on 1/23/23, indicated the facility strived to make the environment as free from accident hazards as possible. Resident safety and supervision to prevent accidents were facility-wide priorities. Safety risks and environmental hazards were identified on an on-going basis through employee training, employee monitoring and reporting processes. Due to their complexity and scope, certain resident risk factors and environmental hazards were addressed in dedicated policies and procedures. Included in the identified risk factors was unsafe wandering.