Based on record review, review of facility policy, and staff interview, the facility failed to provide necessary care and services for 1 of 1 closed record resident (Resident #28) reviewed. Failure to assess, monitor and implement interventions in response to Resident #28's decline in condition may have contributed to the resident's death. Findings include: Review of the facility policy titled Vital Signs occurred on 10/30/24. This policy, dated 12/12/23, stated, . 'Vital signs' are indicators of health status, including temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain. Vital signs shall be obtained at least in the following circumstances: . When the resident's general condition changes. When a resident reports nonspecific symptoms of physical distress (e.g., [example] feeling 'funny' or 'different'). Acceptable ranges for adults: . Oxygen saturation: > [greater than] 90% [percent]. Review of Resident #28's medical record occurred on 10/30/24. Diagnoses included chronic obstructive pulmonary disease (COPD), pulmonary fibrosis (damaged lung tissue), and congestive heart failure (CHF). The baseline care plan identified the resident as independent with bed mobility, transfers, walking, toileting and eating, assistance of one with locomotion grooming/hygiene and bathing and oxygen use at two liters per minute. The care plan also stated the resident, Wants to do as much as possible for himself but feels weak so at least offer assist and supervise. The medical record identified Resident #28 admission date of 08/30/24. The record lacked documentation in the nurse progress notes for August 30, 31, and September 1, 2024. The nurse progress notes dated 09/02/24 stated the following: * At 4:06 p.m. Note Text: Vitals completed. O2 [oxygen] sat [saturation] 81% at 3 liters. Resident has normal respirations at 20 per minute and non labored. and denies shortness of breath. * At 6:22 p.m. Note Text: Resident states he is not feeling well. Vitals are stable and has no fever. O2 sat 89%. It is warm in his room so fan is moved to blow on him per his request. The nurse progress notes dated 09/03/24 stated the following: * At 3:20 a.m. Note Text: Resident told this nurse he is dying and can't eat because it's too hard to breathe. This nurse mentioned Hospice and resident stated, 'That is a great idea because I am definitely dying.' This nurse will pass message on to the day nurse. * At 6:50 a.m. Note Text: Called [family member's name], the president's [sic] son and informed him of his dad's condition. Resident is having SOB [short of breath]. Poor appetite. He said he did not eat or drink for four days. [Resident #28] asked for the nurse's opinion. Informed will consult with the provider and get back to him. Called [Resident #28's son] again but went to his voice. Left message that his dad is on his way to the emergency. Left phone number to call back. * At 7:30 a.m. Note Text: Called the [name of clinic] and spoke with [name of physician] nurse, [name of nurse] Informed her that the resident is having SOB and had not been eating or drinking. [name of nurse] said she will check with [name of physician] and call back. [Name of physician] called and ordered ER [emergency room] transfer for evaluation. Resident sent to the ER via ambulance 0820 [8:20 a.m.]. * At 8:00 a.m. COMMUNICATION - with Physician* Situation: SOB. Accessory muscle for breathing. Background: Poor appetite. SOB. Oxygen 2L [liters] NC [nasal cannula]. Assessment (RN) [registered nurse]/Appearance (LPN) [licensed practical nurse]: BP [blood pressure] 98/62, P [pulse]-96, r[respirations]- 28, Oxygen 82, T[temperature]-97.3. Recommendations [sic]: Send to ER via Ambulance to [name of town]. * At 8:20 a.m. Transfer to Hospital Summary* Note Text: Resident had been experiencing SOB and poor appetite. Complained of pain as well but said 'pain is a lesser evil. I can't breathe' [name of physician] ordered ER transfer for evaluation. * At 8:21 a.m. Note Text: Report given to the ER nurse. Resident on his way in Ambulance to the ER. * At 9:25 a.m. Note Text: [name of person], Nurse from the [name of town] Hospital called and reported that the patient passed away today at 0908 [9:08 a.m.]. Family notified per the nurse. During an interview the morning of 10/30/24, an administrative nurse (#2) confirmed the medical record lacked nurse progress notes for August 30, 31, and September 1, 2024. The medical record lacked documentation or evidence of the following; * An assessment, treatment interventions, and/or symptom management interventions, and/or physician notification on 09/02/24 at 4:06 p.m., when the resident was on three liters of oxygen with an oxygen saturation of 81% and again at 6:22 p.m. (almost two and a half hours later), when the resident's oxygen saturation was 89%. * Vital signs or assessment of resident condition from 09/02/24 at 6:22 p.m. until 09/03/24 at 3:20 a.m. (almost nine hours later) when the resident reported to nurse he is dying and can't eat because it's too hard to breathe. * Physician notification of a change in resident condition when Resident #28 first reported difficulty breathing and statements of dying on 09/03/24 at 3:20 a.m. until four hours later at 7:30 a.m. when the facility first contacted the physician's clinic. The facility failed to promptly identify and intervene for an acute change in a resident's condition resulting in an actual decline in health status, delayed treatment, and a negative outcome.

Based on record review, review of the facility reported investigation, review of facility policies, review of personnel records, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell out of a mechanical lift. Failure to follow the nursing care plan resulted in Resident #1's fall, which caused pain, bruising and fractures. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Safe Resident Handling/Transfers occurred on 08/30/23. This policy, revised 04/10/23, stated, .residents are handled and transferred safely to prevent or minimize risks for injury. Compliance Guidelines:. 10. Two staff members must be utilized when transferring residents with a mechanical lift (Hoyer). Review of Resident #1's medical record occurred on 08/30/23 and include the diagnoses of chronic pain, disorders of bone density, and adjustment disorder with depressed mood. Review of Resident #1's care plan stated, .I am at risk for falls due to body control problems, cognitive loss.I need two staff to assist me to transfer with hoyer lift. Facility reported the incident to the state agency and immediately started their investigation. The facility's investigation report, dated 08/14/23, included the following documentation: Time line of events: * 08/14/23 at 6:56 a.m. Administrative staff member (#1) spoke with CNA (#2) who found Resident #1. The CNA stated Between 6:15 and 6:30 a.m. knocked on [resident room number] to get hoyer lift (door was shut). When I entered curtain was partially pulled. [resident name] bed was empty and wheel chair was empty. [resident] was in the other bed in the room that had no sheets or pillows. (stripped clean) [resident] head was in the middle of the bed one leg cramed [sig] to the footboard and the other leg was over the footboard. Pants and brief was down by [resident] thighs. Sling was under resident but not crossed through the legs. When [CNA #2] walked in and seen [resident] in the other bed I asked 'why is she over here?' [CNA #5] said 'cause [resident] was sliding so [CNA #5] hurried and put [resident] here.' Then finished helping her out of the bed and into the wheel chair. Resident was complaining of leg pain so [CNA #2] told MA #4 and nurse #3 right away. The [MA #4] looked at the leg/ankle then noticed the swelling. * 08/14/23 at 6:58 a.m. Administrative nurse (#1) interviewed CNA (#5). CNA (#5) said he/she was transferring Resident #1 with the Hoyer lift on his/her own and almost lost [resident name]. * 08/14/23 at 7:10 a.m. Nurse (#3) notified [name of community hospital] that Resident #1 would be coming to the ER [Emergency Room] to be assessed. Message left for Resident #1's family member. * 08/14/23 at 2:00 p.m. Nursing staff met for huddle in training room. Reviewed policies and procedures on mechanical lifts, safe transfers and residents care plans. * 08/14/23 at 7:19 p.m. Resident #1 having increased pain with transfers. Provider notified and orders received. * 08/15/23 at 9:15 a.m. Resident #1 taken to [name of community hospital] and then later transferred to [name of higher level of care hospital] During an interview on 08/30/23 at 11:00 a.m. administrative staff member (#1) stated she expects facility staff to follow care plans, care cards and policies and procedures. Based on the following information, non compliance at F689 is considered past non-compliance. The facility implemented corrective actions for the deficient practice by: *The facility completed an investigation with interviews of staff present on 08/14/23. *The investigation showed the CNA (#5), failed to follow policies and procedures on mechanical lifts and failed to follow the resident's care plan. *The facility suspended CNA (#5) pending the investigation and notified the state agency. The facility addressed the deficient practise and implemented systemic changes to ensure the deficient practice does not recur by: Educated all nursing staff on the following policies and procedures: *Safe Resident Handling/Transfers *Using the Hoyer lift *Using the Standing lift *Abuse and Neglect *Fall Prevention Program *Informing the Quality Assurance committee and implementing audits. The surveyor determined a deficient practice existed on 08/14/23. The facility implemented corrective action on 08/14/23 and completed nursing education by 08/15/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, review of facility's fall investigation report, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #4) who fell out of a mechanical lift. Failure to communicate nursing assessments which identified the resident required more assistance with transfers and failure to re-evaluate transfer methods resulted in Resident #4's fall, which caused pain, bruising, and a fracture. Findings include: Review of the facility policy titled POLICY AND PROCEDURE ON USING PAL LIFT occurred on 03/27/23. This policy, dated 10/01/22, stated, POLICY: It is the policy . to ensure that each resident is safely transferred using the PAL [mechanical sit-to stand lift] Lift. PROCEDURE: The PAL Lift is used on residents who are able to use their hands to hang onto the handles and who are able to stand on their legs. When using the PAL Lift, the following will be completed: . OT [occupational therapy] /PT [Physical Therapy] to evaluate for any concerns on PAL Lift transfers. PAL Lifts should never be used on residents who cannot hang onto the PAL Lift handles or who cannot or can no longer stand up using their legs. If a resident can no longer stand using their legs, or they are not able to hang onto the handles for whatever reason, the Hoyer Lift [mechanical full-body lift] may need to be used. This change will be determined by the Charge nurse, Director of Nursing, or OT/PT. PAL Lifts may be utilized by one caregiver unless otherwise care planned. Review of Resident #4's medical record occurred on 03/27/23 and identified multiple sclerosis, muscle spasms, bladder cancer (on Hospice), and a proximal humerus fracture [a break of the shoulder at the top of the upper arm bone]. Review of Resident #4's Hospice Notes identified the following: * 03/07/23 (11 days prior to Resident #4's fall from the mechanical sit-to-stand lift) Functional: patient continues to require sit to stand lift for all transfers. Was utilizing hoyer lift on admit but then graduated to sit to stand. However, patient noted to have increased difficulty with sit to stand lift transfer as she continue (sic) to attempt to lay back during transfer and required physical assistance from staff to stand up straight. Patient also noted in past month to have decreased ability to bear weight on legs during transfer. Patient continues to be extensive assist with feeding, bathing, toileting and dressing. * 03/14/23 . Patient . apprears very fatigued. during assessment. Staff to continue monitoring safety with sit to stand lift transfers. A quarterly Minimum Data Set (MDS) dated [DATE] (six days prior to Resident #4's fall from the mechanical sit-to-stand lift) identified Resident #4 required extensive assist of two persons with transfers. Review of Resident #4's care plan and the CNA (certified nurse aide) care card, prior to the fall on 03/18/23, identified the following: Care Plan: I can again be transferred with the PAL lift and one assist. Staff will use the hoyer lift if I become weak and am unable to stand well. CNA Care Card: Assist x 1 with PAL Resident #4's nurses' notes identified the following: * 03/18/23 at 2:30 p.m., Incident Note . Staff reported she was hooked up to the Pal lift and while they were trying to transfer her, she started to not stand well and they had to lower her to the floor. She denies any injury. This nurse did move all of her limbs and she did not complain of pain. She did not hit her head. Family and hospice both notified of fall, and we will go back to hoyer lift for transfers. * 03/18/23 at 6:54 p.m., Pain Note . Resident displayed grimace and stated ouch. This writer and aide palpated extremities to see where and how resident reacted. Resident unable to verbalize where pain was located. movement to upper R) [right] arm shoulder area resident held breath, squeezed eyes shut, clenched teeth. Resident does have pain to R) arm/shoulder area. Son agrees area looks and feels swollen. This writer noted shoulder area is swollen, no bruising, slightly warm. Unknown if swelling is related to arthritis or injury from fall. This writer will touch base with Hospice for further instructions. * 03/18/23 at 9:13 p.m., Health Status Note . Sling to R) arm in place, resident tolerated applying sling well. Cold pack applied for 20 minutes. Light bruising is now starting to show up to upper R) bicep. * 03/19/23 at 9:40 a.m., Post Fall Note . Resident has been sleepy this morning after receiving prn Morphine during the night for right shoulder pain. No bruising noted to upper area of right shoulder. Edema present in scapula area, no pain on palpitation of site. Staff education given on supporting arm with sling, use of Hoyer lift for all transfers, and to tell nurse if increased pain is noted from resident. * 03/20/23 at 8:34 a.m., Post Fall Note - Late entry: Resident has bruising to right bicep from incident/fall that occurred on Saturday. Area has edema present and is tender to touch. Poor range of motion where sling was under her shoulder. Resident does grimace with movement of arm. Hospice nurse does plan to see resident today . Sling in place to immobilize area as suggested by . Hospice. Staff did report pain with turning this am with cares and advised to use 2 staff with increased pain. Resident has morphine sulfate concentrate solution for pain as needed every hour that can be given. * 03/21/23 at 9:45 a.m., Health Status Note . This nurse heard resident yelling out in pain and went in to check on resident, travel CNA [certified nurse aide] was in her room assisting resident to get AM [morning] cares done and up for the day. This nurse noted large blue/purple bruise on lower front of shoulder around the underneath. Resident vocalized pain and face grimacing noted. Another CNA came to assist resident, resident was unable to lift arm more than 1 inch off of bed. MS [morphine sulfate] was given for shoulder pain . PC [phone call] made to hospice requesting clarification to what type of immobilization device they were wanting to use on resident. Hospice nurse stated she would call MD [medical doctor] to get clarification and ordered MS to be scheduled QID [four times a day] while awake. * 03/21/23 at 12:32 p.m., Health Status Note . Order received to schedule MS and for OT to eval [evaluate] resident for an immobilizing device for right arm, hospice is to use their own therapy contact, hospice ordered x-ray to be done and will be done at . clinic tomorrow AM. * 03/22/23 at 9:54 a.m., Health Status Note . Staff assist x2 . this morning with AM cares. Resident grimaced and vocalized signs and sx [symptoms] of pain with arm movements. MS is provided for pain management. * 03/22/23 at 1:20 p.m., COMMUNICATION - with Family . Resident's daughter, [name] called to talk to DON regarding findings from appointment . [Daughter] voiced the provider talked to her to let her know that resident had a break right below the shoulder and that they were looking at setting up a consultation with orthopedics. Review of the radiology report, dated 03/22/23, stated, Indication: Shoulder Injury. Impression: Acute comminuted proximal humerus fracture . Review of Resident #4's Medication Administration Record (MAR) from March 1-27, 2023, identified Resident #4 received Morphine Sulfate 2 mg on the following dates and times: 03/18/23 at 7:59 p.m. 03/19/23 at 12:00 am, 5:12 p.m. and 10:33 p.m. 03/20/23 at 4:42 a.m. 03/21/23 to 03/27/23 - four times a day Resident #4 did not require any morphine sulfate prior to 03/18/23. An investigation report, dated 03/23/23, stated, Investigation Report: Sit to Stand Incident/Fall. [name of nurse] called to speak with DON about an incident/fall that occurred while resident was in the lift. Resident was strapped into the lift per policy as stated by staff, resident's knees buckled and arms went up (chicken winged) putting pressure on her upper arms and under her shoulders. [Name of nurse] requested we change how we transfer the resident from a sit to stand to a Hoyer lift for safety. [name of nurse] notified the Primary care physician via fax, verbally told Hospice, and called the Family about incident. An Incident Review Quality Assurance Form, signed by the DON and Administrator on 03/23/23, stated, Transfer in progress when she [Resident #4] started to not stand properly and staff at (sic) to lower her. Results of investigation: Sit to stand lift policy and procedure followed by CNA. Family was aware of resident not standing well with lift at all times per Hospice prior to fall, declined use of hoyer for resident dignity. No abuse or neglect found by staff and family. Review of Hospice notes and the facility nurses' notes prior to the fall failed to identify communication to family about changing transfer method from a sit-to-stand lift to a Hoyer lift. An interview with a nursing staff member (#1) occurred on 03/27/23 at 12:56 p.m. When asked how the resident was transferred prior to the fall, the staff member stated she was transferred with the sit-to-stand lift with one person, but at times she was transferred with a Hoyer lift. The staff member (#1) stated the way of transferring was always changing. An interview with a certified nurse aide (CNA) (#4) occurred on 03/27/23 at 1:11 p.m. The CNA stated Resident #4 was a sit-to-stand lift transfer with one person prior to her fall, but states the resident was getting weaker at that time. During an interview on 03/27/23 at 1:42 p.m., a CNA (#3) stated Resident #4 was a sit-to-stand lift transfer with one person prior to her fall, but that sometimes it went back and forth between a sit-to-stand lift and a Hoyer lift. The CNA stated she talks with the charge nurse if they change the type of mechanical lift transfer. An interview with a CNA (#2), who transferred Resident #4 when she fell out of the lift, occurred on 03/27/23 at 2:00 p.m. The CNA stated she was transferring Resident #4 from the wheelchair to her bed with the sit-to-stand lift. Resident #4 was not able to hold onto the handlebars of the lift and the resident refused to stand up. The resident ended up hanging with her arms over the lift belt, slid out of the sling, and she helped the resident to the floor. The CNA stated she was instructed to transfer Resident #4 with the sit-to-stand lift. During an interview on 03/27/23 at 4:40 p.m., an administrative nurse (#5) stated Resident #4's care plan, at the time of the fall, stated if the resident is weak, staff should use the Hoyer lift, but the nurse has to make that judgement, not the CNA.The nurse (#5) stated Therapy completes an assessment to determine assistance requirements. Review of therapy notes identified physical therapy staff last evaluated Resident #4 on 09/09/21 (18 months ago) and stated Reviewed transfers with facility. Res.[resident] is a standing with one and that is appropriate. The Hospice note from 03/07/23 identified Resident #4 was having difficulty with the sit-to- stand lift and in the past month had decreased ability to bear weight during transfer. The MDS note, dated 03/12/13 identified Resident #4 required extensive assist of two persons for transfers. The facility failed to implement interventions based on these assessments and change the plan of care for staff to safely transfer Resident #4. Based on the PAL lift policy, the PAL lift should not be used for residents who cannot hang on to the handles or can no longer stand up and a Hoyer lift may need to be used. A change in type of lift should be evaluated by the charge nurse, DON, or OT/PT. The facility staff failed to communicate nursing assessments and re-evaluate transfer methods when Resident #4 had a decreased ability to bear weight, which resulted in a fall, pain, bruising, and fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on observation, policy review, review of the Volaro Operator's Manual, record review, and staff interview, the facility failed to provide adequate assistance for 3 of 5 sampled residents (Resident #1, #4, and #6) observed during a sit-to-stand mechanical lift transfer. Failure to ensure proper use of the stand lift, and use the leg strap caused the residents unnecessary pain/discomfort and placed them at risk of possible injury. Findings include: Review of the facility policy titled POLICY AND PROCEDURE ON USING PAL [mechanical] LIFT occurred on 09/14/22. This policy, reviewed October 2021, stated, . POLICY . ensure that each resident is safely transferred using the pal lift. 1. All straps will be buckled unless resident specifically requests no straps. Review of the Volaro Operator's Manual occurred on 09/14/2022. These operator's instructions, stated, . ATTACHING SLING TO LIFT . have him hold onto the handle grips. attach the colored loops to the positive-locking J hooks. NOTE: Make sure you use the same colored loops on each J hook. - Review of Resident #1's medical record occurred on all days of survey and included the diagnoses of bursitis (inflammation) to right and left shoulders. The current care plan stated, I have . shoulder pain at all times. I am alert and able to report pain . I need assistance with my activities of daily living . I need the stand-up lift and one assist for transfer . Observation on 09/11/22 at 4:31 p.m. showed a certified nursing assistant (CNA) (#8) assisted Resident #1 out of the recliner using the sit to stand lift. The CNA applied the sling around the resident's abdomen, secured the buckle, attached the gray colored loops to the handle bars and not the J hooks, and told the resident to put her hands on the handle bars. Utilizing the lift, the CNA transferred the resident onto the toilet. During the transfer, the harness sling slid up the resident's back to the axilla area, and the resident leaned forward, causing the resident's elbows to bow outward above the shoulders. While lowering the resident onto the toilet and pulling the resident's pants down the resident stated, Oh I'm going down, I'm slipping and both of the resident's hands fell off the handle bars. The resident fell approximately 3 inches onto the toilet. The CNA left the sling loops connected to the handle bars while the resident used the toilet. When the resident finished, the CNA instructed the resident to place her hands on the square handle bar and attempted to lift the resident off the toilet. The resident stated, I'm slipping again, my arms, oh mercy. The CNA then lowered the resident to the toilet again. The CNA stated, Let's try using the blue loops, and changed the gray loops to the blue loops, attaching them again to the handle bar. The CNA attempted to lift the resident with the sit to stand. The resident stated, My arms and shoulders hurt, oh my arms, ouch (expletive) it hurts ouch ouch. The CNA lowered the resident to the toilet again and stated, Let's try a different lift that's not so hard on your arms and shoulders. The CNA called for assistance with the transfer and requested staff bring a different lift. At 4:45 p.m., a nurse (#16) entered the resident's room with a different sit to stand lift. Using the new lift, observation showed the nurse attached the loops to the correct hooks, secured the feet strap and proceeded to transfer the resident to her wheelchair. Once seated in the wheelchair the resident stated, Oh does that feel good. - Review of Resident #4's medical record occurred on all days of survey and included the diagnoses of osteoporosis and dementia. The current care plan stated, I have . shoulder pain at all times. I am alert and able to report pain . I need assistance with my activities of daily living . I need the Pal [sit to stand] lift and one assist with transfers. Observation on 09/11/22 at 4:16 p.m. showed a CNA (#8) used the sit to stand lift and transferred Resident #4 from her recliner to the toilet. The CNA applied the sling around the resident's abdomen, secured the buckle, attached the gray colored loops and not the J hooks, and told the resident to put her hands on the square handle bar. During the transfer, the harness sling slid up the resident's back to the axilla area, and the resident leaned forward, causing the resident's elbows to bow outward above the shoulders. When the resident finished using the toilet, the CNA attempted to lift the resident off the toilet. The resident stated, Oh boy, that hurts. The CNA then lowered the resident to the toilet again. The CNA changed from the gray loops to the blue loops, attaching them again to the handle bar. The CNA transferred the resident from the toilet to the wheelchair. Again during the transfer, the harness sling slid up the resident's back to the axilla area, and the resident leaned forward, causing the resident's elbows to bow outward above the shoulders. When the CNA was placing the resident in the wheelchair, the resident's buttocks were lower than the wheelchair and the CNA had to tip the wheelchair forward to get the resident seated. - Observation of care on 09/12/22 at 9:26 a.m. showed a CNA (#2) transferred Resident #6 from the toilet to his wheelchair using a sit to stand lift. As the CNA (#2) transferred the resident, observation showed the sling around Resident #6's torso loose, and the velcro strap not closed, the CNA (#2) failed to tighten the loose belt. As Resident #6 semi- squatted in the lift, his elbows rose almost level with his shoulders. The CNA (#2) failed to ensure the torso strap was fitted properly before transferring the resident, which may put him at risk for injury. During an interview on 09/12/22 at 2:30 p.m., an administrative nurse (#3) stated she expected staff to use the sit to stand lift correctly by securing the sling loops to the positive-locking J hooks (and not the handle bar) and using the leg straps at all times when transferring a resident. 2. Based on observation, record review, facility policy, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring to prevent elopements from the facility for 1 of 1 sampled resident (Resident #19) coded for elopement. Failure to provide adequate supervision and monitoring may result in avoidable accidents and/or injury. Findings include: Review of the facility policy titled ELOPEMENT ASSESSMENT FOR NEW ADMITS occurred on 09/14/22. This policy, dated May 2020, stated, . POLICY . To ensure the safety of new residents on admission. 2. If resident is at high risk for elopement a Wanderguard will be placed. Review of Resident #19's medical record occurred on all days of the survey and identified an admission date of 07/19/22. The record included the diagnoses of cognitive communication deficits, delirium, suicidal ideations, and unspecified psychosis. The current care plan stated, . I have behaviors. I try to leave the building, I hit out at staff, am very paranoid. Staff needs to monitor me closely . I have tried to go out the window multiple times. Staff has a wanderguard on me to alert staff if I am trying to leave out the door. Staff monitors often to make sure I do not go out the window. I have removed the wanderguard so staff needs to try to reapply and check often to make sure that I still has this on. Review of Resident #19's electronic treatment record showed on 08/30/22 the facility discontinued monitoring the resident's wanderguard twice a day. Observations on all days of survey showed Resident #19 without a wanderguard. The admission Minimum Data set (MDS), dated [DATE] identified the resident wandered 1-3 times a week. Review of Resident #19's Risk Assessment, dated 07/19/22, indicated the resident scored a 9 out of 10 potential risk factors and was at risk for elopement. Nursing progress notes included the following: * 07/30/22 at 9:07 p.m., . Resident becomes more restless after family leaves. Resident is trying to exit out door 8 x 2 [attempted to exit out of door 8 twice]. * 07/31/22 at 6:31 a.m., . Resident is up in the hall early this am looking for her husband. Resident has her clothes packed up in boxes and folded on her bed. Other personal items also packed up. She is looking for [husband's name] to take her home. * 07/31/22 at 9:15 a.m., . Resident declined to allow staff to assist her with am cares until now. She has a couple staff only today that she is trusting. Increased delusions noted this morning . * 8/10/22 at 5:40 a.m., . Attempted Elopement. CNA was walking on the B wing hall way when she saw someone standing in front of the exit door in A wing. She notified writer through the walkie and writer ran after the resident. resident [sic] was pushing the door to go out and had also tried to push the automatic door button for the door to open. * 8/30/22 at 11:34 a.m., . Resident has shown no signs of elopement behaviors since initial admit, Resident has exhibited no behaviors. Current medication schedule has been working effectively for resident. During an interview on 09/14/22 at 10:00 a.m., an administrative staff member (#3) confirmed the facility failed to adequately assess the resident's current elopement risk and did not complete another risk assessment prior to removing her wanderguard.