**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, family interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, facility staff failed to ensure two of four residents identified as smokers were assessed to determine if they were safe to smoke either independently or were at risk. The residents, one of whom was paraplegic, were observed outside without protective aprons and without direct supervision by facility staff. This was identified as Immediate Jeopardy (IJ) in the area of Quality of Care on 02/05/2019 at 5:01 p.m., with resulting SQC (substandard quality of care). The immediacy was abated on 02/05/2019 at 8:23 p.m. After removal of the immediate jeopardy on 02/07/2019 at 9:30 a.m., the Scope and Severity was lowered to Level III, Isolated. The facility staff also failed to implement interventions and supervision for the prevention of elopement, multiple falls, and falls resulting injury (Harm) for two of 32 residents, and failed to immediately respond and implement safety interventions in response to an emergency door alarm on one of seven units, the 100 unit. 1. Resident #117, a paraplegic, was not assessed to determine her ability to smoke safely and independently. Resident #117 was observed outside smoking cigarettes without a protective apron and without direct staff supervision. This resulted in the identification of Immediate Jeopardy. 2. The facility staff failed to provide adequate supervision to prevent elopement from the facility, multiple falls and falls with injury (harm) for Resident #34. Resident #34 was found in the parking lot on 05/26/2018 requiring evaluation at a local hospital, she had multiple documented falls at the facility including three incidents of harm: a fall with resulting acute proximal humeral shaft fracture on 08/11/2018; a fall on 08/18/2018 with resulting laceration above her right eyebrow requiring 13 sutures; and an acute fracture of the proximal phalanx (ring finger) that was identified on 12/02/2018. 3. The facility staff failed to implement interventions and supervision for the prevention of falls for Resident #129, which resulted in harm. Resident #129 had a fall and was sent to the hospital for evaluation, receiving five staples to the back of the head for a laceration. 4. The facility staff failed to accurately assess Resident #60's ability to smoke independently or safely without direct supervision. 5. Facility staff failed to immediately respond and implement safety interventions in response to an emergency door alarm on the 100 unit. The alarm sounded for almost 30 minutes without any response or interventions from staff members present on the unit. A charge nurse interviewed was not knowledgeable about the alarm or what actions were required in response to the alarm. Findings were: 1. Resident #117 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Paraplegia, acute kidney failure, hypertension, chronic obstructive pulmonary disease, and neuromuscular dysfunction of the bladder (requiring indwelling catheterization). A significant change MDS (minimum data set) with an ARD (assessment reference date) of 1/14/2019, assessed Resident #117 as cognitively intact, with a summary score of 15. Section J: Health Conditions, J1300 Tobacco Use was checked No. In the course of the survey process a list of residents who smoke was requested from the administrative staff. Resident #117 was identified on the list as a smoker. The clinical record was reviewed on 02/05/2019 at approximately 2:00 p.m. A smoking assessment was not observed on the electronic record. The care plan was reviewed. There were no interventions on the care plan regarding smoking. On 02/05/2019 at approximately 3:30 p.m., Resident #117 was interviewed. She was asked if she was a smoker. She stated, Yes, but I don't smoke everyday, or every smoke break .I usually just go down once a day .I went for so long without smoking because I was so sick, but I've started again . I am going out today at 4:00 [p.m.]. Resident #117 was asked where she kept her cigarettes. She stated, They are downstairs with my lighter. During the interview, Resident #117 was asked if she could move her legs or had any feeling in them. She stated, No, they said I have a clot on my spine that is causing it [paralysis] .I don't know if my legs will get better or not. At 4:00 p.m., two surveyors went to the smoking area to observe the residents. The area was located at the end of the facility outside the dining room. OS (Other Staff) #2 was standing in the dining room at the door to the smoking area. She entered a code and allowed the surveyors to walk outside. The smoking area was a covered cement patio with a locked privacy fence in front of it. The dining room door was the only entrance back inside the building and had a narrow, long window above the door knob. The window in the door was the only indoor point of visualization to the smoking area. Three residents were observed smoking. One resident was wearing an apron. OS #2 came outside and offered the other two residents an apron. Both residents declined. OS #2 went back inside the building. Resident #117 was not wearing an apron. She was sitting with her back to the door and her smoking could not be visualized from inside. The residents were talking and Resident #117 stated, My husband brought me some cigarettes, I need to bring them downstairs to the desk, I forgot them in my room. When the observation was complete, OS #2 opened the door for the surveyors to come back into the facility. She was asked what her role was. She stated, I'm here for the smoking time, but I'm not going out there .I don't smoke. A sign was observed beside the door with posted smoking times and the following sentence: Smoking aprons must be worn at all times . A copy of the facility policy was requested at 4:10 p.m. The corporate nurse and the DON (director of nursing) stated that the smoking guidelines were located in the resident admission packet. The Patient Information Handbook was reviewed. Page 3 contained the following information regarding smoking: SMOKING We believe in providing a healthy environment for you. Our center is designated as 'smoke-free.' Smoking is not permitted on the campus or may be permitted in designated area only. Smoking materials, including lighters, matches, cigarettes, and cigars, must be stored at the nurse's station. The DON was again asked if there was a facility policy regarding smoking. She stated, We are looking for it .what we have are called 'guidelines', not a policy. The SMOKING GUIDELINES included the following information: PURPOSE: To determine if a patient is an Independent Smoker or an At Risk Smoker before the patient exercises the privilege to smoke while residing within the center and to establish guidelines for all patients that desire to smoke, as well as non-smokers. GUIDELINES: - Evaluate patients that smoke utilizing the Smoking Evaluation tool either: (a) upon admission; (b) when a previous non-smoking patient takes up smoking; (c) if unsafe smoking practices are observed in a current smoker; or, (d) when a patient that smokes has a significant change in medical condition. -The Smoking Evaluation is generated from the assessment tab in [name of computer system]. -Provide education of the Smoking Guidelines to the patient, family members or responsible party and visitors that may supervise patients during smoking. Education is provided when: (a) a new patient is identified as a smoker; (b) a previous non-smoker patient takes up smoking; (c) if unsafe smoking habits are observed in a current smoker; or, (d) a patient that smokes has a significant change in medical condition. The education is documented and saved in the patient's electronic health record utilizing the Patient Education Progress Note or per state requirements -Upon completion of the evaluation, the Interdisciplinary team [IDT], including the attending physician, will make a decision whether the patient is an Independent or an At Risk Smoker. -If the patient is determined to be an Independent Smoker, the patient may smoke without assistance at center designated times. Independent Smokers must still follow smoking guidelines including, but not limited to, keeping smoking accessories in control of the center staff when not in use and smoking only in designated areas at designated times. -If the patient is determined to be an At Risk Smoker, the patient is required to wear a protective smoking vest or apron if needed and is supervised while smoking. -The IDT completes completes a comprehensive patient care plan that reflects the: -smoking evaluation outcome -smoking supervision that is necessary -type of protective smoking equipment that is needed, e.g., smoking apron or vest - education on the Smoking Guidelines and options for smoking cessation activities offered and/or provided to the patient or family members . -Direct personal supervision is provided to At Risk Smokers while smoking. Center administration provides supervision and direction to center staff responsible for providing direct supervision. Other patients cannot, under any circumstances, provide supervision for At Risk Smokers . -Any non-compliance with the smoking guidelines is addressed with the patient and family members as the non-compliant activities occur. Additional education is provided as needed and the plan of care is updated to reflect the patient's current needs . The survey team met to discuss the smoking observations, the lack of smoking assessment, care plan, and supervision for Resident #117, a paraplegic. The team determined that guidelines for Immediate Jeopardy were met. The team supervisor and the State agency were contacted for validation. The office concurred and Immediate Jeopardy was implemented at 5:01 p.m., with subsequent Substandard Quality of Care. On 02/05/2019 at 5:11 p.m., the survey team met with the administrator and the DON (director of nursing). The team leader informed them that the survey team with concurrence from the main office had implemented Immediate Jeopardy at 5:01 p.m., and SQC due to the facility's failure to assess Resident #117, a smoker with paraplegia for safe smoking. They were told that Resident #117 was observed outside smoking without a protective apron, without direct supervision, without a care plan or assessment for smoking, and that her MDS did not identify her as a smoker. The administrator was informed that a plan of removal for immediacy would need to be developed and presented to the survey team for approval before the immediacy would be abated. The facility staff presented the following five point plan of correction that was accepted by the survey team on 02/05/2019 at 8:23 p.m.: This serves as Manor Care Health Services Arlington [sic] response to the Immediate Jeopardy Notification that the center received on February 5, 2019. The facility Quality Assessment and Performance Improvement [QAPI] Committee met on February 5, 2019 to resolve the alleged failure to assess a smoking patient for smoking needs. 1. Resident [initials of Resident #117] was observed smoking without direct supervision. Further investigation also showed that the same resident does not have a smoking assessment on record, there was no care plan completion, and there was no MDS assessment completed. The resident, [initials of Resident #117], has been educated regarding the facility smoking policy. 2. The facility has completed a smoking assessment on [initials of Resident #117] today, 2/5/19. The patient's care plan has been completed to reflect her smoking status. Furthermore, a significant change in status MDS for [initials of Resident #117] has been initiated. The staff responsible for smoking supervision have been educated on direct supervision and use of apron during smoking. 3. The facility would [sic] continue to educate the entire staff on Manor Care's smoking policy. Education has begun today, 2/5/2019, and anticipated to be completed by end of day, 2/7/19. 4. The facility has completed an audit of all residents presently in the facility for smoking. No new smoker was identified above those it currently has on the smoking list. The facility will complete a smoking assessment for all new residents admitted in the facility going forward. 5. This plan of correction has been forwarded to an ad hoc QAPI committee for adoption or further recommendation. Also presented was a Staff Development Program Attendance Record with five staff listed who had received training on DIRECT SUPERVISION FOR SMOKERS. The education attached was: 1. IF ANY RESIDENT IS NOT ON THE CURRENT SMOKERS LIST AND THEY COME OUT TO SMOKE. [sic] YOU MUST STOP THEM AND NOTIFY NURSING FOR RESIDENT TO HAVE SMOKING ASSESSMENT COMPLETED TO DETERMINE THEIR SAFETY. THE SUPERVISOR OF SMOKERS WILL CHECK THE CURRENT LIST TO ENSURE ONLY THOSE RESIDENTS LISTED ARE SMOKING. 2. WHILE OBSERVING THE SMOKERS YOU WILL NEED TO MAINTAIN VISUAL CONTACT AND ENSURE RESIDENTS ARE FACING YOU. 3. WHEN INDICATED ENSURE THE RESIDENT HAS SMOKING APRON ON. 4. NURSING/DESIGNEE WILL UPDATE THE SMOKERS LIST FOR NEW ADMISSIONS AND CHANGES OF CONDITIONS AS NEEDED. Resident #117's smoking evaluation was presented and reviewed. Resident #117 was assessed by the facility as an At Risk Smoker, Requires family, friend or staff for physical support or supervision to smoke .Patient able to smoke with apron, and educated on times and need for smoking materials to be secure during non-smoking hours. On 02/07/2019, during the morning, the survey team conducted random interviews throughout the facility to ascertain that staff had received the training outlined on the plan of removal. All interviewees had been trained and were knowledgeable regarding the facility's smoking policy. The facility checklist indicated that all staff had received training as of 9:30 a.m. on 02/07/2019. No further information was obtained prior to the exit conference on 02/07/2019. 2. Resident #34 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Type II Diabetes Mellitus, Parkinson's disease, dementia with behavioral disturbance, major depressive disorder, and hypertension. Her admission MDS (minimum data set) with an ARD (assessment reference date) of 05/22/2018 coded Resident #34 as having impairment with both long and short term memory, and severely impaired for daily decision making skills. Resident #34 was also coded as needing limited assistance of one for walking in her room and in the corridor. Under the area Balance During Transitions and Walking (G0300) she was coded as Not steady, only able to stabilize with staff assistance in the areas of Moving from seated to standing position; Walking; turning around; moving on and off toilet; and surface-to-surface transfer. The quarterly MDS with an ARD of 11/22/2018 also coded Resident #34 as impaired with both long and short term memory, and severely impaired for daily decision making skills. She was coded as needing limited assistance of one for walking in her room and in the corridor. Under the area Balance During Transitions and Walking she was coded as Not steady, only able to stabilize with staff assistance in the areas of Moving from seated to standing position; Moving on and off toilet; and surface-to-surface transfer; and coded as Not steady, but able to stabilize without staff assistance in the areas of Walking and turning around. Resident #34's room was located at the end of the the unit on the second floor. Her room was not visible from the nurses station. On 02/05/2019 at approximately 9:15 a.m., Resident #34 was observed in her room eating breakfast. She was sitting in a chair beside her bed. Food was on the floor around her, she got up and down out of the chair and walked to a different chair in her room and then returned to the chair where her breakfast tray was located multiple times. When an interview was attempted Resident #34 spoke no English. No staff was in the vicinity to assist her. On 02/05/2019 from approximate 2:30 p.m. until 2:35 p.m., Resident #34 was observed walking around her room. She was wearing only a wander guard and a sock on her left foot. She walked back and forth from a chair in her room to her bed. She was observed to lay down in the bed, cover up and then immediately get back up. Her clothes and brief were in a pile on the floor. This surveyor walked around the third floor looking for someone to assist Resident #34; a CNA (certified nursing assistant) was located at the far end of the floor and was asked if she was working with Resident #34. She stated, No, I am on the other end. What does she need. When the situation was described the CNA went to the room to assist Resident #34. The clinical record was reviewed on 02/05/2018 at approximately 6:30 p.m. Review of the progress note section indicated that Resident #34 had a history of wandering, falls and falls with injury. The clinical record included documentation of approximately 17 falls, 2 elopements, two fractures and two lacerations requiring sutures/staples since admission to the facility. Documentation in the progress notes included the following: 05/15/2018 23:47 (11:23 p.m.) Patient present(s) with diagnosis of weakness, post status fall, deep dark bruises on her body, bruises and bumps on the forehead, red scabs to both knees, confusion, mental status change, she speaks and understands very little English . 05/16/2018 4:20 [a.m.] she is monitored frequently as she gets up unassisted and gait is unsteady . 05/17/2018 08:51 [a.m.] Resident found lying on the floor at 11:55 p.m no signs of discomfort . 05/29/2018 07:34 [a.m.] Patient is alert, stable and very confused, refuses to stay on the bed or chair, trying to get up but she does not have good gait or good balance, staff have [sic] baby siting [sic] most of the night . 05/17/2018 16:56 [4:56 p.m.] POST FALL NURSES ASSESSMENT; Resident was very combative and refused to stay sitting on her W/C [wheelchair]. Resident was put in bed to rest and few minutes later, she got up and began to walk down the hall-way to 2-west unnoticed by staff. She accidentally fell in room [number] @1:30 p.m. today .no new skin impairment . 05/23/2018 00:07 [12:07 a.m.] Patient found on the floor on her right side by 3 E [east] [not Resident #34's floor] nurses station during shift change. Staff reported she has been wandering around most of the shift .[no injury] 05/26/2018 11:45 [a.m.] Front desk paged writer and stated come down stair [sic] to see resident for Spanish Interpreter, came to front desk and saw resident with fire department, ambulance, stated they found her in Manor Care back of the parking lot .MD gave order to transfer resident to ER for evaluation . 05/26/2018 16:54 [4:54 p.m.] Resident is alert and oriented .Resident up walking independently .writer saw resident around 11:15 a.m. sitting in Longue [sic]with no distress noted .At 11:45 [a.m.] supervisor call writer stated come in front desk [sic], noted resident with fire department, ambulance, they stated they found her in back of Manor Care parking lot .send to ER . 05/26/2018 20:01 [8:01 p.m.] Patient skin reveals bruises to the lower left back, left temple and right arm possible from the reported fall on 5/23/18. She returned from ER for evaluation to rule out dehydration .[physician name] notified for wander guard for safety. 06/11/2018 17:00 [5:00 p.m.] Patient fell out of the facility on her way in for readmission. She was discharged home early at 10:00 AM with her daughter .writer was told that she [Resident #34] refused to stay at [name of facility] and returned to Manor Care .She fell at door entrance and got a cut on the back of her head .911 . 06/11/2018 22:59 [10:59 p.m.] Patient was readmitted from [hospital] .patient has stitches in her head related to fall: wounds noted on the head. One has 4 staples and the other has 1 staple . 06/21/2018 13:08 [1:08 p.m.] Resident is confused, while transferring from bed to w/c lost her balance and sat on floor . 08/11/2018 08:18 [a.m.] Resident was alert with intermittent confusion. Neurocheck was in progress send resident to emergency department to evaluate for acute proximal humeral fracture via 911 .order due to X-ray result shown [sic] fracture on the proximal hum oral shaft .[NOTE: No documentation in clinical record regarding aforementioned x-ray or fall] 08/11/2018 11:32 [a.m.] During AM care this writer was called to resident room by CNA [certified nursing assistant] stating resident right elbow appears swollen. On assessment skin warm to touch, no redness noted in skin, resident alert and verbal, s/s [signs and symptoms] of grimacing noted while touching right elbow .limited ROM [range of motion] on right extremity . 08/11/2018 12:44 [p.m.] .on call MD notified .new order given to do x-ray of shoulder 2 views . 08/11/2018 13:10 [1:10 p.m.] .spoke to RP [responsible party] that she [Resident #34] has an accident and fell from her bed. Neurochecks initiated. 08/11/2018 16:39 [4:39 p.m.] Resident fell in front of her room while ambulating to her room to use the bathroom around 2:00 p.m no apparent injury, redness noted in left side of the head, passive ROM in left upper extremity and both lower extremities within normal limits .right upper extremity has limited ROM . 08/11/2018 18:00 [6:00 p.m.] Mobile tech in X-ray done results pending. 08/11/2018 08:30 [a.m.] [Name] emergency was called to ascertain patient condition and her nurse .indicated that her doctor might discharge her back today. 08/12/2018 16:36 [4:36 p.m.] Resident arrived back from [name] ER at 3:45 p.m noted on her left upper side of the face slightly swollen with redness, right upper shoulder noted swollen, with bruising, and the right lower arm in a cast wrap with ace wrap and in sling .left fifth finger noted with old open area but dry measuring 0.5 cm X 0.5 cm, left knees noted with open area measuring 2.0 cm X 1.0 cm, below left knee noted with scabbed measuring 1.0 cm X 1.0 cm . 08/12/2018 19:58 [7:58 p.m.] .came back with diagnosis of closed fx [fracture] of right proximal humerus .During skin assessment old healing scar with scabbed [sic] noted to the back of the head, right upper shoulder at the back noted with open area measuring 1.0 cm X 1.0 cm, mid back noted with open area measuring 2.0 cm X 0.3 cm and also another tiny open area to mid back measuring 0.3 cm X 0.3 cm and at the right outer back noted with old healed scar resident pulling on her cast and sling . 08/18/2018 10:40 [a.m.] Writer [NAME] [sic] at this time to attention stating resident fell in lunch room on west side and sustained a laceration to upper right eyebrow measured 4 cm X 2 cm with large amount thick red blood from site. Ice pack applies to site .resident transferred to [hospital name] at 10.5 am {sic], report given to ER nurse. 08/18/2018 15:36 [3:36 p.m.] Resident back from the hospital .13 sutures noted intact to facial laceration .Resident in bed at this time but trying to get out of the bed . 08/21/2018 08:23 [a.m.] Patient was found sitting [on] the floor at 7:30 a.m., neurological check done and no change notice [sic] 08/21/2018 16:56 [4:56 p.m.] Loud Portuguese language heard coming from the room and this writer went to check, patient was observed lying on her right side, the right arm on the pillow. No apparent injury noted, skin assessment done, resident noted with right eye lid dark purple color, and stitches in place in right forehead close to right eye, large dark purple discoloration noted in right thigh all those from previous falls .resident was transferred with tow assist to bed, bed was in low position. 08/28/2018 01:54 [a.m.] .very combative with staff going from room to room unsteady on her feet, requires one on one monitoring to prevent falls . 09/05/2018 19:50 [7:50 p.m.] .called writer to room and resident was observed on the floor at 6:20 p.m. lying on her right side beside the entrance door. Based on observation, resident was consuming her dinner meal when she decided to got [sic] up and walk from his [sic] Mw/c and she accidentally fell to the floor at 6:30 p.m. today. Resident assessed head to toe .no new skin impairment .ROM performed .no limitations noticed except little limitation observed on her right fractured humerus from post fall recently . 09/21/2018 15:41 [3:41 p.m.] Resident was observed sitting in wheelchair at the nursing station with other residents at 2:25 p.m. This writer went to assist the aide to transfer another patient from the chair to bed, when she came out of the room this patient was observed sitting on the floor .no apparent injury observed . 09/23/2018 22:35 [10:35 p.m.] .oob to w/c sitting in front of nurses station and as soon as staff goes to attend to other resident, resident will get up from her w/c and ambulate to other resident room and nurse redirected back to her w/c . 10/06/2018 15:26 [3:26 p.m.] Resident was observed at 1:55 PM sitting on the floor in front of her room, bedside table behind her .no apparent injury .resident was last seen lying in her bed resting around 1:40 p.m . 11/17/2018 17:35 [5:35 p.m.] .at 4:10 p.m. sitting in her w/c in front of nurses station, per assign [sic] cna resident wants to stand up, her w/c was locked but the w/c moved a little bit and resident slide [sic] to the floor. Assign [sic] cna said she hold resident on one side and she try to hold resident on the other side but resident slide and sit on floor and resident head, a little bit touch on the wall .no apparent injury .do neurochecks for 24 hours if any change in mental status send resident to ER . 11/28/2018 00:07 [12:07 a.m.] Resident is alert and very confused wander into physical therapy room and lock self up in there the room several attempt patient before patient open room, skin audit done assessment done no acute distress noted . 12/02/2018 16:50 [4:50 p.m.] .resident ambulating in her room when nurse making round at the start of shift at 3:05 PM and no distress noted .staff from activity dept came and wheeled resident to activity upstairs in w/c before 3:30 p.m. Daughter visited and nurse told daughter that resident went upstairs with activity .daughter went upstairs and came down with resident and daughter brought to nurse [sic] attention of resident left 4th finger reddening and swollen. When nurse asked resident what happened resident stated I hit it somewhere 2 days ago and it pain a little .left 4th finger assessed noted swollen and reddening 4th palm noted bruising .daughter requesting x-ray . 12/03/2018 18:26 [6:26 p.m.] .x-ray results positive for acute fracture of the proximal phalanx of the ring finger .to schedule appointment with ortho . 12/08/2018 09:57 [a.m.] .resident walking in the hallway all naked. Aide working with this resident was in the shower room given [sic] shower to resident in room [number]. Writer took resident in the room, provided ADL care and dress resident . 12/08/2018 16:28 [4:28 p.m.] Writer was called to attention by another staff stating resident is sitting on the floor at west unit station .resident in upright position on floor. Head to toe assessment done, no s/s pain noted . 02/01/2019 15:32 [3:32 p.m.] Resident was observed sitting on the floor in room [number] [NOTE: not Resident #34's room], no apparent injury noted . The care plan was reviewed at approximately 7:00 p.m. and contained the following focus area: Exit seeking/elopement risk multiple attempts to leave facility related to: cognitive impairment, new admission/change of environment. Interventions listed included: Accompany to meals and scheduled activities; ALERT BRACELET; Calmly redirect; Engage in activities/tasks to keep occupied An additional focus area for: At risk for falls due to history of fall, recent fall, non steady gait, not using safe judgement D/T dementia disease process was observed on the care plan. Interventions included: Administer Calcium and Vitamin D per protocol; Administer medication per physician orders; All intervention reviewed and continue with plan of care; Bed in low position; Encourage resident to sit in front of nursing station; have commonly used articles within easy reach; Reinforce w/c safety as needed such as locking brakes; visual monitoring as resident allows; FALL RISK (FYI); Reinforce need to call for assistance. On 02/06/2019 at approximately 7:50 a.m., the DON (director of nursing) was asked for any investigations/incident reports that had been completed on Resident #34 since her admission to the facility in May 2018. The DON was also asked if the facility used bed or chair alarms. She stated, No. She was asked what the facility did to call attention to residents getting up unassisted who may fall. She stated, We make frequent rounds and care plan them for falls. At approximately 8:00 a.m., RN (registered nurse) #1, the unit manager, RN #6 and LPN (licensed practical nurse) #3 were interviewed regarding Resident #34's wandering, falls, and falls with injury. All three were asked what was done by the facility staff to prevent her falls and injuries. RN #6 stated, On nights we bring her with us. LPN #3 and RN #1 were asked what was done during day shift. LPN #3 stated, We have a care plan that we follow. Concerns were voiced to RN #1 and LPN #3 that while the survey team had been in the building, staff had not been readily available on that end of the hallway. Observations of staff being at the far end of the floor when needed was voiced. Concern over the visualization of Resident #34 were also discussed. Resident #34's room was not visible from the nursing station. LPN #3 and RN #1 were asked how often Resident #34 was observed. RN #1 stated, Yes, I see what you are saying .I am new here, I will see what we can do. At approximately 1:45 p.m., Resident #34 was sitting in her room. Her daughter was at her bedside. The daughter was interviewed regarding Resident #34's care at the facility. The topic of Resident #34's falls were discussed. The daughter stated, They talked to me just now about moving her to a room where they can see her better .my mother needs to be in a private room or she messes with other peoples things .the problem isn't her room, the problem is the staff is never down here where she is .they don't watch her .I always have to look for them when she needs something .the only time she is watched is when I am here .she can't go home with me because my home has steps, and she is less safe there. At approximately 3:20 p.m., after multiple requests, the DON presented incident reports for Resident #34 and they were reviewed. The DON was interviewed regarding staff interventions to supervise Resident #34. The first elopement of Resident #34 on 05/23/2018 when she was found lying in front of the nurse's station on a different floor was discussed. The DON stated, That's when we implemented the wander guard. The DON was informed that the wander guard was not implemented until Resident #34 was found in the back of the facility parking lot on 05/26/2018. She was asked if the wander guard should have been implemented when the resident was found on another floor of the facility after falling She stated, Yes, I would think so. Resident #34's fall with fracture, fall with laceration requiring sut[TRUNCATED]