**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and interviews, the facility failed to properly supervise Resident (R)1, resulting in R1's successful elopement from the facility. Specifically, on 05/24/24 at approximately 9:00 PM, R1 crawled through the window in his room to elope from the facility. R1 was found by local law enforcement on a highway and sent to the local hospital. R1 suffered a skin tear to the right forearm, while crawling out of the window. On 05/29/24 at 1:07 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to properly supervise a resident, resulting in a successful elopement from the facility, constituted Immediate Jeopardy (IJ) at F689. On 05/29/24 at 1:07 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 05/24/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 05/29/24 at approximately 2:30 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The survey team considers the IJ at Past Non-Compliance as of 05/28/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled Resident Check/Elopement Policy with an effective date of 10/23, revealed, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle . Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia, dementia, lack of coordination, bipolar disorder, anxiety disorder, major depressive disorder, Type 2 diabetes, and dizziness and giddiness. Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R1 was cognitively intact. Further review of the MDS revealed R1 wandering behaviors were not exhibited. Review of R1's Elopement Risk Took dated 02/29/24, revealed diagnoses that may increase the risk of elopement: depression, bipolar disorder with mania, and Dementia. Further review revealed, Resident has been found to be at risk for elopement . Review of R1's Progress Note dated 05/25/24 at 3:31 AM, revealed, Note entry for 1230 AM, Law enforcement from [local police dept.] arrived at front door of facility. The officer stated, We found [R1] on Hwy 101. Do you know him? This writer answered, Yes and asked if he was injured. Officer stated, He is ok, no injury. We have ems taking him to the hospital. Review of R1's Progress Note dated 05/25/24 at 5:22 AM, revealed, Late entry for 415 am. [R1] had returned from ER with son . Body audit completed . Skin assessed with findings of a discoloration to right outer aspect of forearm. It is irregular in shape, approx. 4 cm long. Per [R1], he hit it on the window sill. He is not c/o in that arm. The bottom of his feet are reddened, friction r/t wearing croc slip on shoes with no socks. Review of R1's Care Plan revealed no Care Plan, related to wandering/elopement, was in place prior to the elopement. Review of the facility's undated Resident Check/Elopement Policy revealed R1 was last seen at 9:30 PM, going to his room with a cup of ice. Immediate eyes on head count of all residents completed by staff. Facility parking lot and grounds search completed. R1 was not located during eyes on count. Elopement determined date documented 05/25/24 at 12:45 AM. Review of a Witness Statement dated 05/25/24, written by Nurse Supervisor revealed, Last saw [R1] going to his room at 915 PM after asking for water. I continued to chart at the desk on unit one. No activity was noted coming from room [ROOM NUMBER]P. No alarms for doors or beds were sounding. Review of a Witness Statement dated 05/25/24, written by an unidentified Nurse revealed, At about 1245 am I was sitting at the nurses station and saw blue lights piercing through the front double doors. A police officer was outside and notified us of resident found out there on the highway. As I entered the resident's room, noted his window was wide open and the gate outside was also open. Review of a Witness Statement dated 05/25/24, written by Certified Nursing Assistant (CNA)2 revealed, I witnessed the police at the door, the doorbell rung and I was headed to answer but the nurse beat me. As I was walking the police asked if we had a [R1] and we went to his room and he was gone and the window was open. Review of a Witness Statement dated 05/25/24, written by CNA1 revealed, I was assigned to [R1] I gave [R1] his meds and treatment at 804 PM. [R1] was calm and standing at nursing station when I left him and continued med pass. [R1] was last seen by nurse when he asked aide for water around 9:15 PM. Review of Google Maps revealed, the entrance to Highway 101 is approximately 3 miles from the facility, however the exact location that R1 was found on Highway 101 was undetermined. Review of the Weather Channel revealed on 05/24/24, the high was 88 degrees Fahrenheit and the low was 65 degrees Fahrenheit. And on 05/25/24, the high was 83 degrees Fahrenheit and the low was 61 degrees Fahrenheit. During an interview on 05/29/24 at 10:51 AM, R1 revealed, I went out the window in my room. The window slides open, and I got it to work. I hurt my arm; I got a little scratch on my arm crawling out the window. I walked from [NAME] down to McDonalds and got on Highway 101, there was a lot of traffic. I was trying to get home to [NAME] [[NAME], South Carolina]. A deputy sheriff stopped me and questioned me, and they took me to the [local hospital]. I left because I don't like this place. I feel like a puppy dog trapped in a cage. I've told several nurses. I walked for about 3 hours. It was about 9:00 PM when I left and the sheriff stopped me around 12:00 AM. I still feel like I want to leave, I want to be home. I was wearing a dark blue t-shirt, khaki shorts, and crocs with no socks. During an interview on 05/29/24 at 10:59 AM, Registered Nurse (RN)1 revealed that R1 does say that he wants to go home and be with his wife, but R1 seems happy and content. RN1 stated, I didn't take him (R1) seriously when he made those comments. During an interview on 05/29/24 at 11:02 AM, Licensed Practical Nurse (LPN)1 revealed that R1 likes it here, but he wants to be home. He always tells us that he is capable of being home. LPN1 further stated, I never thought he would try and do something like that. During an interview on 05/29/24 at 11:06 AM, Social Services (SS) revealed that after the elopement, R1 stated he was planning to do this. He wanted to go home with his wife and didn't understand why he was here. SS further stated, I never thought he would do that. During an interview on 05/29/24 at 11:37 AM, the Administrator and DON revealed R1 was found about 3 miles away. The DON stated, R1 had a small discoloration on his arm and R1 told her that his feet were hurting, but felt fine after about an hour. The DON revealed nurses are supposed to generally do rounds every 2-4 hours, depending on the need of the resident. The Administrator stated, [R1] is independent and he isn't one that they would have to check on very frequently. The DON stated R1 left the facility about 9:30 PM and the police notified the facility about 12:30 AM, that they found R1 on Highway 101. The Administrator stated that R1 did say that he would like to spend time with his family and go home every once in a while. During an interview on 05/29/24 at 11:45 AM, the Nursing Supervisor (NS) revealed, I was doing some charting on Unit 1, the Certified Nursing Assistants (CNA)s were putting residents to bed and nurses were passing meds. [R1] did not appear to be nervous or exit seeking or upset. Around 9:30 PM the resident asked for a glass of ice and the CNA got it for him. I was still charting and [R1] went to his room. Around 12:30 AM we hear the door bell ring. The staff answered the door and told me the police were here. The police officer asked if I know a [R1] and I said yes. I thought the resident called 911. The officer stated no and that we found him on Highway 101. The officer said they were taking him to the hospital. I asked the staff to check the residents and check his room. they came back to me and told me the window and gate were open. [R1] wasn't the happiest to be here. I didn't think he would try to elope. On 05/29/24 at approximately 2:30 PM, the facility provided a removal plan, which included the following: Resident sent to ER for evaluation when located. Resident assessed with no major injury. Resident returned safely to facility. Post-elopement procedures initiated on 05/25/24 and family at bedside. Resident window secured to prevent exit. Resident relocated to interior, courtyard-view room for safety. Resident care plan has been reviewed and revised as needed. Resident evaluated by in-house provider and Lifesource Psychiatry on 05/28/24 for follow up. All residents are at risk. Resident check completed for all residents at 12:45 am 5/25/24. All resident windows were assessed and secured to prevent exit by 10:30 am 5/25/24. This includes all resident room windows and common area windows. All resident and common area windows were assessed and secured to prevent resident exit on 5/25/24. Added a motion detector alarm to the exterior gate. Staff educated on motion detector alarm initiated on 5/29/24 by Administrator, DON, or designee. Staff education on Wander/Elopement risk; Precautions and missing resident powerpoint and Resident check/Elopement policy 100.149 initiated on 5/28/24 by SNF Educator or designee. Audits for window security were initiated on 5/25/24 and will continue daily for 4 weeks, then weekly by 4 weeks, then 3 times per week for 4 weeks. Continue elopement drills daily for 4 weeks, then weekly by 4 weeks, then 3 times per week for 4 weeks. Correction action will be completed 5/28/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed ensure residents remained free of neglect, for 1 of 3 residents. Specifically, a nurse administered medications to Resident (R)1 that belonged to another resident, resulting in R1 being sent to the emergency room (ER) via Emergency Medical System (EMS). On [DATE] at 9:52 AM, the Administrator was notified that the failure to administer the correct medications to a resident, based on physician orders, constituted Immediate Jeopardy (IJ) at F600. On [DATE] at 9:52 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.12 Freedom from Abuse, Neglect. On [DATE] at 3:15 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the IJ at F600 is considered at Past Non-Compliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility's policy titled Adult and Elder Abuse, Mistreatment and Neglect policy #200.119, effective date 6/23 revealed, Residents are to be free from mental, physical, sexual, and verbal abuse, neglect, corporal punishment, and involuntary seclusion. The policy defines neglect as the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or medical care. The policy also defines abandonment as the desertion of an older adult by his or her designated caregiver. Review of R1's Physician Order, dated 09/23, revealed scheduled medications as: Vitamin D3 1250 microgram (mcg) one (1) tablet twice a month, Aspirin Enteric-Coated (EC) 81 milligram (mg) one (1) tablet daily, Namenda 10 mg (used to treat moderate to severe dementia of Alzheimer's) one (1) tablet twice a day, Keppra 500 mg (used to control epilepsy) one (1) tablet every 12 hours, Doxycycline Hyclate 100mg (used to treat bacterial infections) take one (1) capsule every 12 hours. Review of Licensed Practical Nurse (LPN)1's Personnel file revealed the facility employed LPN1 on [DATE]. LPN1 was provided orientation competency on [DATE] which included but was not limited to Medication Administration. Review of LPN1's time sheet for the week of [DATE] - [DATE], revealed LPN1 clocked out of the facility on [DATE] (date of medication error) at 11:07 AM and did not return. Review of R1's Medication Error Report, dated [DATE], revealed the medication error occurred at 9:15 AM, when the resident received her/his roommate's medications. The report indicated that R1 received Lisinopril/Hydrochlorothiazide combination (used to treat high blood pressure), Amlodipine 10 mg (used to treat high blood pressure), Tylenol, Vitamin D3 5000 U and Ferrous Sulfate 325 mg (milligrams). The report revealed that R1 became hypotensive (low blood pressure) and was transferred to the emergency room (ER) via Emergency Medical System (EMS). The facility assessed the medication error to be caused from failure to identify resident. A phone interview was conducted on [DATE] at 9:30 AM, with LPN1 who acknowledged herself and informed the surveyor to contact her attorney. During an interview on [DATE] at 10:40 AM, Certified Nursing Assistant (CNA)1 revealed caring for R1 consistently. CNA1 voiced that the resident was confused without any behaviors. CNA1 recalled working the day of the medication error. CNA1 stated that at the start of morning shift (before breakfast) vital signs are obtained on residents. (Reviewed R1's V/S on [DATE] were 97.9, 02 saturation 93%, heart rate 72 and respirations 17, and blood pressure (b/p) 124/82). CNA1 continued to recall retrieving breakfast trays and upon entering R1's room the CNA noticed the resident was pale and did not respond to verbal stimuli. The CNA went to the hall, requested, and informed LPN1 that something was wrong with R1. CNA1 recalled, also at the same time requesting another CNA to assist with obtaining a set of vital signs. However, the vitals were unobtainable. During this time LPN1 had not yielded any assistance to the resident. CNA1 called for another nurse (LPN5) on Unit 100 to assess R1. LPN5 immediately arrived at R1's room. CNA1 defined neglect as not providing needed care to a resident such as not providing incontinent care. During an interview on [DATE] at 11:00 AM, LPN5 revealed working in the facility for 12 years but as an LPN for the past year. LPN5 recalled on the morning of [DATE], she was requested to assess R1. Upon LPN5's assessment of R1, it was revealed that the resident needed immediate assistance and informed the resident's nurse (LPN1) that the resident was not responding. LPN 1 did not provide assistance. Sternal rub was implemented, and the resident responded slightly. By this time, the Director of Nursing (DON) had arrived to assist. LPN5 revealed being trained on abuse and neglect yearly. She provided an example of neglect as leaving a resident who needs assistance. During an interview on [DATE] at 12:10 PM, the DON revealed upon arriving to R1's room, LPN1 was in the hallway by a medication cart. The DON requested LPN1 to provide copies of R1's medication administration record for EMS. At that time, LPN1 revealed that R1 received the roommate's morning medications. The DON immediately removed LPN1 from the floor. The DON stated from the initial investigation findings, LPN1 had prefilled her/his medications. While the investigation was being conducted, LPN1 resigned. The DON revealed that R1 expired on [DATE]. During an interview with the Administrator and DON on [DATE] at 12:00 PM. revealed they both are the Abuse Coordinator, and they were aware of the medication error. The Administrator stated immediate corrective action was taken and medication administration continues to be a part of Quality Assurance (QA). On [DATE] at 3:15 PM, the facility presented an IJ Removal Plan which included the following: The identified resident was sent to the ER for evaluation. The incident was reported to the state on [DATE]. All residents in the facility were identified as having the potential to be affected by the deficient practice. Involved nurse was placed on immediate administrative leave pending investigation on [DATE]. A DHEC reportable and related investigation was completed and submitted. Education entitled Med Pass education was initiated by MSN, RN, Director of Nursing, which included policy 100.104 entitled Administration of Medication as well as 10 rights of medication administration on [DATE] and [DATE]. Immediate initiation of Medication pass observations on all nurses present in the building with ongoing observations as each nurse reported for shift until 100% was complete. 100% initial observations were completed on [DATE]. [NAME] Manor continues 3 medication observations per week by MSN, RN, or designee since [DATE] with 100% compliance. Education entitled Change in resident condition, Abuse and Neglect, Resident's Right was initiated on [DATE], [DATE], [DATE], [DATE], and [DATE]. Stand up education regarding resident identification utilizing wristbands was initiated on [DATE] by MSN, RN, Education Coordinator, or designee using policy 200.130 entitled resident identification. Stand up education was initiated [DATE] for abuse and neglect all staff all shifts by MSN, RN, Educator or designee. [NAME] Manor continues 3 medication observations per week since [DATE] performed by MSN, RN or designee with 100% compliance. These audits continue and are ongoing as of [DATE]. Audits for resident identification utilizing wristbands was initiated on [DATE] to be included with med pass observations audit. These audits will continue 3 times per week for 4 weeks, then 3 times per week for 2 additional months. Audits for abuse and neglect initiated [DATE] will be conducted in conjunction with Med Pass observations 3 times per week for 4 weeks, then 3 times per week for 2 additional months. Education was complete on [DATE] for Medication administration. Stand up education for resident identification utilizing wristbands and abuse and neglect was initiated and complete on [DATE] with all associates present at 100% compliance. No associate will report for duty until education has been complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure that 1 of 3 sampled residents, Resident (R)1, was free from significant medication error. Specifically, the nurse administered medications to R1 that were ordered for R1's roommate, resulting in R1 being transported to the emergency room (ER) via Emergency Medical System (EMS). Findings include: On [DATE] at 9:52 AM, the Administrator was notified that the failure to administer the correct medications to a resident, based on physician orders, constituted Immediate Jeopardy (IJ) at F760. On [DATE] at 9:52 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.45 Pharmacy Services. On [DATE] at 3:15 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the IJ at F760 is considered at Past Non-Compliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F760, constituting substandard quality of care. Review of a policy titled The 10 Rights of Drug Administration updated [DATE], revealed understanding the 10 rights of Drug Administration helps prevent medication errors. Nurses at all times are responsible for ensuring safe and quality patient care. The policy indicates medication error rate is 60% in the form of wrong time, rate, or dose. However, some medication errors cause permanent disability and for others the errors are fatal. Nevertheless, the policy revealed following the 10 rights of drug administration will ensure safe patient care. The 10 rights to drug administration are: 1. Right Drug 2. Right Patient 3. Right Dose 4. Right Time and Frequency 5. Right Documentation 6. Right History and Assessment 8. Drug approach and Right to Refuse 9. Right Drug-Drug Interaction and Evaluation 10. Right Education and Information. Step #2 Right Patient reiterate ask the name of the resident and check his/her ID band before giving the medication. The policy notes: .if you know that resident you should still ask their name in order to verify. Review of R1's clinical record revealed an admission date of [DATE] and re-admission date of [DATE], with diagnoses including, but not limited to: Cellulitis of Left Lower Limb, Alzheimer's disease, Dementia, Type 2 Diabetes, and Chronic Kidney Disease. The facility had assessed the resident's code status as a Full Code. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R1 has severe cognitive impairment. Further review of the MDS revealed the facility assessed the resident to have no concerns with mood or behaviors. Review of R1's Physician Order dated 09/23 revealed schedule medications as follows: Vitamin D3 1250 microgram (mcg) one (1) tablet twice a month, Aspirin Enteric-Coated (EC) 81 milligram (mg) one (1) tablet daily, Namenda 10 mg (use to treat moderate to severe dementia of Alzheimer's) one (1) tablet twice a day, Keppra 500 mg (use to control epilepsy) one (1) tablet every 12 hours, Doxycycline Hyclate 100mg (use to treat bacterial infections) take one (1) capsule every 12 hours. Review of Licensed Practical Nurse (LPN)1's Personnel file revealed the facility employed LPN1 on [DATE]. LPN1 was provided orientation competency on [DATE] to include Medication Administration. Review of R1's Medication Error Report, dated [DATE], revealed the medication error occurred at 9:15 AM, when the resident received her/his roommate's medications. The report indicated that R1 received Lisinopril/Hydrochlorothiazide combination (used to treat high blood pressure), Amlodipine 10 mg (used to treat high blood pressure), Tylenol, Vitamin D3 5000 U and Ferrous Sulfate 325mg. The report revealed the resident became hypotensive (low blood pressure) and was transferred to the ER via Emergency Medical System (EMS). The facility suspended LPN1 pending investigation. She/he implemented medication pass audits. The facility assessed the medication error to be caused from failure to identify the resident. A phone interview was attempted on [DATE] at 9:30 AM, with LPN1, who acknowledged herself but declined to discuss any information and directed the surveyor to contact her attorney. During an interview on [DATE] at 10:40 AM, Certified Nursing Assistant (CNA)1 revealed caring for R1 consistently. CNA1 voiced that the resident was confused without any behaviors. CNA1 recalled working the day of the medication error. CNA1 verbalized, that at the start of morning shift (before breakfast) vital signs are obtained on residents. (Reviewed R1's V/S on [DATE] were 97.9, 02 saturation 93%, heart rate 72 and respirations 17, and blood pressure (b/p) 124/82). CNA1 continued and recalled retrieving breakfast trays, and upon entering R1's room she noticed the resident was pale and did not respond to verbal stimuli. CNA1 went to the hall, requested and informed LPN1 something was wrong with R1. CNA1, at the same time, requested another CNA to assist with obtaining a set of vital signs. The vital signs were unobtainable, and LPN1 had not entered the resident's room to assist. CNA1 called for another nurse (LPN5) on unit 100 to assess R1. LPN5 immediately arrived to R1's room. During an interview on [DATE] at 11:00 AM, LPN5 revealed working in the facility for 12 years but as an LPN for the past year. LPN5 recalled on the morning of [DATE], he/she was requested to assess R1. Upon assessing R1 LPN5 informed R1's nurse (LPN1) that the crash cart (used to hold emergency medications and equipment) was needed. LPN5 informed the resident's nurse (LPN1) that the resident was not responding, and assistance was needed. LPN1 did not provide assistance. A sternal rub was implemented, and the resident responded slightly. By this time, the Director of Nursing (DON) had arrived to assist. LPN5 stated he/she was unsure who notified EMS. During an interview on [DATE] at 12:10 PM, the DON revealed, that upon arriving to R1's room, LPN1 was in the hallway by the medication cart. The DON requested LPN1 to provide copies of R1's medication administration record for EMS. At that time, LPN1 revealed that R1 received the roommate's morning medications. The DON immediately removed LPN1 from the floor. The resident was transferred to the emergency room. During the investigation, the DON revealed that LPN1 had prefilled his/her residents' medications. While the investigation was being conducted LPN1 resigned. The DON concluded that R1 expired. During an interview with the Administrator and DON on [DATE] at 12:00 PM, revealed they are both the Abuse Coordinator and were aware of the medication error. The Administrator stated immediate corrective action was taken and medication administration continues to be a part of Quality Assurance (QA). On [DATE] at 3:15 PM, the facility presented an IJ Removal Plan which included the following: The identified resident was sent to the ER for evaluation. The incident was reported to the state on [DATE]. All residents in the facility were identified as having the potential to be affected by the deficient practice. Involved nurse was placed on immediate administrative leave on [DATE] pending investigation. Education entitled Med Pass education was initiated by MSN, RN, Director of Nursing, which included policy 100.104 entitled Administration of Medication as well as 10 rights of medication administration on [DATE] and [DATE]. Immediate initiation of Medication pass observations on all nurses present in the building with ongoing observations as each nurse reported for shift until 100% was complete. 100% initial observations were completed on [DATE]. [NAME] Manor continues 3 medication observations per week by MSN, RN or designee since [DATE] with 100% compliance. Stand up education regarding resident identification utilizing wristbands initiated on [DATE] by MSN, RN, Education Coordinator or designee using policy 200.130 entitled Resident identification. Stand up education regarding medication administration and Abuse and Neglect was initiated by MSN, RN, Educator or designee on [DATE]. On [DATE] Social Worker, interviewed decisional residents regarding agreement to wear wristband. All decisional residents agreed on [DATE]. On [DATE], a wristband was placed on all residents currently admitted to the facility. [NAME] Manor continues 3 medication observations per week since [DATE] performed by MSN, RN, or designee with 100% compliance. These audits continue and are ongoing as of [DATE]. Audits for resident identification utilizing wristbands initiated on [DATE] to be included with med pass observations audit. These audits will continue 3 times per week for 4 weeks, then 3 times per week for 2 additional months. Education was complete on [DATE] and [DATE] for Medication administration. Stand up education regarding resident identification utilizing wristbands and medication administration/Abuse and Neglect was initiated on [DATE] with all RN and LPN associates present and any associates who will report for duty with 100% compliance. No associate will report for duty until education has been complete. On [DATE] Social Worker, interviewed decisional residents regarding agreement to wear wristband. All decisional residents agreed on [DATE]. On [DATE], a wristband was placed on all residents currently admitted to the facility.