**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide care consistent with professional standards of practice promoting healing and prevent new pressure ulcers from developing for 1 (CR#1) of 7 residents reviewed for pressure ulcers. -The facility failed to ensure CR #1 received the care and services to prevent a stage 2 pressure wound on her sacral from deteriorating to a Stage 4 measuring 7 (L) x 13 (W) x 3 (D). CR#1 was sent to a local hospital after family intervention and was diagnosed with fever and Sepsis. -The facility failed to immediately begin treatment after CR #1 was admitted on [DATE], a referral made by primary Physician on 3/14/2025 and the first visit by the wound care doctor/NP was on 3/26/2025. -The facility failed to implement new interventions when the sacral wound was not healing and required debridement for necrotic tissue. -The facility failed to ensure re-positioning was performed for CR #1, Resident #2, and Resident #3and did not have documentation on repositioning/turning frequency. An Immediate Jeopardy (IJ) was identified on 05/30/2025 at 1:28pm. While the IJ was removed on 6/4/2025 at 12:39pm., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of pain, worsening of wounds, infection, emotional distress, hospitalization, and death. Findings Included: Record review of CR #1's face sheet dated 5/28/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of partial intestinal obstruction (a blockage in the intestines that allows some but not all digested material to pass through), unspecified dementia(cognitive impairment), pressure ulcer of sacral region(injury to skin and underlying tissue due to prolonged pressure), stage 2, pressure-induced deep tissue damage of left heel, dysphagia (difficulty swallowing), hypothyroidism (a condition in which the thyroid gland does not produce produce enough thyriod hormone), and hyperlipidemia (condition in which there are high levels of lipids in the blood). Record review of CR #1's Discharge summary dated [DATE] from a local hospital revealed CR#1 was discharged on 3/13/2025 with an open abdominal wall wound due to the small bowel obstruction surgery, stage 2 sacral wound, unstageable right heel pressure wound, stage 2 left buttock and dementia. Record review of CR #1's admission MDS dated [DATE] revealed the following: *Section C0500- Brief Interview of Mental Status summary score was coded as 03-representing severe cognitive impairment. *Section GG- Functional Abilities: toileting, shower/bathe, oral hygiene, roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer were coded as 01- Dependent on helper for all the effort. *Section H0400- Bowel Incontinence- was coded 3. Always incontinent *Section M0150- Risk of pressure ulcers were coded 1. Yes *Section M0210- Skin Condition Unhealed pressure ulcer was coded 1. For the number of unhealed ulcers (1) *Section M0300- C. Stage 3 number of ulcers was coded (1). Number of pressure ulcers that were present upon admission. *G. Unstageable - Deep tissue injury (1). Number of unstageable wounds *Section M1200- Check all that apply revealed: pressure reducing device for chair and bed, nutrition or hydration intervention, pressure ulcer, surgical wound, application of ointments and application of dressings to feet. Further review revealed Turning and re-positioning was not checked. Record review of CR #1's updated care plan dated 5/20/2025 revealed the following: *Focus: Wound management *Goal: CR#1 wound to show signs of improvement, will be free of signs of infection, management of pressure ulcer and prevention of future pressure ulcers. *Interventions: Administer antibiotic treatment as prescribed, encourage resident to elevate legs, if drainage present get order for culture, measure ulcer on regular intervals, monitor ulcer for signs of progression or declination and notify provider if no signs of improvement on current wound regiment. Further review of the care plan revealed the wound care focus did not have the location of the wound (s). Record review of CR #1's Care plan dated 4/14/2025 revealed: *Focus: Pressure ulcer prevention *Goal: CR#1 will remain free of skin breakdown *Interventions: Barrier cream, encourage floating heels, pressure redistribution mattress, turn/reposition q2 hours and PRN and use suspension devices, pillows, and/or wedges. Record review of CR #1's Braden scale for predicting pressure sore risk dated 3/13/2025 had a score of 9. This represented she was at high risk due to her being bedfast, limited mobility, poor nutrition, and constantly being moist. According to the score sheet, a total score of 12 or less represented high risk. Record review of CR #1's Wound Care progress note dated 3/14/25 written by Nurse A stated CR#1 was a new admission, skin assessment performed upon admission. Resident noted with surgical wound of the abdomen, wound to the sacrum, bilateral heel, also noted with G-tube and foley. Wound team will follow up with CR#1 on Wednesday/Friday during their next weekly visit. Record review of CR #1's Physician's progress notes for March 2025 written by Primary Physician or NP indicated: *3/14/25 the Primary physician wrote Chief Complaint: Evaluation and management of resident small bowel obstruction, stroke, lacunar infarct, glaucoma, and unstageable sacral wound. NPO and foley catheter noted. Referral to wound care. It was e-signed by primary physician on 3/18/2025 at 9:23pm *3/16/25 NP B wroteB wrote Chief complaint: Evaluation and management of resident small bowel obstruction, stroke, lacunar infarct, glaucoma, and unstageable sacral wound. Skin/breast: Abdominal wound covered with dressing, sacral wound. It was e-signed by NP B on 3/18/2025 at 9:56 p.m. *3/17/25 NP A wrote Chief complaint: Follow-up for small bowel obstruction, constipation, sacral wound reported, surgical site infection and CVA. Plan: Pain management, PT/OT, Vitamins, plan discussed with patient and nursing. It was e-signed by NP A on 3/22/2025 at 9:41pm. Record review of CR #1's weekly skin assessment dated [DATE] written by Nurse A revealed weekly evaluation completed by Wound doctor. Resident noted with post-surgical wound to the abdomen (13 w x 0.1 x not measurable, Stage 3 wound to sacrum was (0.5 X 1 X 0.2) noted to have no tunneling/normal skin (Zinc and turn and repositioning Q2 hours)and DTI to left heel (2 X2 X unmeasurable). Updated care plan notified family and physician. E-signed by WCN A on 3/19/2025 at 3:29pm Record review of Wound care doctors' initial assessment for CR#1 dated 3/26/25 were as follows: *Site #1-Post surgical wound abdomen full thickness (LxWxD) 13x 0.1x not measurable. *Site #2 - Stage 3 pressure wound sacrum measured 8x10x0.2 cm. Dressing treatment - Zinc ointment apply once daily and as needed for 16 days. Secondary dressing: Gauze Island w/bdr apply and as needed for 16 days. Turn side to side in bed every 1 -2 hours. Group 2- mattress; Reposition per facility protocol. *Site #3- Unstageable DTI of the left heel Record review of CR #1s weekly skin assessment written by Nurse A dated 3/26/2025, Weekly wound evaluation completed by wound doctor revealed CR#1 post-surgical wound to the abdomen (13 x 0.1 x not measurable depth, wound to sacrum (8 X 10 X 0.2) apply zinc cover with dry dressing. Low air mattress, offload bony prominences. Turn and reposition q2hours. Right foot abrasion (non-pressure) resolved. Left heel had the same measurements of 2X2X unmeasurable. Record review of CR #1's Weekly skin assessments written by Nurse A from 4/2/25 to 4/9/25 indicated: - dated 4/2/2024, Surgical abdominal wound was resolved. Stage 3 pressure injury sacrum wound 6x12x0.2 - Low air mattress, offload bony prominences. Turn and reposition q2hours, vitamin therapy wound supplement were nutritional interventions. Left heel had the same measurements of 2X2X unmeasurable. - dated 4/9/2024, Stage 3 pressure injury sacrum wound 6x14x0.2 - Low air mattress, offload bony prominences. Turn and reposition q2hours, vitamin therapy wound supplement were nutritional interventions, xeroform treatment. Left knee- scratch- resolved 4/9/2025. Record review of CR #1's Physician's progress notes dated 4/14/25 written by NP A revealed, Sacral wound reported- Decubitus ulcer of sacral wound care daily and PRN. Wound care following blisters to the wound was reported by wound care NP. It was e-signed by NP A on 4/15/2025 at 9:09 pm Record review of CR #1's Weekly skin assessments written by Nurse A from 4/16/25 to 4/23/25 indicated: *dated 4/16/25, Stage 3 pressure injury sacrum measured 6x15x not measurable treatment changed from xeroform to calcium alginate Santyl. Response to treatment: No change. Left heel had the same measurements of 2X2 X unmeasurable. *dated 4/23/25, Stage 3 pressure injury to sacrum changed to a Stage 4 on 4/23/2025 and measured 6x15x not measurable. Record review of CR #1's Wound care doctors' progress note dated 4/23/2025 revealed CR#1's sacrum wound was now a Stage 4 and measured at 6 x14 x unmeasurable (due to presence of nonviable tissue and necrosis (death of body tissue). Debridement performed on the sacral. Record review of CR #1's Wound care doctor's progress note dated 5/28/2025 revealed he did a debridement of CR#1's sacrum wound to decrease necrotic tissue. The wound measured at 5(L) x 14 (W) x 1 cm(D). Record review of CR#1's Medication administration log for March 1-31, 2025 3/14/2025 Jevity 1.2 cal 0.06 gram - 1.2 kcal/mL oral liquid order date 3/13/2025 discontinued 3/16/2025 Wound supplement (30cc) one time daily starting 3/14/2025 discontinued 3/16/2025. Multivitamin with minerals 1 tab oral one time daily Aspirin 81 mg tablet delayed release G-tube every one day starting 3/14/2025 Enoxaparin 40mg /0.4 mL subcutaneous syringe every one day starting 3/14/2025 Vitamin C 500 mg tablet oral two times daily start 3/15/2025 discontinued 3/16/2025 Lidocaine patch 4% topical patch every one day 3/16/2025 Jevity 1.2 cal 0.06 gram oral liquid (60ml/hr) starting 3/16/2025 Levothyroxine 88 mcg tablet every one day starting 3/14/2025 Melatonin 3 mg tablet Multi vitamin with minerals (1 tab) G-tube one time daily Vitamin C 500 mg tablet (1 tab) two times daily Liquid wound supplement (30 cc) one-time daily G-tube Doxycycline hyclate 100 mg tablet two times daily for seven days starting 3/19/2025 for local infection of skin (abdomen) 3/25/2025- Isosource HN 0.05 gram- 1.2 kcal/mL liquid tube feed (replaced Jevity) Record review of treatment administration log for March 2025, revealed the wound care doctor ordered Zinc Oxide one time daily starting on 3/27/2025. The order notes stated: Cleanse sacrum with normal saline or wound cleanser, pat dry, apply Zinc Oxide and cover with dry dressing. Further review revealed there were X's representing treatments were not done between March 1-27, 2025. Record review of CR#1's medication administration for April 1-30, 2025, revealed the following medications had no administration times nor a specified date range: -Multivitamin with minerals -Vitamin C 500 mg tablet two daily -Amoxicillin 875 mg g-tube every 12 hours Record review of CR#1's medication administration record for May 2025 revealed an order for wound supplement one time a day for wound, Give 30 cc -start date 5/3/2025 and discontinued 5/9/2025. -Protein supplement had X's from May 1-31st. This represented medication not given. Record review of POC (Plan of Care) bed mobility for CR#1 from 5/1/25-5/30/25 was documented as follows : -BED MOBILITY: SELF-PERFORMANCE - How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. -BED MOBILITY: SUPPORT PROVIDED - How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Further review revealed there was no documentation of assistance with bed mobility on 5/6/25, 5/9/25, 5/13/25, 5/17/25 nor 5/23/25-5/26/25. Observation of CR#1 on 5/28/2025 at 9:33 am revealed her to be asleep in supine position. There was a stench odor in her room. She was covered with a blanket. Observation of CR#1 on 5/28/2025 at 10:27am, observed to be in supine position FM and EMT inside of the room. An interview with CR#1's RP on 5/28/2025 at 3:20pm she stated before CR#1 was admitted to the facility, she resided at an assisted living facility but had been hospitalized due to a bowel obstruction. She said the hospital recommended she go to a rehabilitation for therapy. She said her family visited CR#1 almost daily. She said every time she visited, she had to ask staff about changing her briefs and/or giving her a bed bath. She said her room had a stench smell. She said she was not aware of the sacral wound was opened or infected until a few days ago . She said the wound care doctor and nurses provided care before 8am in the morning and she usually came much later in the day. She said this was why she did not know about the sacral wound. She stated they would come in and change her, yet they never said anything about her wound, it was covered. She denied staff informing her of the condition of CR#1's wounds. She stated that she had photos from the hospital a day before being admitted to the facility and the sacral wound was the size of a pea. She said the sacral wound she saw a couple of days ago had a large hole that she could put her fist inside of it. She said she was sickened by what she saw. She said she called 911 today (5/28) to get her emergency medical attention. She said CR#1 was lethargic and not herself on the previous day. An interview with attending physician for CR#1 at a local hospital on 5/28/2025 at 3:37pm, said CR#1 was admitted on [DATE] with a low-grade fever of 100.4 degrees Fahrenheit, had elevated WBC, a kidney infection and sepsis. He stated the Sepsis was likely coming from the wound in his clinical assessment. He stated that the sacrum wound had been measured at 7 (L) x 13 (W) x (3) depth upon admission. The hospital started CR#1 on IV fluids and two different antibiotics, vancomycin and Septra. He stated the wound was badly infected. The measurement taken at the hospital was larger than what the facility's wound care doctor documented on the same day . He stated that CR#1 had been admitted to the facility from their hospital. He stated that CR#1's wound was tunneling. He said it was not even opened when she left their hospital. He had reviewed her history. An interview with CR#1's primary doctor's NP on 5/29/2025 at 10:22am, she stated she had been in the building for about 1 year. She said some of her duties see all of the patients and provide medical care. She stated she visited the facility once a week. She stated upon initial assessment they look at the skin and if there are wounds the WC team follow the wounds. She said Wound care Doctor and nurses at the facility made up the wound care team. She stated CR#1 had wounds in her lower extremities but the sacral wound was not seen recently. She her abdomen wound had healed. She was not compliant with offloading and had a right to refuse. CR#1 was on an air mattress and was usually sitting up 45 degrees when she visited. She stated CR#1 did not like those heel boots. She said CR#1 had a poor prognosis. She said her nutritional status does not get great absorption with G-tube. She was not making any progress, so it was just about doing your best. She said she made the family aware of her poor prognosis and recommended hospice. She said she did not recall talking with CR#1's RP about the wound, just medically she was declining. She said repositioning was important for all patients especially if they were not ambulatory. She said CR#1 had an air mattress and it deflated in one area and inflated in another. It helped with moving but it was beneficial for someone to turn her. She said as a medical professional, some form of offloading and turning was necessary. She said she did not see her every day, so she had no way of knowing if she was being re-positioned and turned Q2 hours or not. She said she was not sure of her BIM score. She said CR#1 could nod or say no. She was not able to make two-or three-word sentences. She said the last visit with CR#1 was on 5/21/2025 when she saw herher, she was sitting up at 30-40 degrees, she noticed that her secretions had decreased. She would pocket secretions in her mouth. She said she did not have her boots on her heels. She allowed staff to put them on her. She encouraged her to wear the heel boots. She did not view the sacral ulcer that day. She did not see the dressing. Vitals were stable, no signs of infection to her. An interview on 5/29/2025 at 12:01pm with CNA A said she had been employed for 1 year on 6-2pm shift. She stated some of her duties were to feed residents, give showers, dental hygiene, getting residents dressed, change resident briefs, and drain catheters. She said she had not worked on CR#1's hall. She said CNAs did not assist with wound care. She said she had residents down her hall that had wounds. She said the wound care nurse and doctor are the only two that are in the room. She said in the past she had assisted with wound care by changing the briefs or helping to turn or re-position residents for treatment. She said they are supposed to turn residents every two hours. She said they were able to put in every time they provided care when they had electronic charting system 1. Now they have electronic charting system 2, and it only allowed them to check when they assisted with bed mobility. She said the nurses were able to enter care into electronic charting system 2, as2, as well. An interview with LVN A on 5/29/2025 at 12:09pm, she said she had been employed for 2 years as a charge nurse on 6a-2p. She said her duties were to make rounds, assessments, take blood sugars, vitals, insulin, g-tube feedings and sign off on CNA tasks were completed. She said she had to do wound care from time to time and TAO (triple antibiotic ointment) was used until there was a physician order. She said they had two fulltime wound care nurses so she rarely did wound care. She said she did not have CNA's help with wound care when she had to do it. She said the doctor, or his NP were the only people in the room. She stated she had not done wound care for CR#1. She said she documented any refusals for brief changes, re-positioning, and showers in the electronic charting system 2,.2, She said there had been some issues with CNA's giving showers on second shift and they had an in-service about it. She said she had to talk to several CNAs on her shift as well. She said she went behind them if they said there was a refusal. She said most residents will not deny care if you explain the importance. She said turning and re-positioning was vital to wounds healing. She said the electronic charting system 2 had turning and re-positioning on their task list. She said she would check off for the entire shift that they had been done. There was no way for nurses to document for example that it was done at 1pm, 3pm, or 5pm. She said keeping the residents clean and dry, showered, and re-positioning was important for wound healing or to prevent new wounds. An interview with CNA B on 5/29/2025 at 12:25pm, stated that she had been employed at the facility for about 4 years on both 6-2 and 2-10pm shifts. She stated CNAs did not assist with wound care. She said usually it was the nurse, doctor, or his NP. She denied observing CR#1's wound. She denied being asked to change CR#1's brief. She stated turning and re-positioning and keeping them dry was important for residents' wounds to heal especially on the sacral, but also on hip and heels. She said they did not document every time they turned because they keep up with it themselves and tell the nurse at the end of the shift that it had been done. The nurse would then check it off that it was done on their shift. She said some CNAs did not have access to the electronic charting system 2. There had been some log in issues. She was able to access the electronic charting system and stated she documented at the end of her shift. She said she turned all her patients to the left and then right every two hours. She said she kept up with it on her own. In an interview with the Wound care doctor on 5/29/2025 at 12:45pm, he said he had been coming to the facility about 6 months and saw about 25 patients a week. He stated his NP would also visit during the week. He said most of their visits were early mornings starting at about 6am. He said he saw CR#1 on yesterday (5/28/2025). He said he started visiting with CR#1 back in March 2025. She had wounds on her sacral, heels and the knee and surgical wounds were resolved. He said initially the sacral pressure wound was a stage 3 and it had deteriorated and became unstageable with necrotic tissue. He stated in the last two weeks, he had been debriding her slowly and it was improving. There was no necrotic tissue remaining on yesterday (5/28/2025). He said she did have a completely necrotic wound, one like hers was done gently and carefully. The remaining necrotic tissue was removed on yesterday. He said wounds are sometimes unavoidable due to co-mobility, nutrition, mental status, or infection of the wound. He said a combination of all of that determined whether they heal, stall or deteriorated. He denied the sacral wound was infected. He said his goal was to remove all of her necrotic tissue and that was done. He said she was not on any antibiotics because he had not identified any infection on her. He said he typically would round and order a wound culture before ordering antibiotics. He said her primary doctor could also order antibiotics/ labs if she had access or received the results of the wound culture before he does. He said he had not ordered a wound culture because she had no necrotic tissue left and no reason to order antibiotics. He said CR#1 was not able to follow directions. He said she did not have the capacity to turn herself nor remove the boots off her heels. He stated the wound care nurse made calls to inform FM of change in condition. He said CR#1 never refused care from him. He said she was not verbal. He said the nurse never notified him of any issues. He said when he visited her, she was often in the supine position, and this was not best for her sacral wound. He said she should not be in the supine position for more than 2 hours. He said turning and re-positioning was vital for wounds healing. He denied the sacral wound had an odor. He stated he ordered Daiken as it was a wound cleanser. It helps with odors, but that was not his reason for using it, just as a cleanser. He stated CR#1's wound had 0% necrotic tissue when he left her on 5/28/2028 around 6:45am. In an interview with wound care nurse A on 5/29/2025 at 1:56pm, she stated she had employed at the facility about here 1 year as WCN on day shift. She stated she worked on CR#1's hall and conducted wound assessments weekly for her. She stated CR#1 sacrum wound was difficult to heal since she was bedfast, and she required re-positioning every 2 hours. She said her right heel wound was resolved. She stated she had boots for her heels to prevent breakdown. She was admitted with the heel and sacrum wounds. She said she could not recall what the sacrum looked like when she was admitted . She could not recall the size. She said her documentation that the wound was a Stage 3 pressure injury wound and measured (0.5 X 1 X 0.2) noted to have no tunneling/normal skin (Zinc and turn and repositioning Q2 hours) when CR#1 was admitted on [DATE]. She said that was the measurements at the time. She said CR#1's measurements the next week was (8 X 10 X 0.2) came from the wound care doctor, who gave her the measurements and she documented that. She said he did the measuring. She said she cleaned and replaced CR#1's dressing daily. She said her treatment started when she was first admitted with maybe TAO but changed to alginate and calcium once the wound care doctor saw her for the initial visit. She said she was not sure why CR#1 was not seen by the wound care doctor until 3/26/2025. She said CR#1's doctor had made the referral a day or so after her admission. She said at some point, CR#1 was on IV antibiotics and this caused a lot of loose stool so she needed to be changed more often than 2 hours. She said this might be why the family said she had an odor. She said the residents sacral did have a slight odor. She said the WCD ordered Daikin which was also called sodium hypochlorite. He ordered it on yesterday (5/28/2025). She said the WCD would often start the Daikin if there was an odor. She said odor was a sign and symptom of infection. She stated she could not be sure if staff were turning and re-positioning her as needed. She stated turning and re-positioning was vital to helping heal wounds. She said CR#1 would say yes or no. But, never spoke using a full sentence. She said CR#1 never refused or said no to her. She said they do not use the assistance of CNA's while providing wound care. She said CR#1's wound was covered. She said loose stool could make a wounds worst on the sacral, especially since CR#1 had loose stools. She said she updated care plans with changes and called FM about changes as well. An interview with CR#1's primary physician on 5/29/2025 at 3:54pm she said she had been CR#1's physician for about two months. CR#1 was admitted with small bowel obstruction, dementia, stroke and not able to swallow. She had a feeding tube. She came to the facility for OT/PT, and with wounds. She stated as far as she knows the sacrum wound had improved and was smaller than when she was admitted . She said she did not measure the wound. She said the facility's WCN told her there was a wound and so she made the referral. She stated re-positioning would be important to be done every 1-2 hours for anyone bedfast or not mobile. She stated the resident had a poor prognosis, and the wounds were unavoidable because they were doing everything for her. She had an air mattress, g-tube feeding and was taking Vitamin C and a multi-vitamin. She did not recall if she had any protein or if she was on any antibiotics. She stated she did not know why the vitamins had not been given in April, she would have to check on that information. She said she recalled writing it as a tablet and then realized it had to be given via G-tube, but she made that change quickly because she was NPO. She said Daikin was used as a wound cleanser. She said odor was a sign and symptom of infection. She said she could not attest to the size or condition of the wound. She understood it was smaller than when she arrived. In an Interview with the DON on 5/29/2025 at 4:20pm, she stated she had been employed at the facility since March 2025. She said some of her duties were to make rounds, assessing charts, auditing charts, make sure orders are in, ensure staff are doing their jobs and the overall clinical management of the building. She stated she had not personally met CR#1. She stated she had not observed her wounds. She said they had a WC team that gave report at morning meetings if there were any issues. She said once a week they would discuss the wound report. The clinical team was made up of charge nurse, DON, ADON and wound care nurses. She said the WCN was required to perform weekly assessments. She said every Friday she printed the report to ensure weekly assessments are done. She stated she had not heard CR#1's wound was deteriorating. She said Daikin was used as a cleanser and could be used due to odors. She said odors were a sign and symptom of infection. She stated if a wound upon admission was a Stage 2 and now a stage 4 if would appear that it had gotten worst. She said some of the reasons some sacral wounds does not heal was due to not being turned and positioned, nutritional status, and not being adequately hydrated. She denied any complaints from CR #1's RP about her not being changed or re-positioned. She expected CNA's to change briefs at least every 2 hours, provide hygiene care and wound care nurses to assess, treat and let her know if there are any issues. In an interview on 6/3/2025 a confidential staff stated she had been employed at the facility for less than 1 year and worked the 2-10pm shift. She stated she worked on the Hall where CR#1 resided. She stated when CR#1 was admitted , she saw the spot on her sacral. She said CR#1 was incontinent of bowel and had a lot of diarrheas. She said the sacral was the size of a quarter, but it had healed and was not opened. She stated the last month or so, the wound was covered, and she had no idea how bad it had gotten. She said most of the time her boots were not on. She said she was not sure who took them off, but she was not capable of taking them off herself. She said they must keep up with every 2-hour turning and re-positioning themselves or put under bed mobility. She said she did not think it was made clear on where to put it because they had turning/re-positioning in the ecteronic charting system 1, but not in the electronic charting system 2, just bed mobility which was where she documented. She said she went down the hall and turned all Residents in the same direction and then 2 hours later to the opposite side. In an interview on 6/3/2025 at 3:45pm CNA D stated she had been employed at the facility for 1 month. She worked on the 6-2pm shift but working a double today on Hall 100. She stated her duties were to shower residents, hygiene, personal care and turn them every 2 hours. She stated she was aware CR#1 had a sacral wound, but it was always covered by a patch or dressing when she went in to change her. She stated CNAs did not assist with wound care. She said she heard recently that the wound was bad. She stated she never saw it. She said the doctor rounded with the wound care nurse. She stated CR #1 had a stench smell and received bed baths. She stated she always gave her bed baths and showers as scheduled. She said no one wanted to have an odor. She stated re-positioning was not in the electronic charting system 2, it was under bed mobility, and they have to put whether they assisted CR#1 or not. She denied CR#1 refused care. In an interview on 6/3/2025 at 3:45pm CNA D stated she had been employed at the facility for 1 month. She worked on the 6-2pm shift but working a double today on Hall 100. She stated her duties were to shower residents, hygiene, personal care and turn them every 2 hours. She stated she was aware CR#1 had a sacral woundwound, but it was always covered by a patch or dressing when she went in to change her. She stated CNAs did not assist with wound care. She said she heard recently that the wound was bad. She stated she never saw it. She said the doctor rounded with the wound care nurse. She stated CR #1 had a stench smell And received bed baths .baths. She stated she always gave her bed baths and showers as scheduled. She said no one would wanted to have an odor. She stated re-positioning was not in the electronic charting system 2, it was under bed mobilitymobility, and they have to put whether they assisted CR#1 or not. She denied CR#1 refused care. . 2. Observations of Resident #2's positioning while in bed revealed the following: 6/2/2025 at 11:47am- observed on to be on right side 6/2/2025 at 12:59pm- Observed on right side 6/2/2025 at 2:49pm- Observed to be on right side 3. Observation of Resident #3's positioning while in bed revealed the following: 6/2/2025 at 11:46 am - Observed to be on his back 6/2/2025 at 2:47pm- Observed on his ba

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 10 residents (CR #1 and Resident #440) reviewed for pharmaceutical services 1. The facility failed to ensure accurate administering of all drugs and biological to meet the needs of Resident #440, who was administered morphine more frequently than prescribed by the physician on [DATE] and who was administered with the incorrect dosage on [DATE]. 2. The facility failed to acquire, dispense, and timely administer all medications to meet the needs of CR#1, who missed 4 doses of Posaconazole (antifungal) 100mg delayed release tablet between [DATE] and [DATE]. An Immediate Jeopardy was identified on [DATE] at 1:28 PM, and on [DATE] at 9:27 AM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on [DATE]. due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the resident at risk for not receiving medications as ordered resulting in serious injury, decline in health, and death. Findings included: 1. Record review of Resident #440, who was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the prostate (growth in the prostate gland), urethral stricture (narrowing of the urethra), and stage 4 pressure ulcer to the sacral region (full thickness tissue loss that extended to the underlying muscle, tendon, or bone). Record review of Resident #440's Baseline Care Plan dated [DATE] revealed, the resident was alert & cognitively intact and on high-risk pain medications (narcotics). Record review of Resident #440's physician orders dated [DATE] revealed the resident was on morphine ER (extended release) 30 mg tablet, extended release every 12 hours. Record review of Resident #440's physician orders dated [DATE] revealed the resident was on morphine IR (immediate release) 15 mg tablet, every 6 hours as needed. . Record review of Resident #440's February 2025 medication administration record revealed morphine 30 mg tab ER, every 12 hours was administered as a scheduled order on [DATE] at 7: 00 AM and 7:00 PM. Record review of Resident #440's Controlled Drug Record revealed morphine 15 mg tab IR, every 6 hours as needed, was administered on [DATE] by the Med-Aides at 5:00 AM (1 tab), 8:00 AM (2 tabs), 11:30 AM (1 tab), 3:00 PM (1 tab), 11:00 PM (1 tab). [DATE] at 4:00 AM (2 tabs), and 8:00 PM (2 tabs) were administered. Review of Resident #440's progress note dated [DATE] revealed that while the NP was rounding, the residnet was alert x's 1 (person) and lethargic. She gave order to administer Narcan due to excessive sedation. Resident #440 was on continued monitoring by LVN K after Narcan administration. Record review of Resident #440's February 2025 indicated that the residnet was administered Narcan by LVN K on [DATE] at 4:00 PM. Record review of Resident #440's vital signs on [DATE] at 11:00AM indicated a Blood Pressure of 116/70; Resipration-18; and oxygen saturation of 96% on room air, however, his pulse was not recorded. His oxygen saturations were record on [DATE] at 4:04 PM with an oxygen saturation of 97% on room air. Vital sign reading post narcan administration on [DATE] at 5:00 PM indicated a blood pressure of 147/64; Respiration-18; oxygen saturation and pulse was not recorded. Observation and interview on [DATE] at 12: 58 PM with Resident #440 lying in bed. He was alert to person. He said he did get his pain meds earlier today and was without c/o pain. Resident #440 was less verbal than on [DATE] and [DATE]. He said he did not have an appetite but was very thirsty. The CNA was at bedside assisting the resident with his water intake. Telephone interview [DATE] at 3:57 PM with Med-Aide C, who said she administered Resident #440 Morphine IR 15 mg (2 tabs) instead of Morphine ER 30 mg 1tab after clarification with RN E on [DATE] at 8:00 AM and 11:30 AM. She said she was aware of the discrepancy between the medication administration record and the blister pack. However, she was given the ok to administer the Morphine IR 15 mg (2 tabs) instead of the scheduled Morphine ER 30 mg by RN E. She said the risk of administering too much morphine could cause decreased blood pressure, drowsiness, and/or death. Telephone interview on [DATE] at 7:16 PM with RN E, who said Resident #440 was administered Morphine for pain. She said the side effects of administering too much Morphine was sedation. RN E said the MD should be contacted if the resident shows signs of oversedation. She said Resident #440 was administered Narcan as ordered as an antidote for an overdose of opioids, after the NP was rounding and observed a decrease in his alertness and cognition. She said the risk of Morphine overdose was a resident could go in respiratory distress and may require rapid response/CPR. Interview on [DATE] at 7: 30 PM with the DON, who said Morphine was a pain medication. She said there was a discrepancy between the Morphine 30mg ER that was ordered and the Morphine 15mg IR that was administered. She said her expectation was that the staff would follow the MD's orders and clarify orders with the MD if they were incorrect or if the staff had questions or concerns regarding the orders. She said the risk of not following the orders and administering the correct Morphine dosage could cause the resident to go into respiratory distress. Interview at [DATE] at 11:18 AM with Dr D., who said she ordered Morphine IR 15mg Q 6 hours prn and scheduled Morphine 30mg ER q 12 hours. She said the difference in the 2 medications ordered was the onset, peak, and duration. She said just because the order was for morphine 30mg does not mean that the staff could give Morphine 15 mg, 2 tabs to equal 30mg because the difference was the morphine 15 mg IR tabs were PRN and Immediate release, and the Morphine 30 mg ER tabs were scheduled q 12 hrs and extended release. Dr. D said when she gives an order, the staff should follow the order or call for clarification if there are any concerns or questions. She said Resident # 440 should have been administered the Morphine ER, as ordered. She said the milligrams of the Morphine administered were the same, but the long-acting and short have different onset and duration of the medication. The NP was rounding, so she gave the Narcan, which was appropriate due to his drowsiness. She said the risk of not following the orders could lead to a bad outcome. Record review of pharmacy services policy, revise date 4/2019, read in part .Policy Interpretation and Implementation: 4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration . Record review of the medication administration policy, undated, read in part . 2. The 6 Rights of Mediation Administration. b. Right Drug. Verify prescription label to [DATE] times in different ways: i. Drug name ii. Drug strength. c. Right Dose. Verify the label to MAR, these MUST MATCH. e. Right Time. Confirm med-pass time window (1 hr. before to 1 hr. after administration time on MAR . On [DATE] at 1:18 PM, the administrator was informed that an Immediate Jeopardy situation was identified due to the above failures and a Plan of Removal was requested. Observation on [DATE] at 9:43AM of medication administration in-service was conducted by the DON to include the weekend supervisors with the initiation of the posttest. Interview on [DATE] at 11:17 AM with MA A, who works the 100-300 halls. She said the last in-service on medication administration and pharmaceutical services was on [DATE], and she had a competency post-test after the in-service. She said she would inform the nurse of a missed or unavailable medication. She said she would follow up with the nurse but would notify the DON and the doctor if it were still missing. MA A said the nurses have access to the E-Kit and can pull medication from it. If the medications were not in the E-Kit, the nurse would send a STAT order to the pharmacy. Interview on [DATE] at 11:26 AM with RN C, who said she was last in-service on medication administration and pharmaceutical services was [DATE]. She said she would check for missing/unavailable medication in the Pyxis and/or E-Kit. If it was not available in E-Kit, she said she would contact the pharmacy and MD regarding the missing medication. RN C said that she would fax the medication order to the pharmacy for new admission. She said the fax machine gives an ok confirmation that the pharmacy received the fax. She said the pharmacy delivers between 4-6 hrs after faxing the order. She said she would contact the doctor if the medication was unavailable after the 4-6 hours to see if there was a compatible medication or contact the pharmacy to get the medication STAT. She said she would also inform the weekend supervisor and/or DON that the medication was missing or unavailable. Interview on [DATE] at 11:38 AM with LVN B, who said her last in-service was on [DATE] with the DON on missing medication with a post-test at the end. She said the process was to 1st go to the E-Kit if the medications were missing. Contact the pharmacy for a STAT medication If the meds were not in the Pyxis or E-kit. She said she should contact the weekend supervisor and MD if not available and let them know that the medication was unavailable. Interview on [DATE] at 12:11 PM RN D, who said her last in-service was [DATE] with the DON on missing medication with post-test at the end. She said we initially would look in the pyxis for the missing medication. She said that if medications are not in Pyxis, the pharmacy delivery comes within 2-3 hours. She said for new residents, we fax the medication order to the pharmacy and receive an ok from fax machine, but we can also call to verify the orders were received. We get short slip for unavailable meds, but not for every medication. We let the DON know the medication was missing. We inform the MD to let them know that we need an order for another medication. We can also contact the pharmacy for the medication to be delivered Hot Shot (STAT). Record review on [DATE]-[DATE] of the pharmacy delivery sheets. Record review on [DATE] revealed and Immediate release and extended-release medication in-service was conducted by the regional nurse for the DON and Nurse managers. CR# 1 of undated facesheet revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Acute Myeloblastic Leukemia and Neutropenia (a condition characterized by an abnormally low number of neutrophils in the blood). CR#1 was immunocompromised due to the low neutrophil count. Review of CR#1's MD progress notes dated [DATE] revealed the resident was on neutropenic precautions (Important preventive steps you need to take while you have neutropenia). Review of CR#1's physician's orders revealed on [DATE] the resident was prescribed Posaconazole 100mg (3 tablets) one time daily, which is an antifungal. Review of CR#1's [DATE] medication administration record revealed Posaconazole was not administered as ordered on [DATE],[DATE], [DATE], and [DATE] because they were unavailable. Interview [DATE] at 10:11 AM with the RP, who said the staff did not administer CR#1's antifungal medications during his stay at the facility. She said his antifungal and antiviral medications were his most important meds due to his completion of chemotherapy and neutropenic status. The RP said on [DATE], she informed LVN J that she had his Posaconazole medications available in the resident's room. LVN J declined the medication and said his medications had to come from the facility's pharmacy. She said CR#1 was readmitted to the hospital on [DATE] because he had a fever at his MD appointment. Interview [DATE] at 3:19 PM with RN A, who said CR#1's physician's orders included Posaconazole 100mg tablet, delayed release (3 tablets). She said the medication was reconciled and faxed to the pharmacy on [DATE]. She said she gave report to the floor nurse after completing the initial admission process. She said CR#1's medication should have been administered to the resident as ordered by the physician. She said the resident who was immunocompromised and had a fever was an indication of infection. She said not receiving his antifungal medication for 3 days can lead to a serious illness and/or death. Interview on [DATE] at 3:51 PM with LVN C, she said most medications are usually delivered on the next pharmacy delivery if it is unavailable from the E-Kit (emergency medication kit). The next scheduled delivery was [DATE]. She said residents should have all medications administered as ordered within 24 hours. She said neutropenic residents were immunocompromised. LVN C said a fever (temperature >100.3) was an indication of infection. She said residents who were immunocompromised and had not received their antifungals for several days could cause the resident to be hospitalized and/or death. Interview [DATE] at 4:17 PM with the DON, who said the medication was not received until [DATE] at 11:00 PM. She said the staff did not administer the medication at that time because CR#1 was not in the facility until the early morning of [DATE]. The DON said the staff did not administer the medication when the resident returned to the facility, and she was uncertain why the medication administration did not occur upon arrival. She said the staff should have notified the physician that the medication had not been administered to CR#1 on [DATE], [DATE], [DATE], and [DATE]. The DON said that the nurses should have followed up with the pharmacy and/or doctor to see if the facility could have received a compatible antifungal until the medication arrived. She also said the facility could have accepted the medication offered by the RP and administered it to the resident. She said that based on his medical history and the resident being immunocompromised, fever was an indication of possible infection. She said not administering CR#1 prophylactic antifungal medication could place the resident at risk for his health being in danger. Telephone Interview on [DATE] 4:58 PM with Med-Aide A, who said she administered all medications that were available for CR#1. She said missing or non-available medications were reported to the nurse. She said she verbally reported to the nurse that CR #1 did not have his Posaconazole but does not remember the day. Interview on [DATE] at 5:23 PM with Med-Aide B, who said she informed the nurse on [DATE] that CR#1 was missing his Posaconazole. She said she does not remember the name of the nurse she reported to. Interview on [DATE] at 5:53 PM with MD, who said CR#1 was admitted to the facility with a neutropenic fever. She said the facility should have administered all medications, including Posaconazole, as ordered due to his neutropenia. She said the resident had an increased risk of infection because he did not receive his medication as ordered. Telephone Interview on [DATE] at 12:05 PM with the contracted pharmacist, Dr. X, who said he received the order for the Posaconazole on [DATE]. He said the medication was delivered on [DATE] at 11:22 PM. Telephone interview on [DATE] at 1:02 PM with LVN J, who said the admitting nurse (RN A) conducted the admit assessment and reconciled the orders. She denied getting report for CR#1 from the admitting nurse on [DATE]. She said the RP informed her on [DATE] that she had available meds for CR#1, but LVN J said the facility used their own pharmacy to administer medications. Interview [DATE] at 10:54 AM with the administrator, who said she was unaware that the Posaconazole was not administered until [DATE]. She said it was a specialty med, and the pharmacy could not get the medication sooner. The administrator said the process was for the nurse to notify the DON and the MD of the missing Posaconazole. The risk of CR #1 not having his Posaconazole could cause injury or harm if the resident required his medication because of a fungal infection. The administrator was informed of an Immedicate Jeopardy situation on [DATE] at 1:28 PM, and on [DATE] at 9:27 AM. A Plan of Removal was requested. The following Plan of Removal was submitted by the facility and accepted on [DATE] at 11:16 AM. Immediate Action: An Emergency QAPI was held to review the findings of the citations and the community's present practices and processes. The DON and administrator will have a collaborative effort with respect to monitoring medications upon admission, and daily thereafter for established residents regarding missing or unavailable medications. There will be ongoing daily monitoring by DON or designee, to review medications for compliance. Upon notification of the deficient practice on [DATE], the following measures were put into place for nurses and medication aides as well as in-services to be completed by [DATE] (the DON/designee will teach the in-services) to ensure that the deficient practice will not recur: a 100% audit of all residents receiving both immediate release and extended-release medications will have MAR to Cart audits daily to ensure appropriate medications are being given. -Initiation of the Medication Availability Log, in which each Nurse/Med-Aide validates that they have all available medications for Administration each shift. This will be kept in the Narcotic Count Book and will be brought to the morning meetings for review and further evaluation by the Nurse Managers. After hours the Charge Nurses will notify the DON/Administrator of any deficits, the Weekend Supervisor will complete this on the weekends. -24- hour report will be reviewed 2x daily in clinical stand up for morning and afternoon shift to review communication with physician on medications not available, this will be done by the DON/Designee of Nurse Management. -A New order report will be printed every morning by the DON/Nurse Managers, this will be crossed referenced to validate physical availability of new medications in the community. -Pharmacy Delivery Sheets will be reviewed every morning by DON/Nurse Managers for medications that were delivered the previous evening. -The Clinical Smart Board, which is within our EMR, displays missed medications, will be reviewed twice daily, by the DON/Nurse managers, in clinical stand up for both morning and afternoon shift to review medications given, missed medications. -The DON/Nurse Management will communicate with pharmacy regarding medications not available and get estimated time of arrival or need to STAT medications. -The DON/Nurse Management will communicate with physician and/or medical director on medications missed or not available on patients that issues were identified. -The DON/Nurse Management will communicate all with physician and/or medical director on medication errors. _The DON/Nurse Management will notify the Administrator on all issues identified with pharmacy and medication delivery, availability and missed doses as well as medication errors. In addition to education on utilizing the Pyxis and Pharmacy Service in-services, a review of current policies and procedures were completed with the QAPI team determining that the current policy was sufficient and new protocols were put into place to achieve compliance. The Plan of removal was accepted on [DATE] at 11:16 AM and reflected the following: Record review of the 24-hour Report started on [DATE] and review twice daily. Record review on [DATE] of new medication order report. Record review of the clinical smart board review on [DATE] for both morning and evening shifts. Record review of missing medication log with administration signature and date noted on [DATE]. Record review on 02/17 and [DATE] of pharmacy communication log regarding medication not available and get estimated time on arrival or need for STAT. Record review on 02/17 and [DATE] of the Physician communication log regarding medication missed or medication not available. [DATE], no information noted on the pharmacy log. Record review of in-services that were conducted by the DON and administrator on [DATE] and [DATE] with topics to include: Pharmaceutical services (reviewing the 24-hour report for missing medications, how to review the smart board for missing medication and communicating with pharmacy regarding medications not available to get and estimated arrival or need to STAT medications), 6 Rights of Medication administration with competency validated by a posttest, Verifying prescription label to MAR, and Notification to physician of missing or unavailable medications. Record review revealed on [DATE], the facility completed an audit of all residents in the facility with orders for new admission medications and exiting residents' medication availability. Interview on [DATE] at 3:04 pm with LVN A. Who said she did attend the medication in-service was conducted by the DON. She said for new admits, she would verify the orders and place them in the system. She said the medication should be at the facility. She would look in the facility to ensure the medication was not in the Med room, on a med cart, or in the Pyxis. She said if she still was unable to locate the medication, she would contact the pharmacy to check if it had been ordered. If the medication was not ordered, she would fax the orders to the pharmacy and call and verify with the pharmacy that the order was received. She said staff should notify the DON, provider, and pharmacy if medications are missing. She said staff should always follow-up with DON, physician, and pharmacy if medications are missing. Interview on [DATE] at 3:45 PM with MA B, who said she did attend the medication in-service conducted by the DON. She said she documents the missing medications on the Missing Medication Log on her cart and reports the missing medications to the nurse and the DON. She said once the resident reaches the last blue line of the blister pack, she can scan and fax the sticker to pharmacy. She said the nurse would also follow up with the pharmacy. She said the difference between extended release and immediate release mediations was the duration it takes for the medication to last. MA B was able to provide the 6 medication administration rights, which included the right resident, dose, route, time, medication, and diagnosis. She said If the blister pack label was different from the MAR, she would inform the nurse so they could clarify with the doctor. Interview on [DATE] at 3:58 PM with MA C, who said she did attend the medication in-service conducted by the DON. She said she would notify the nurse of missing medications and document the missing medication on the new non-available medication log. She said depending on the type of medication it may be found in the Pyxis/E-kit. MA C said that for new residents, the staff should notify the nurses, who would check the pyxis to see if the medication was available. She said the nurse should contact the doctor to see if the MD wanted to use a substitute for the unavailable medication. She said that if medications are not available for the resident, I would also follow up with the pharmacy for STAT delivery. MA C provided the 6 medication administration rights to include the right name, dosage, resident, reason, route, and time. She said the difference between Immediate release and extended release was immediate release works immediately, while extended release was over time. She said she could not give the medication if the MAR and blister pack were different. She said she would report it to the DON if needed for medication clarification. Interview on [DATE] at 4:13 pm with MA H, who said if there were missing medications, we would notify the nurse. She would look in the Pyxis, and they would contact the DON. She said the 6 rights of medication administration were to verify the right resident on the MAR, the label, the dosage, route, and the right time. She said IR meds last for 6 hours and ER last for 12 hours. She said she would check the MAR, inform the nurse that a medication was missing, and document in the administrative notes. Interview on [DATE] at 4:31PM with LVN O, who said if medications were unavailable, she would notify the supervisor and the physician. She said if meds were missing, she would notify the supervisor, check with the pharmacy, and document on the EMR. She said the 6 rights were the right resident, medication, dose, route, time, documentation, and indication. She said the difference between ER and IR medications, was that immediate release meds are designed to start working immediately 4 to 6 hour and extended release last for 12 hours. LVN O said that for new residents, she would verify the medications with physician, enter them into the system, and fax to pharmacy with facesheet. She said if the resident does not get their medication, she would follow up with pharmacy, document, and fill out the medication reconciliation sheets. Interview on [DATE] at 4:38 pm with LVN Z, who said she would contact the DON, doctor or NP and document if a medication was unavailable or missing. She said with new residents, she would enter the medication into the EMR, verify the meds with doctor, and fax orders to the pharmacy and would call to confirm that the orders were received. She said to follow up on missing meds, she would call the pharmacy, call doctor and ask if there were any alternative meds. LVN Z said the 6 rights included the right resident, mediation, route, dose, time, documentation, and indication. She said Immediate release was based on the duration of the medications. Interview on [DATE] at 5:21 AM with LVN N, who said if medication was not available, he would check the Pyxis. He would notify the MD and the ADON/DON if the meds were still not there. He said that as soon as he got a new admission, he would contact the MD and verify medication orders. He would enter the orders into the system, print them, and fax the order to pharmacy. LVN N said the duration of ER medications was 12 hours, and the duration of IR was 4 to 6 hours. Interview on [DATE] at 5:27 AM with LVN T who said we check the med carts and pyxis for missing/unavailable medications. If we cannot get it STAT, we notify the doctor, pharmacy, and DON. LVN T said for new admits, after orders are verified with MD, we fax the medication order to the pharmacy. She said if it's a narcotic, she would get assistance for the DON with the ordering process; however, if the family had home meds, she would put the order in the system and make sure it matches the MD orders. She said the process for administering meds was to look at the label, verify the name, dose, and route, and compare it the MAR. LVN T said IR medication last from 4-6 hours, and ER meds can last up to 12 hours. Interview on [DATE] at 5:36 am with LVN S, who said that the staff calls the pharmacy, DON, and MD know that there are missing or unavailable meds. She said for the new admits, we verify orders from the doctor, put the orders in the system, and print and fax the order to the pharmacy. She said the rights for medication administration was the right resident, time, dose, route, reason, and the right medication. She said we should document all meds that are not available and place them on the medication log. LVN S said the difference between IR-immediately release, which lasts 4-6 hours and ER, which lasts for 12 hours. Observation on [DATE] at 7:50 AM of the med cart (100 and 300 hall) med pass performed by MA B without discrepancies. Missing Medication log noted on the med cart. No missing/unavailable meds were noted on the log. Interviews were conducted from [DATE] to [DATE] with staff from all shifts (6:00 AM.to 2:00 PM., 2:00 PM. to 10:00 PM., 10:00 PM. to 6:00 AM) The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 9:03 AM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.