This citation pertains to Intake # MI00143491. Based on observation, interview, and record review, the facility failed to immediately treat a hot liquid burn per professional standards of practice in 1 of 5 residents (Resident #103) reviewed for quality of care, resulting in an Immediate Jeopardy when on 2/22/24 Resident #103 spilled a cup of hot liquid on her lap. Facility staff did not immediately apply cool liquid to the site to stop the burn, resulting in additional skin breakdown, prolonged healing, infection requiring IV (intravenous) antibiotics, and ongoing pain. Findings include: Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included second-degree burn of thigh, skin infection, stroke with left sided weakness, peripheral vascular disease, dementia, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 2/8/24, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated severe cognitive impairment. In an observation and interview on 4/10/24 at 9:57 AM, Resident #103 was in bed in her room, eating independently from her breakfast tray. No hot liquids observed on breakfast tray. Resident #103 reported she used to drink hot tea, but had a spill in the dining room which resulted in burns. Resident #103 reported her burns are still healing, and she goes out to the wound clinic for treatment. Review of an Incident/Accident report for Resident #103, dated 2/22/24 at 10:30 AM, revealed .Nurse was informed that resident spilled hot liquid on her lap while eating breakfast .Immediate Action Taken .Nurse had resident taken to the room where she resides and did a full skin assessment on her and the finding was red skin . Review of a Skin Assessment for Resident #103, dated 2/22/24 at 11:30 AM, revealed .Inner thighs have a red area to the skin due to a hot beverage getting spilled on her legs. Will continue to monitor the area until no longer red . No additional interventions noted. In an interview on 4/10/24 at 10:29 AM, Family Member LL reported Resident #103 had a hot liquid spill in the dining room on 2/22/24. Family Member LL reported Resident #103 spilled a cup of hot tea on her lap, which resulted in burns to both her legs and her buttocks. Family Member LL reported Resident #103 had to go to the wound clinic for care, and has treatments completed twice a day. Family Member LL reported Resident #103's wounds are painful, and stated .She still cries because it is so painful . Family Member LL reported staff did not know how to respond to the hot liquid spill, and stated .She sat in the (hot) water. They didn't know how to treat it . Review of a Health Status Note for Resident #103, dated 2/22/24 at 12:41 PM, revealed .Resident went to kitchen and asked for a cup of coffee. Kitchen manager gave resident a cup of coffee with a lid on the cup. Resident then took the lid off the cup of coffee and was trying to drink from the cup. Resident spilled the cup of coffee on her lap. Resident was immediately taken to her room to do a skin assessment of the area. Inner thighs had a red area to it. Cream was applied to the red area and clothes were changed. Resident was re-educated on the importance of keeping the lid on hot beverages. Staff will continue to monitor the area until it is healed . Note, no cool water was applied to stop the burning process prior to placing cream on the burns. Review of a Health Status Note for Resident #103, dated 2/22/24 at 4:46 PM, revealed .Resident was drinking hot liquids in the dining room for breakfast and spilled the hot beverage on her legs. A full skin assessment was performed after the incident. The finding was red area on the inner thigh. Resident c/o (complained of) pain at the area. Another skin assessment was performed at (4:00 PM) and the finding was blisters noted on the inner thighs all the way back to the buttocks. (Nurse Practitioner J) assessed the areas and gave orders to the nurse to start for wound care. Will continue to monitor the area until healed . Review of a Health Status Note for Resident #103, dated 2/22/24 at 5:40 PM, revealed .Measurement for blisters on inner thighs. Left thigh and buttocks blister 36cm (this runs all the way across left buttocks.) 36cm x 8cm. Right inner thigh 10.5cm x 5.5cm blister. skin tear below right thigh blister 5.5cm x 2.5cm . Review of a Physician's Progress Note for Resident #103, dated 2/23/24 at 11:39 AM, revealed .Apparently yesterday she was drinking hot tea and spilled her tea in her lap - subsequently skin was burned and nursing requesting evaluation .Second degree burns with two large blisters of left thigh - one intact and the second one has opened with pink wound bed .Second degree burns on right thigh with long nearly circumferential blister that is fluid filled and three additional circular burns with fluid filled blisters .Plan: Second degree burns on thighs after tea spilled in her lap. Cover open blister with TAO (triple antibiotic ointment) and sterile dressing, changing dressing daily and monitoring for drainage. Monitor fluid filled blisters and try to keep blisters intact - avoid friction or rubbing . In an observation on 4/10/24 at 12:24 PM, Assistant Director of Nursing (ADON) W and Licensed Practical Nurse (LPN) Q completed wound care for Resident #103. Observed extensive burns to Resident #103's right and left thighs, with reddened wound bases and a small amount of blood-tinged drainage. Observed Resident #103 flinch as the old dressings were removed from the wounds, and state .ow, ow, ow . while holding her hand over her mouth. In an interview on 4/10/24 at 2:53 PM, Registered Nurse (RN) AA reported she was Resident #103's assigned nurse on 2/22/24 when the hot liquid spill occurred. RN AA reported staff brought Resident #103 to the unit from the dining room immediately after the hot liquid spill. RN AA stated Resident #103 .had removed the top from her coffee cup and it had spilled on her lap . RN AA reported she brought Resident #103 to her room and removed her pants to assess the affected area. RN AA stated .There was slightly red skin . when the area was initially assessed. RN AA reported no other treatment or intervention was done at that time, and stated .just the assessment of the skin . RN AA reported later on that day, Resident #103 was complaining of pain. RN AA reported she completed another assessment of Resident #103's skin, and noted blisters had formed on her thighs. In an interview on 4/10/24 at 3:20 PM, Server DD reported she served Resident #103 a cup of hot tea with a lid on 2/22/24. Server DD stated .Next thing you know I hear her screaming .She had spilt it all over herself . Server DD reported she and Server EE immediately brought Resident #103 to her assigned nurse. Server DD reported that since the incident, she was educated that cool liquid should be immediately applied to the burned area. Server EE stated .I didn't know that was what we were supposed to do . In an interview on 4/10/24 at 4:01 PM, ADON W reported she was working the day Resident #103's burns occurred. ADON W reported after staff notified her of the incident, she went in to assess Resident #103's skin to determine the severity of the burn. ADON W stated when she assessed Resident #103's skin .It wasn't blistered at the time .It looked like a dark area on her skin . ADON W reported Resident #103 reported pain from the affected area. In an interview on 4/11/24 at 9:05 AM, Nurse Practitioner (NP) J reported she was notified after Resident #103's hot liquid spill on 2/22/24. NP J reported when she assessed the wounds, she noted second-degree burns on Resident #103's thighs. NP J reported after the incident, Resident #103 complained of increased pain and was sent out to the hospital on 2/25/24. NP J reported Resident #103 returned to the facility with orders to be seen at the wound clinic. NP J reported Resident #103's wounds began draining, her wound was cultured, and she was started on IV antibiotics. NP J reported topical lidocaine was initiated during dressing changes .because she is so painful . and a Foley catheter was placed for wound management. NP J reported Resident #103's wounds were .more than just superficial break down . Review of a Hospital After Visit Summary for Resident #103, dated 2/25/24, revealed .has second-degree burns on the inner thighs .A referral was placed to the burn clinic for follow-up . Review of a Burn and Wound Center note for Resident #103, dated 2/27/24, revealed .Chief Complaint .evaluation and management of second degree burn on thighs .Location: bilateral thighs .Burn occurred due to staff handing pt (patient) a cup of hot tea and she spilled it on her lap .Wound #1 status is Open. Original cause of wound was Thermal Burn. The date acquired was: 2/22/2024. The wound is currently classified as a Partial Thickness wound with etiology of 2nd degree Burn and is located on the Right, Circumferential Upper Leg. The wound measures 26cm length x 23 cm width x 0.1cm depth .There is Fat Layer (Subcutaneous Tissue) exposed .There is a large amount of serous drainage noted. There is medium (34-66%) red granulation within the wound bed. There is a medium (34-66%) amount of necrotic tissue within the wound bed including Eschar .Wound #2 status is Open. Original cause of wound was Thermal Burn. The date acquired was: 2/22/2024. The wound is currently classified as a Full Thickness Without Exposed Support Structures wound with etiology of 2nd degree Burn and is located on the Left, Circumferential Upper Leg. The wound measures 8.5cm length x 18.5cm width x 0.1cm depth .There is Fat Layer (Subcutaneous Tissue) exposed .There is a large amount of serous drainage noted. There is medium (34-66%) red, pale granulation within the wound bed. There is a medium (34-66%) amount of necrotic tissue within the wound bed including Eschar . Review of a Burn and Wound Center note for Resident #103, dated 3/5/25, revealed Chief Complaint .evaluation and management of second degree burns on thighs .Pt has bilateral thigh burns due to a cup of hot water spilling on her thighs. The kitchen staff took pt back to her room which may have contributed to the burns depth . Review of a Health Status Note for Resident #103, dated 3/11/24 at 5:42 PM, revealed .Observed green drainage from burns on left and right thigh and buttocks. NP notified. Order to culture wound completed . Review of a Physician's Progress Note for Resident #103, dated 3/14/24 at 11:14 AM, revealed .Recent burns on upper thighs after spilling hot liquid - blistered - treated with antibiotic therapy Keflex and appeared to be improving .additionally going to the wound clinic .2 days ago nursing reported malodorous green discharge from wounds - wound cultures and grew Pseudomonas aeruginosa, E. coli, providencia stuartii, and Pseudomonas aeruginosa #2 .Wound dressings are changed twice daily according to wound clinic treatment .Increased pain noted with wound dressing changes .Plan: Burns on bilateral inner thigh now infected with multiple organisms. Ordered Midline placement by access RN .Cefepime IV twice daily for 10 days .Topical lidocaine prior to dressing changes and Tramadol . Review of a Burn and Wound Center note for Resident #103, dated 3/19/24, revealed .Chief Complaint .evaluation and management of second degree burns on thighs .Wound #1 status is Open. Original cause of wound was Thermal Burn .The wound is currently classified as a Full Thickness Without Exposed Support Structures wound with etiology of 2nd degree Burn and is located on the Right, Circumferential Upper Leg. The wound measures 32cm length x 14cm width x 0.1cm depth .There is Fat Layer (Subcutaneous Tissue) exposed. There is a large amount of serous drainage noted. There is small (1-33%) red granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including Eschar and Adherent Slough .(note, this necrotic tissue had increased in size) .Wound #2 status is Open. Original cause of wound was Thermal Burn .The wound is currently classified as a Full Thickness Without Exposed Support Structures wound with etiology of 2nd degree Burn and is located on the Left, Circumferential Upper Leg. The wound measures 14cm length x 15cm width x 0.1cm depth .There is Fat Layer (Subcutaneous Tissue) exposed .There is a large amount of serous drainage noted. There is small (1-33%) red, pale granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including Eschar and Adherent Slough (note, this necrotic tissue had increased in size) .Per caregiver, Patient now on IV (intravenous) Cefepime . In an interview on 4/11/24 at 10:45 AM, Server EE reported he was present at the time of Resident #103's hot liquid spill on 2/22/24. Server EE stated .I heard her yell and then turned and rushed her to the nurses' station . Server EE reported cool water was not applied to Resident #103's burned area. In an interview on 4/11/24 at 3:36 PM, RN AA reported in regard to treatment immediately after a hot liquid spill, cool liquid should be applied to the affected area. RN AA reported in regard to Resident #103's burns that occurred on 2/22/24 cool liquid was not applied to the affected area immediately after the hot liquid spill occurred. RN AA stated this intervention .Wasn't anything I was thinking of at the time . Review of a WebMD article titled Thermal Burns Treatment, dated 2024, revealed .For All Burns .Stop Burning Immediately .Put out the fire or stop the person's contact with hot liquid, steam, or other material .Remove hot or burned clothing. If clothing sticks to the skin, cut or tear around it .Remove Constrictive Clothing Immediately .Take off jewelry, belts, and tight clothing. Burns can swell quickly. Then take the following steps: For First-Degree Burns (Affecting Top Layer of Skin) 1. Cool Burn .Hold burned skin under cool (not cold) running water or immerse in cool water until the pain subsides. Use compresses if running water isn't available .For Second-Degree Burns (Affecting Top 2 Layers of Skin) 1. Cool Burn .Immerse in cool water for 10 or 15 minutes. Use compresses if running water isn't available. Don't apply ice. It can lower body temperature and cause further pain and damage . Obtained from https://www.webmd.com/first-aid/thermal-heat-or-fire-burns-treatment Review of a Cleveland Clinic article titled Second-Degree Burn, dated 2022, revealed .Care and Treatment .Use cool water to gently wash your burn. Try to keep your burn area under water for at least five minutes, up to 30 minutes. Gently pat the burn dry with a clean towel . Obtained from https://my.clevelandclinic.org/health/symptoms/24527-second-degree-burn Review of an American Family Physician article titled Outpatient Burn Care: Prevention and Treatment, dated 2020, revealed .Most patients with burn injuries are treated as outpatients. Two key determinants of the need for referral to a burn center are burn depth and percentage of total body surface area involved. All burn injuries are considered trauma, prompting immediate evaluation for concomitant injuries. Initial treatment is directed at stopping the burn process. Superficial (first-degree) burns involve only the epidermal layer and require simple first-aid techniques with over-the-counter pain relievers. Partial-thickness (second-degree) burns are subdivided into two categories: superficial and deep. Superficial partial-thickness burns extend into the dermis, may take up to three weeks to heal, and require advanced dressings to protect the wound and promote a moist environment. Deep partial-thickness burns require immediate referral to a burn surgeon for possible early tangential excision .Pruritus, hypertrophic scarring, and permanent hyperpigmentation are long-term complications of partial-thickness burns. Burn injuries are more likely to occur in children and older people .Burn injuries are dynamic in nature, and even minor-appearing injuries can worsen with time (burn wound conversion) and need to be reassessed in 24 to 72 hours. Superficial partial-thickness burns can deepen spontaneously to deep partial-thickness or full-thickness involvement within 48 hours. Depth can also increase because of inadequate treatment or superinfection .For all types of minor burn injuries, the goals of initial treatment are to minimize the extent of the burn, clean the wound, and address pain. For scalds, immediate clothing removal lessens burn injury .Active cooling of the burn surface with running tap water (at 46.4°F [8°C] to 77°F [25°C]) for at least 20 minutes has been shown to reduce burn depth, improve healing time, and decrease grafting requirements. Cooling should commence within 30 minutes of the initial burn, but emerging evidence suggests this benefit may be achieved up to three hours after the burn. Wet dressings are not effective at cooling wounds. Ice should not be used because of its vasoconstrictive effects and risk of further tissue injury . Obtained from https://www.aafp.org/pubs/afp/issues/2020/0415/p463.html On 4/11/24, Administrator A was notified of an Immediate Jeopardy that began on 2/22/24 when the facility failed to immediately treat Resident #103's hot liquid burn per professional standards of practice. On 4/12/24, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Resident #103 was assessed by the Licensed Nurse and Nurse Practitioner on 2/22/2024 with new orders for continued assessment of the reddened area. On 2/23/24 new orders were obtained for wound treatment. Based upon continued nursing assessment, Resident #103 was sent to the ER (Emergency Room) for evaluation on 2/25/24 and was referred to the Wound Clinic to obtain further treatment orders. Facility staff are trained, based upon the policy, to apply cool liquid immediately after a hot liquid spill and take the resident to a licensed nurse for further assessment and treatment. Per protocol, nurses report to the provider and obtain orders for treatment. 2. Residents residing in the community were reassessed for safety with hot liquids by the Director of Nursing or designee by 3/01/2024. Care plans were updated to reflect appropriate interventions. Hot liquid evaluations were added to the admissions checklist to ensure residents are assessed upon admission. 3. The policy/procedure for Hot Liquid Safety was reviewed by Administrator A on 2/23/2024 with updates as necessary. 4. On 2/23/2024 education was initiated for all active staff on the policy/procedure for Hot Liquid Safety through the Relias platform (a computer-based training system). This education includes directions to pour cool liquid on the spill immediately and escort the resident to their nurse. The policy also ensures nursing staff assess the area for 24 hours after the incident. Nursing staff should take direction from the provider for further treatment of the area. Education has been completed by 142 out of 157 employees. Employees who have not yet completed their education have not worked the floor since 3/01/2024. 5. The Director of Nursing or designee will conduct a daily audit of residents, Monday through Friday, during meal service to ensure appropriate interventions for hot liquid spills are in place per resident care plan. During the weekend, licensed professionals on shift should continue to follow the policy by offering clothing protectors to all residents and providing a lid for all hot liquids. This audit will continue for 12 weeks. 6. The Dining Services Manager will conduct a daily audit of the coffee machine for 12 weeks to ensure temperatures of hot liquids are not greater than 140 degrees based upon the policy. This policy was adopted via The Compliance Store, and has references observed: Centers for Medicare and Medicaid Services. State Operations Manual, Appendix PP: Guidance to Surveyors, F-689 Free of Accidents Hazards / Supervision / Devices. Should a resident request their hot liquids be hotter than what is indicated in the policy, the community would utilize the Resident Assessment process where the Interdisciplinary Team would review the request, assess the resident, assess the staff ability to accommodate the request, and if the accommodation can be made, discuss how to provide that service in a safe manner. All documentation would then go into the resident care plan. 7. Results of the audits will be brought to the Quality Assurance Performance Improvement Committee meetings for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible for attaining and maintaining compliance. Compliance was attained by 3/01/2024. The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the Hot Liquid Safety policy was developed and implemented, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake # MI00137543. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement and ensure a functional alarm system was in place in 1 of 5 residents (Resident #103) reviewed for wandering/elopement, resulting in an Immediate Jeopardy when on [DATE] at approximately 5:50 PM, Resident #103, who was cognitively impaired, exited the facility unbeknownst to facility staff and traveled on foot along a busy four lane road with a speed limit of 30 miles per hour to a store to purchase a beverage. Resident #103 was found by a staff member who was driving in to work between 6:00 PM-6:15 PM. The resident had an alarm bracelet in place, however, it was not functional. The facility had initiated 15-minute checks prior to the elopement. The last observation of Resident #103 was at 5:48 PM. This deficient practice placed 5 additional residents identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of a Health Status Note for Resident #103, dated [DATE] at 5:53 PM, revealed .Resident was found walking around outside. Activity personnel saw resident walk outside and immediately started going out to talk to him. this nurse witnessed the resident walking by the front door. This nurse immediately went outside to bring the resident back inside and noticed the activity personnel was heading towards him as well. No injuries occurred. Skin assessment was completed. This nurse asked the resident where he was going, and he stated for a walk. this nurse informed the resident that he needs to notify someone if he wants to go for a walk. Wander guard was placed on the left ankle. Family was notified. Administrator was notified . Review of an Elopement Assessment for Resident #103, dated [DATE], revealed a score of 14, which indicated Resident #103 was At Risk for elopement. Per the assessment, a Wander Guard (alarm bracelet used to alert staff when a resident attempts to exit the building) was in place. Review of a Behavior Note for Resident #103, dated [DATE] at 5:51 PM, revealed .Wanderguard alarm went off for main entrance. Resident was found sitting in chair in area between the doors. He said, I am cold. This RN (Registered Nurse) asked the resident to please come back in the building. Resident went to his room . Review of a Health Status Note for Resident #103, dated [DATE] at 6:29 PM, revealed .Resident took a shower at (5:45 PM), got dressed and went down to dining room for dinner at (5:48 PM). This nurse laid eyes on resident in dining room eating. At (5:48 PM) resident was in the facility. Resident at some point walked out of the facility. Resident (may) have walked to the store and walked back to the facility. Resident is safe in bed room at this time. Resident has no new skin concerns or pain noted. Will (continue) to monitor for changes . In an interview on [DATE] at 9:49 AM, LPN Q reported she was assigned to Resident #103 on [DATE]. LPN Q reported they were doing 15-minute checks on Resident #103 because the Wander Guard bracelet he had on was not working. That's why he was on around the clock checks, because we were waiting for a new shipment (of Wander Guard bracelets) to come in . LPN Q reported Resident #103 had a shower, and then went to the dining room for dinner. LPN Q reported she last saw Resident #103 in the dining room on [DATE]. LPN Q reported at some point after that he left the building, purchased a beverage at the store, and returned. LPN Q reported another staff member found him outside and brought him back in through the front door. LPN Q reported at the time he exited the facility on [DATE], he was wearing two alarm bracelets. LPN Q stated in regard to Resident #103 .He gets mistaken for a visitor . LPN Q reported when Resident #103 returned to the facility on [DATE] a new alarm bracelet was applied. LPN Q reported she completed an incident report in regard to Resident #103's elopement on [DATE]. In an observation on [DATE] at 11:56 AM, noted the road in front of the facility had four lanes of traffic, with a speed limit of 30 miles per hour. Noted the nearest gas station was 0.5 miles away and a ten minute walk in one direction. In an interview on [DATE] at 2:37 PM, RN F reported in regard to Resident #103's elopement on [DATE] she was driving into work and observed Resident #103 on the sidewalk outside of the facility, along the four lane road. RN F reported Resident #103 told her he went to the store to get a pop. RN F reported she was unsure what time this occurred, and estimated it was around 6:00 PM. RN F reported she was not asked to provide a statement after the incident. RN F reported she notified Resident #103's assigned nurse, the manager, and Administrator A. In an interview on [DATE] at 3:09 PM, LPN Q reported Resident #103 returned to the facility on [DATE] between approximately 6:00 PM and 6:15 PM. In an observation and interview on [DATE] at 10:18 AM, noted the front entrance door to the facility was locked and required a code for entry. Administrative Assistant C reported the code to unlock the doors has not been changed for .years . Noted the front entrance door utilized a Wander Guard alarm system. Review of a Health Status Note for Resident #103, dated [DATE] at 6:57 PM, revealed .Resident has new (Wander Guard) on left ankle. (Wander Guard) is functioning, resident in bed room with call light at reach . In an observation and interview on [DATE] at 3:40 PM, Licensed Practical Nurse (LPN) G reported the front entrance door utilizes a Wander Guard system, and it is the only exit door at the facility that has this system in place. LPN G reported if the door is opened when a resident wearing a Wander Guard alarm bracelet is near, an alarm will sound. Observed LPN G demonstrate the functioning of the front entrance door Wander Guard system. LPN G reported there is a separate alarm system for the back door near the rehabilitation room, which requires a second bracelet be worn for residents at risk for elopement. LPN G reported this second bracelet does not sound an alarm, but instead sends a notification to the call light system that the resident is in the back section of the facility. LPN G stated in regard to Resident #103 .He might know the code . to unlock the doors. LPN G reported all the exit doors at the facility utilize the same code. In an interview on [DATE] at 9:47 AM, Registered Nurse (RN) GG reported residents at risk for elopement generally wear only one alarm bracelet. RN GG reported all of the exit doors at the facility utilize a Wander Guard system, which alarms at the doors and sends a notification to the call light system. Note this information is different than what was reported by LPN G. In an interview on [DATE] at 12:21 PM, RN E reported a resident with a Wander Guard bracelet will have a Physician Order to check function and placement of the bracelet daily. RN E reported the batteries in the newer bracelets last longer, and require a magnet to check function, while the older bracelets utilize a special device to check function. RN E reported she was unsure if residents at risk for elopement were required to wear two alarm bracelets and stated .I don't know if they have to have both of them on or not . In an observation on [DATE] at 12:50 PM, RN E checked Resident #103 for function/placement of alarm bracelets. Noted two bracelets on Resident #103's left ankle, a Wander Guard bracelet (for the front entrance) and a [NAME] bracelet (for the back door by the rehabilitation room). In an interview on [DATE] at 2:52 PM, with Administrator A and Director of Nursing (DON) B, DON B reported residents at risk for elopement should have two alarm bracelets in place, the Wander Guard bracelet and the [NAME] bracelet. DON B reported the front entrance door utilizes the Wander Guard alarm system, and the back door by the rehabilitation room utilizes the [NAME] system. DON B reported those two doors are the only ones with alarms linked to resident bracelets. The remaining exit doors have a 15-second egress system or key code entry. Administrator A reported Resident #103 had an incident where he exited the facility without supervision on [DATE] to go for a walk. Administrator A reported Resident #103 was re-assessed for elopement risk at that time, and a Wander Guard bracelet was added as a new intervention. Review of an admission Record revealed Resident #103 was a male, with pertinent diagnoses which included kidney disease, high blood pressure, obstructive lung disease, and Alzheimer's disease. Review of a Social Services Note for Resident #103, dated [DATE] at 7:54 AM, revealed .CC (Care Conference) held on [DATE] with (Family Member V) via phone .Had concerns regarding (Resident #103's) elopement risk and wandering behaviors . Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a current Care Plan for Resident #103 revealed the focus .I have impaired cognitive function/dementia or impaired thought processes r/t (related to) Dementia . initiated [DATE]. Review of a current Care Plan for Resident #103 revealed the focus .I am a wanderer and like to go outside for fresh air and to walk. I sometimes go outside to the courtyard, I sometimes walk with someone from activities or nursing department and sometimes I walk outside by myself in a straight line to the gas station and back for fresh air and a soda. POA (Power of Attorney) aware and in agreement with plan. POA has later requested a Wanderguard for his dad which has been reapplied . initiated [DATE] and revised [DATE], with interventions which included .WANDER GUARD to the left ankle . initiated [DATE]. Review of an Administration Note for Resident #103, dated [DATE] at 11:18 AM, revealed .Wanderguard is not functional. There is not currently a replacement in the facility. Med rooms on both halls and the purchasing room were searched .Notified on call, awaiting instructions on how to proceed . Review of an Administration Note for Resident #103, dated [DATE] at 12:00 PM, revealed .On call provided orders for every 15 minute whereabout checks . Review of an Order Summary Report for Resident #103 revealed an order to .check residents whereabouts every 15 minutes due to non functioning (Wander Guard) . with a start date of [DATE]. Noted this order was discontinued on [DATE]. Review of an Administration Note for Resident #103, dated [DATE] at 10:18 AM, revealed .(Wander Guard) not functional .Fifteen minute check implemented . In an interview on [DATE] at 12:09 PM, Agency LPN T reported he identified Resident #103's Wander Guard bracelet was not working in August during a routine check for placement/function. Agency LPN T reported he attempted to locate a replacement Wander Guard bracelet, but there were none available. Agency LPN T stated .I checked everywhere in the building . Agency LPN T reported since there were no functional Wander Guard bracelets available .we implemented 15-minute checks . Agency LPN T stated .The system is kind of weird. Some bracelets work for the other doors and some work for the front doors . Agency LPN T reported he did not remove the non-functional Wander Guard bracelet from Resident #103, and stated he .thought it would be to our advantage if he (Resident #103) thinks it (the Wander Guard bracelet) works . In an interview on [DATE] at 12:55 PM, DON B reported she was not aware that Resident #103's Wander Guard bracelet was non-functional. DON B reported there was an order placed for more Wander Guard bracelets at one point, however they were on backorder. DON B reported she had a conversation with Family Member V in early October where they discussed Resident #103 going outside. DON B reported she and Family Member V agreed that it was OK for Resident #103 to be outside of the facility without supervision for ten minutes. DON B stated .He (Family Member V) was fine with that and agreed . DON B clarified that this conversation occurred after Resident #103 exited the facility without supervision on [DATE]. DON B reported she was unsure where Resident #103 had went on [DATE] to purchase a beverage, and stated .He may have gone to the dollar store .I heard gas station . DON B reported an incident/accident report was not completed in regard to Resident #103's elopement on [DATE]. In regard to the Health Status Note for Resident #103, dated [DATE] at 6:57 PM, DON B stated .The staff sometimes call the pendant (Beacon alarm) the Wander Guard . In an interview on [DATE] at 8:41 AM, Family Member V reported he was not notified that Resident #103 had exited the facility without supervision on [DATE]. Family Member V stated .The next day I was there and someone came to talk to me about it . When asked if he was OK with Resident #103 walking outside of the facility without supervision, Family Member V stated .No, not really . Family Member V reported Resident #103 admitted to the facility due to Alzheimer's dementia and stated .I had concerns that he would get lost if he were alone. That's the reason why he was there . Family Member V reported when Resident #103 first admitted to the facility, he had a Wander Guard in place which was later removed. Family Member V reported a Wander Guard bracelet was reapplied in [DATE] after a staff member saw him (Resident #103) attempt to leave the facility. Family Member V stated .Then it seems like the Wander Guard died or ran out of battery. For a while, when I went to go pick him (Resident #103) up and take him out (on a leave of absence) the alarm would not go off. I kept telling them it was not working . Family Member V reported the incident where Resident #103 eloped from the facility on [DATE] was during the period of time where the Wander Guard bracelet was not working. Family Member V stated DON B .was asking me that day ([DATE]) if I was OK with him going outside by himself. She told me that he seems to be aware enough where he would be able to go out for a walk by himself. I was hesitant because again I'm not sure (what) the risk would be. What if he takes a wrong turn? I think we kind of left it as I am a little skeptical about that (going out of the facility without supervision). Only in a very controlled way. She was saying like we could let him out and have him back in ten minutes. I was just not sure. I said I would be OK but I would need more details . Review of a Health Status Note for Resident #103, dated [DATE] at 4:45 PM, revealed .Writer spoke with resident's son regarding resident's desire to walk outside and get fresh air at times when the weather is nice. Resident has a slight language barrier and son is POA (Power of Attorney); son was able to translate conversation to resident and resident was able to understand and converse back. Son mentioned that he likes when someone from activities walks with him as he worries about resident getting lost but is ok with resident going outside on his own, with staff knowing when he leaves and when he returns (if someone from activities is not available). Son agrees that a 10 minute walk is ok as resident states that he likes to get fresh air and per resident, he only goes in a straight line and likes to get soda. Resident showed son that he does have a couple dollars in his wallet for the soda but son said it's not about the soda, it's about the walk. Writer and son also spoke about encouraging resident to walk when family visits and also within facility and utilize the courtyard for fresh air; son thought that was a great idea. IDT (Interdisciplinary Team), NP (Nurse Practitioner) made aware of communication with son/resident. Staff aware . In an interview on [DATE] at 2:00 PM, Life Enrichment Staff X reported she would often take walks with Resident #103 outside of the facility. Life Enrichment Staff X described the route taken with Resident #103, and stated .It was a long walk. We could have went even further. He is a good walker . Life Enrichment Staff X reported in regard to whether or not Resident #103 was safe to walk outside without supervision .I don't know .I did not determine that but someone else did. I was still trying to walk with him as much as possible . In an interview on [DATE] at 3:59 PM, CNA N reported in regard to Resident #103's elopement on [DATE] .it happened so quick .We did his shower .Must have been right after dinner . CNA N reported a third shift nurse came and asked if Resident #103 was still a resident at the facility. CNA N reported this nurse saw him walking on the sidewalk along the street and brought him back to the facility. CNA N stated .(Resident #103) went to the store and got a pop and came back . CNA N reported Resident #103 was on 15-minute checks at the time of the elopement on [DATE]. CNA N reported a nurse applied a Wander Guard bracelet after the elopement on [DATE]. CNA N reported was unsure why Resident #103 was on 15-minute checks, and stated it was .probably the attempts to escape . In an interview on [DATE] at 4:10 PM, CNA R reported she was assigned to Resident #103 at the time of his elopement on [DATE]. CNA R reported Resident #103 had just taken a shower, and gone down to the dining room for dinner. CNA R stated .One of our nurses came running in asking if he was still a resident . CNA R reported Resident #103 walked through the front door with a pop. CNA R reported they asked Resident #103 why he went outside and he stated for some .fresh air . CNA R reported Resident #103 told her he went to the gas station which was a .significant walk . CNA R reported Resident #103 was on 15-minute checks at the time of his elopement on [DATE], and that he was gone from the building for approximately 15 minutes. CNA R stated after Resident #103's elopement on [DATE] .They took his 15-minute checks more seriously . and a new alarm bracelet was applied, a [NAME] alarm. CNA R reported a couple days after the elopement, it was determined that Resident #103 could go outside for a walk as long as a staff member was present. Review of the policy/procedure Elopement Prevention/Procedure/Reporting, dated [DATE], revealed .(Company Name) will strive to provide a safe and secure environment for its residents at all times. It is the policy of (Company Name) to assess all residents upon admission, as well as after a significant change in condition and quarterly for possible elopement risks. Residents found to be at risk will remain in a safe environment at all times .The safety and well-being of residents who live in our communities is a priority .Definition of Elopement: When a cognitively impaired resident leaves the premises or a safe area without authorization and/or necessary supervision to do so .ELOPEMENT PREVENTION .Residents will be assessed upon admission, upon exhibiting exit seeking behaviors and/or with a change in condition and reviewed quarterly for elopement risk utilizing the elopement assessment form .Residents found to be at risk shall be identified to the staff .A Plan of Care will be developed for those residents assessed as being at risk for elopement including interventions to prevent elopement .Residents determined to be at risk for elopement will have a wander guard signaling device as appropriate. The wander guard may be worn around a wrist or ankle and in unique situations on an assistive device. The wander guard is an electronic monitoring system with an audible warning signal for entrance/exit doors that is activated by a signaling device worn by a resident .Residents identified as being at risk for elopement will have placement of wander guard verified each shift and initialed in the Residents MAR (Medication Administration Record). Proper functioning of the residents signaling device will be checked daily (every 24 hours) and initialed in the residents MAR .The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision .After an elopement .the Resident Incident/Unusual Occurrence report will be completed and reviewed by the inter-disciplinary and behavior symptom management teams .for appropriateness of the care plan, corrective measures and current interventions . On [DATE], Administrator A was notified of an Immediate Jeopardy that began on [DATE] when Resident #103, who was identified as an elopement risk, exited the facility, unbeknownst to facility staff. On [DATE], this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1) Resident #103 no longer resides in the community. 2) On [DATE] Elopement Education was initiated in the Relias platform to include the difference between wander guards and beacon bracelets. As of [DATE] at 4:00 PM, 54 staff of 176 have completed this education. Education must be completed prior to working on [DATE]. 3) On [DATE] the Elopement Policy and Procedure was reviewed by the Administrator, and education was initiated in the Relias platform. As of 4:00 PM on [DATE], 39 staff of 176 have completed this education. Education must be completed prior to working on [DATE]. 4) On [DATE] the community modified the front door system to be locked at all times with key-pad entry. 5) On [DATE] Like residents were assessed by the LMSW to ensure elopement assessment, physician orders, and care plans for each resident were accurate and up to date for appropriate supervision. 6) On [DATE] Like residents had both wander guard and beacon bracelets tested by the DON to ensure proper function with no concerns noted. 7) On [DATE] All egress doors were assessed by the Administrator to ensure proper function with no concerns observed. 8) Beginning [DATE], The Director of Nursing and/or designee will audit the MAR to ensure all wander guard and beacon alarm systems are in place and functional according to Physician order. This audit will be completed daily X12 weeks. Results of the audits will be brought to the QAPI Committee Meeting monthly for review. Any changes to the auditing process will be made by the QAPI Committee. 9) The Administrator is responsible for attaining and maintaining compliance. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for minimal harm that is not Immediate Jeopardy due to the fact that all education had not yet been completed and sustained compliance had not yet been verified by the State Agency.