Bostonian Nursing Care & Rehabilitation Ctr, The

F 0656 - Dated 11/22/24: Wanderguard to right ankle. Check function daily, every shift, replace Wanderguard bracelet per expiration date located on device. Level of Harm - Minimal harm or potential for actual harm Review of Resident #62's Elopement Risk Assessment Form dated 4/14/25 indicated that the Resident scored 16. The Assessment indicated that a score above 10 indicates a high risk to wander. Residents Affected - Few

Review of Resident #62's care plan dated 10/5/23 indicated the following:

- Problem: Resident #62 is an elopement risk/wanderer and has a Wanderguard in place to left ankle.

- Intervention: Wanderguard.

During an interview on 5/28/25, Unit Manager #1 said Resident #62 wanders up and down the unit all the time and he/she should have a Wanderguard on his/her ankle. Unit Manager #1 and the surveyor reviewed Resident #62's physician's orders and Unit Manager #1 said she would expect the Wanderguard to be in place. Unit Manager #1 and the surveyor observed Resident #62 sitting in his/her bed, the Resident was barefoot and no Wanderguard was observed on either ankle. Unit Manager #1 asked for permission to look for it in the Resident's room, Unit Manager #1 was unable to locate the Wanderguard. Unit Manager #1 said if staff noticed Resident #62 not wearing a Wanderguard she would expect to be notified.

During an interview on 5/28/25 at 2:17 P.M., the Director of Nursing said Resident #62 should have been wearing a Wanderguard per the physician's orders.

During an interview on 5/29/25 at 7:54 A.M., Social Worker #1 said Resident #62 wanders up and down the hallway all the time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 2 225436