**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and Resident Representative and staff interviews, the facility failed to provide the resident representative with a written notification of the bed hold policy upon a resident's transfer to the hospital for 1 of 2 residents (Resident #224) reviewed for discharge. Findings included: Resident #224 was admitted to the facility on [DATE] with the Resident Representative listed as his legal representative according to the medical record. A review of the baseline care plan dated 10/20/23 revealed Resident #224 was cognitively impaired. The discharge Minimum Data Set (MDS) Discharge Return Not Anticipated assessment dated [DATE] revealed Resident #224 was discharged to the hospital. Further review of the medical record revealed there was no written notice of the bed hold policy provided to the resident or resident representative when he was transferred to the hospital on [DATE]. An interview was conducted with the Resident Representative on 2/12/25 at 9:24 AM. She indicated she was not provided with a written notice of the bed hold policy upon the resident's transfer to the hospital. An attempt was made to interview Nurse #1 who was assigned to Resident #224 at the time of discharge, but attempts were not successful. An interview was conducted with Administrator #1 on 2/14/25 at 11:24 AM. She indicated after Resident #224 was sent to the hospital, the facility team felt they could not permit Resident #224 to return to the facility due to his behaviors, and the resident was not offered a bed hold option.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, family and staff interviews, the facility failed to provide the resident and/or responsible party (RP) written notification of the reason for a hospital transfer for 2 of 3 residents reviewed for hospitalization (Residents # 32 and #14). The findings included: 1. Resident #32 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #32 had moderately impaired cognition. Resident #32's medical record revealed she was transferred to the hospital on 8/23/22 for mental status changes. There was no documentation that a written notice of transfer was provided to the resident and/or responsible party (RP) for the reason of the transfer. Resident #32 returned to the facility on 8/26/22. The Administrator was interviewed on 9/7/22 at 3:35 PM and explained a written reason for hospital transfer was sent with the resident in the hospital discharge packet. The Administrator added there was no other written notification regarding the hospital transfer that was sent to the RP and/or resident, but they were always notified verbally. She stated she would expect the resident and/or RP to be notified in writing for the reason of the hospital transfer per the regulation. During a phone call on 9/8/22 at 3:15 PM, with Resident #32's RP, she indicated she had not received anything in writing regarding the reason for hospital transfer on 8/23/22, although she was notified by phone. 2. Resident #14 was admitted [DATE]. Review of Resident #14's medical record indicated a family member was listed as her responsible party (RP). Review of Resident #14's significant change Minimum Data Set, dated [DATE] indicated she was cognitively intact. Resident #14's medical record revealed she was transferred to the hospital on 6/21/22 due to a fall. There was no documentation that a written notice of transfer was provided to the resident and/or RP for the reason of the transfer. Resident #14 returned to the facility on 6/24/22. The Administrator was interviewed on 9/7/22 at 3:35 PM and explained a written reason for hospital transfer was sent with the resident in the hospital discharge packet. The Administrator added there was no other written notification regarding the hospital transfer that was sent to the RP and/or resident, but they were always notified verbally. She stated she would expect the resident and/or RP to be notified in writing for the reason of the hospital transfer per the regulation. During a phone call on 9/8/22 at 1:50 PM with Resident #14's RP, she indicated she had not received anything in writing regarding the reason for hospital transfer on 6/21/22, although she was notified by phone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plan in the area of falls. This was for 1 (Resident #48) of 4 residents reviewed for falls. The findings included: Resident #48 was admitted on [DATE] with a diagnosis of Coronary Artery Disease. The quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and was coded for one fall without injury. Review of Resident #48's comprehensive care plan last revised on 8/10/22 included a care plan for a risk of falls initiated on 5/21/22. Review of Resident #48's medical record revealed she sustained an actual fall on 7/17/22 and another fall on 8/22/22. There were no injuries and interventions implemented were appropriate. On 9/9/22 at 12:00 PM, an interview was completed with MDS Nurse #1. She stated Resident #48's fall care plan should have been revised after the quarterly MDS dated [DATE] to include the fall she sustained on 7/17/22. She also stated the fall that occurred on 8/22/22 should have also been added to the fall care plan to reflect Resident #48's current falls with updated interventions. MDS Nurse #1 stated it was an oversight. On 9/9/22 at 12:45 PM, the Administrator stated Resident #48's fall care plan should be an accurate reflection of her current status along with the new interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #68 was originally admitted to the facility on [DATE] with diagnoses that included dementia. Resident #68's active physician orders included an order for a wander alarm dated [DATE]. A review of Resident #68's nursing progress notes from [DATE] to [DATE] revealed the following behaviors that staff described as wandering: stating she needed to go home, walking in the hallway, looking for her purse and/or family members in other rooms, and walking on a different hallway stating she was lost or looking for markers. There were no further behavioral symptoms after [DATE]. An Elopement Risk Assessment form dated [DATE] indicated the resident was at risk of getting to a dangerous place and had an elopement deterrent device was implemented. A review of Resident #68's behavior logs from [DATE] through [DATE] did not show any behaviors logged by the Nurse Aides (NA). Per the legend on the behavior log, pacing, rummaging, and wandering were included for choices to select if present. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #68 was alert and oriented and displayed no behaviors, wandering or rejection of care. She required supervision and setup for walking in the room/corridor and locomotion on the unit. She required supervision and 1 staff member for locomotion off the unit. She was coded with a wander/elopement alarm used daily. An Elopement Risk Assessment form dated [DATE] indicated the resident was not at risk for elopement but an elopement deterrent device remained implemented. A review of Resident #68's behavior logs from [DATE] through [DATE] did not show any behaviors logged by the NAs. The MDS Nurse #2 was interviewed on [DATE] at 3:45 PM and was the staff member that completed the Elopement Risk Assessment from [DATE]. She reviewed and verified she marked all wandering and exit seeking behavior as no because Resident #68 was not exhibiting any of those behaviors but felt the wander alarm should remain on due to the potential for exit seeking and wandering due to her confusion at night and not as many staff are here during the evening and night times. When asked if the wander alarm had been discussed for the potential of removal since there had been no behaviors of wandering or exit seeking since February 2022, the MDS Nurse #2 stated no, because what if she needed it again. An interview occurred with Resident #68 on [DATE] at 11:30 AM. She was sitting on the side of her bed with a wander alarm present to her right ankle. Resident #68 stated she didn't understand why she had the alarm on her ankle because I never leave this room. An interview occurred with Nurse #3 on [DATE] at 10:40 AM, who was familiar with Resident #68. She explained Resident #68 rarely left her room and received all meals in her room. She had not witnessed her wandering in the hallways for some time. On [DATE] at 10:47 AM, NA #2 was interviewed. She was typically assigned to care for Resident #68 during the day shift (7:00 AM to 3:00 PM) and stated she rarely left her room. At times she would stand in her doorway or want to sit at the door way or hallway to watch staff and others. She added Resident #68 was able to ambulate with her walker or a wheelchair, but she had not witnessed her attempting to seek an exit from the facility. A phone interview occurred on [DATE] at 1:30 PM, with Nurse #5 who worked as the weekend supervisor from 7:00 AM to 7:00 PM. He stated he was familiar with Resident #68 and had not witnessed her wandering in the building or exit seeking. Stated she rarely came out of her room. On [DATE] at 2:33 PM, a phone interview was conducted with NA #3 who was familiar with Resident #68 and provided care to her in the evenings (3:00 PM to 11:00 PM). She stated Resident #68 stayed in her room and at the most would come to her doorway to request assistance or talk to staff. NA #3 stated Resident #68 was still alert and oriented but had some confusion at night. NA #4 was interviewed via phone on [DATE] at 2:42 PM, stating she provided care to Resident #68 on the 7:00 PM to 7:00 AM shift. Stated Resident #68 normally only came to her doorway of her room to ask staff for assistance, to look up and down the hallways or to talk with staff as they passed by. NA #4 stated about four months ago Resident #68 walked to the memory care unit doors (on the same hallway that she resided on) looking for family and her purse, but she had not witnessed this behavior since. She denied Resident #68 came out and wandered in the facility or attempted to exit seek. A phone interview was held with Nurse #6 on [DATE] at 9:56 AM. He stated he was familiar with Resident #68 and cared for her on the weekends 7:00 AM to 11:00 PM. Nurse #6 explained 95% of the time she stayed in her room but would come up to the common area at the nurse's station but no longer was looking for things/people or exit seeking. Typically, though, she would come to her doorway or out in the hall looking around but found her way back to her room without any incidents. Nurse #6 stated he didn't consider these behaviors as wandering or exit seeking. The Nurse Practitioner (NP) was interviewed on [DATE] at 12:50 PM, and reviewed the Elopement Risk Assessment form dated [DATE], showing there was no exit seeking behavior present. The NP stated Resident #68 still required the wander alarm because she walked out in the halls, she had seen her in the common area of the unit at times when she worked at night and added, she could go into any of these rooms, and we wouldn't know where she was. The Administrator was interviewed on [DATE] at 10:35 AM and stated when the NA's completed the behavior log there was an icon that popped up asking if the nurse had been made aware before they were able to complete what behaviors were present. She would expect if a resident exhibited behaviors, such as wandering, to be marked on the behavior log as well as in the nursing progress notes. She continued to explain the Elopement Risk Assessment forms, that were completed every three months, should be utilized to assess the need for continuation of a device such as a wander guard. A trial removal should have been discussed with the Interdisciplinary Team (IDT) since Resident #68 no longer displayed any wandering or exit seeking behaviors. Based on observations, resident, staff interviews and record review, the facility failed to discontinue a wander/elopement alarm in the absence of wandering. This was for 2 (Resident #14 and Resident #68) of 2 residents reviewed for personal alarms. The findings included: 1. Resident #14 was admitted on [DATE]. Resident #14's significant change Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact, exhibited wandering behaviors for 1 to 3 days and not coded for wander/elopement alarm. A wander/elopement alarm was ordered for Resident #14 on [DATE]. Review of Resident #14's nursing notes for April, May and [DATE] revealed occasions of wandering, gathering her things and verbalizing she was going to leave and go back to her apartment. There were nursing notes documenting her increased confusion and episodes of delusions thought to be related to her urinary tract infections. There was no documented evidence of an actual elopement. Review of a nursing note dated [DATE] at 10:00 PM, Resident #14 had ambulated to the bathroom and slipped. She did not call for staff assistance prior to her fall. An x-ray revealed a left hip fracture and she was sent out to the hospital on [DATE] and readmitted to the facility [DATE]. Review of a Resident #14's readmission Physician order dated [DATE] read her wander/elopement alarm was reordered. Review of an Elopement Risk assessment dated [DATE] indicated Resident #14 was not an elopement risk. Review of Resident #14's care plan initiated [DATE] did not include a risk area related to wandering behaviors with the use of a wander/elopement alarm. Resident #14's significant change MDS dated [DATE] indicated she was cognitively intact, exhibited no wandering behaviors and was coded for wander/elopement alarm. The MDS was coded for no ambulation in her room or on the unit and coded for extensive staff assistance for locomotion on and off the unit. Review of Resident #14's Treatment Administration Records for [DATE] to [DATE] indicated the nurse's checked the function of her wander/elopement alarm each shift. An observation and interview was completed on [DATE] at 11:47 AM with Resident #14. She was asked pull up her right pant leg to allow visualization of her wander/elopement alarm. She stated the alarm had been in use for a while and stated that she was not able to ambulate anymore and accepted the facility as her home. She stated at one time she was ambulating throughout the facility with her friend. An interview was completed on [DATE] at 4:00 PM with Nurse #1. She stated prior to Resident #14's fall in [DATE], she was able to ambulate throughout the skilled halls. She stated Resident #14 never breeched the locked door leading to the assisted living hall and the front exit but the potential was there. That was the reason she was ordered a wander/elopement alarm back in [DATE]. Nurse #1 further stated since Resident #14 was readmitted on [DATE] after her fall and resulting hip fracture, she was no longer ambulating and the alarms should probably come off. Review of Resident #14's electronic medical record included an order dated [DATE] discontinuing the wander/elopement alarm. An interview was completed on [DATE] at 11:07 AM with Nursing Assistant (NA) #5. She stated started working at the facility a few months ago and since she started, she had never observed Resident #14 wandering or stating she wanted to leave the facility. An interview was completed on [DATE] at 11:10 AM with NA #2. She stated she had worked at the facility for 7 years. NA #2 stated Resident #14 used to have a male friend and they would walk about the facility before he died earlier this year. She stated since his death, Resident #14 was more confused and was having delusions. She stated the wander/elopement alarm was added for her safety. NA #1 stated since Resident #14 fell and broke her hip, she was no longer a risk for wandering or elopement. A telephone interview was completed on [DATE] at 1:21 PM with Nurse #5. He stated Resident #14 was no longer a wander/elopement risk. He stated her alarm should have been discontinued once it was determined that she was not going to rehabilitate to ambulating again after her readmission in [DATE]. A telephone interview was completed on [DATE] with Nurse #7. She stated Resident #14 at one time was experiencing increased confusion after her friend died but since falling and breaking her hip, she appeared to have really gone downhill quickly and was no longer able to wander or exit seek. She stated she was unsure why Resident #14 still had the alarm. A telephone interview was completed on [DATE] at 1:54 PM with Nurse #8. She stated Resident used to get up and wander about the facility but never had an unsupervised exit. She stated since her readmission in [DATE], she was no wandering and seldom got out of the bed. She stated she did not understand why she still had the alarm. An interview was completed on [DATE] at 12:45 PM with the Administrator. She stated when Resident #14 was readmitted in [DATE], her wander/elopement alarm order was carried over without considering the Elopement Risk Assessment completed on her readmission and she was unable to explain why the alarm was not discontinued at that time. She stated it should have not been reordered on her readmission.