**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Recertification Survey completed on 12/7/21, the facility failed to ensure sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services and safety to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for residents on 1 of 3 units reviewed. Specifically, on 12/1/21 the Registered Nurse Supervisor (RNS) #3 Nurse Supervisor, was scheduled as the facility supervisor and the sole nurse on the Lake Unit. RNS #3 was not able to complete the medication pass timely, as the RN was assigned additional duties due to staff shortage on one (Lake Unit) of three units, that delayed medication pass. Resident (#1) with history of seizures did not receive medications timely. Resident (#2) with history of diabetes did not receive medications timely. Resident (#3) with history of hypertension did not receive medications timely. Resident (#4) with history of GI issues did not receive medications timely, resulting in GI issues including diarrhea and the potential to develop skin issues, electrolyte imbalance and dehydration. RN did not complete scheduled treatments for 13 of 28 residents with standing orders. Staff stated they are unable to administer and provide treatments within the allotted time frame due to being pulled away from their nursing duties on one (Lake) of three resident units. This resulted in no actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy to resident health and safety. This had the potential to affect all 28 residents on Lake Unit in the facility. The findings are but not limited to: The facility policy and procedure (P&P) titled Emergency Staffing dated February 2020 documented the purpose was to secure needed staff in event of emergency situations and that when the facility staffing level was critical impeding on resident care, the facility will take certain actions. These actions include staff remaining on duty, the Director of Nursing (DON) will notify administrative nursing staff to enlist their services, staff members who are a Certified Nurse Aide (CNA) will work with residents directly and arrange for a loan of nursing personnel from sister facilities. Review of the Facility Assessment for staffing plan (tool used to determine resources necessary to care for facility residents competently during both day-to-day operations and emergencies) modified date April 2021 and signed and dated by the current Administrator on 11/30/21 documented the facility was currently licensed for 134 beds with an average daily census of 126. There were no specific staffing requirements documented under staffing plan in the facility assessment. During an interview on 12/1/21 at 1:45 PM, the Administrative Assistant to the Administrator stated the facility assessment that we gave to you was sent to us from the former Administrator and they had updated it earlier this year. The staffing levels should be on it, but I do not know why they are not. The facility Resident Roster dated 12/1/21 documented a facility census of 98 and Lake Unit had a census of 28. The facility Matrix dated 11/29/21 for the Lake Unit documented 14 residents had a diagnosis of dementia, three residents had facility acquired pressure sores (stage 3 and unstageable), six residents had falls and three had excessive weight loss without a prescribed weight loss program. The facility nursing schedule dated 12/1/21 for the 6:00 AM to 2:00 PM shift documented RN Supervisor #3 was scheduled as the facility supervisor and the sole nurse on the Lake unit. The policy and procedure (P&P) titled Medication Administration Schedule dated 2/25/2015 documented the Licensed Nurse (RN, LPN (licensed practical nurse)) was responsible for adhering to the Standard Medication Administration time codes which are used in each long-term care facility to indicate when medications are to be given to their residents. Unless a specific hour is ordered, all medication will be given within established standard time codes. Standard medication administration time codes were documented as follows: Time/class: 7:00 - 10:00 AM carry as AM. Insulin (routine and sliding scale coverage doses) carry as upon arising in the AM, 30 minutes - 1 hour prior to a meal or at HS (hour of sleep) depending on the type of insulin and the resident's preference and sleep schedule. Medications ordered to be given at a specific time will be administered within one hour of that time. During an interview on 12/1/21 at 11:45 AM, RNS #3 stated that AM medications still needed to be administered to 10 more residents. These Residents were #'s 1, 2, 3, 14, 26, 34, 43, 54, 67 and 85. a.) Resident #4: During an observation on 12/1/21 from 11:23 AM to 11:45 AM, RNS #3 prepared medications for administration for Resident #4. RNS #3 dispensed the 8:00 AM and the AM medications totaling 11 medications at this time. Resident #4 had diagnoses which included gout (a type of arthritis that causes inflammation of joint), protein-calorie malnutrition (not receiving or absorbing adequate nutrient/s from the diet) and hypertension (elevation in blood pressure). The Minimum Data Set (MDS, a resident assessment tool) dated 9/1/21 documented Resident #4 was usually understood, usually understands, and was cognitively intact. Review of food and environmental allergies for Resident #4 revealed the resident had a lactose intolerance (inability to break down or digest lactose). Physician's Orders dated 12/3/20 through 12/1/21 documented active orders for Lactaid (an enzyme to aid in digestion of milk) 9,000-unit chew tablet-1 tablet by mouth (po) three times a day (TID) for lactose intolerance and Simethicone (an aid to reduce abdominal gas) 80mg (milligrams) tab chew po four times a day (QID) for gas with meals and at bedtime (HS). Additionally, Resident #4 had active treatment orders for Ketoconazole (antifungal medicine) 2% shampoo topical 3 times a week apply to scalp and leave in for 5 minutes before rinsing out. The Medication Record dated 12/2021 documented Lactaid 9,000-unit chew tab was to be administrated at 8:00 AM, 1:00 PM, and 5:00 PM. Simethicone 80mg tab was to be administered at 8:00 AM, 12:00 PM, 5:30 PM, and 8:00 PM. Review of the Medications/Treatments Administered document dated 12/1/21 revealed Lactaid and Simethicone were administered after the breakfast meal at 11:26 AM. Review of the Treatment Record dated 12/2021 for Resident #4 revealed AM treatment orders for Ketoconazole (antifungal medicine) 2% shampoo were not signed as having been completed as scheduled. During a telephone interview on 12/1/21 at 3:44 PM, the Nurse Practitioner (NP) stated medications were to be administered within the parameter of one hour before or after the scheduled time. Resident #4 had complaints of diarrhea and abdominal issues. Residents missing scheduled medications that can prevent diarrhea and GI (gastrointestinal) issues was upsetting. This can be embarrassing to the resident, they can develop skin issues, electrolyte imbalances and dehydration, if they are having frequent diarrhea. During an interview on 12/1/21 at 5:16 PM, Resident #4 stated they have bouts of diarrhea after their meals, and they can't control it. b.) Resident #1: Resident #1 had diagnoses which included epilepsy (a neurological disorder that causes seizures), anxiety disorder, and dementia with behavioral disturbance. The MDS dated [DATE] documented Resident #1 was usually understood, usually understands, and was moderately cognitively impaired. The Physician's Orders printed 12/3/2021 documented active orders for Ativan (medication used to treat anxiety and seizure disorders) 0.5mg tab, take 0.25mg po twice daily (BID), Ativan 0.5mg tab, take 0.5mg po daily at 8:30 PM for generalized anxiety disorder and epilepsy; Lamictal (medication used to prevent/control seizures) 100mg tab po twice a day (BID) for seizures. Additionally, Resident #1 had active treatment orders: AFO (ankle foot orthosis) off-once daily (AM) nurse to remove AFO once resident was ready to get out of bed for the day or if requests for it to be removed. Inspect skin after removing; skin prep to top of left foot- 1 application twice daily (AM/ hour of sleep (HS)) for red area; Icy Hot Balm 10/30% -topical twice daily (8:00 AM and 8:00 PM) to B/L (bilateral) hands and knees; Hydrocortisone 1% cream topical twice daily until clear to B/L ears. Review of the Medication Record dated 12/1/21 revealed Ativan 0.25mg was to be administered at 7:30 AM and 1:30 PM and Lamictal 100mg was scheduled to be given in the AM (7:00 AM-10:00 AM) and HS (7:00PM- 10:00 PM). Review of the Medications/Treatments Administered document dated 12/1/21 revealed the 7:30 AM Ativan 0.25mg dose was administered at 12:26 PM and the 1:30 PM Ativan dose was administered at 1:09 PM. Lamictal 100mg was administered at 12:26 PM- two hours after the medication administration window of the physician ordered AM dose. Resident #1 received two doses of Ativan 0.25mg within 34 minutes of each other. Review of the Treatment Record dated 12/2021 for Resident #1 documented on 12/1/21 AM treatment orders for the removal of the AFO, skin inspection the application of Hot Balm, Hydrocortisone cream were not signed revealing the resident's treatments were not completed within the administration window. c.) Resident #2: Resident #2 had diagnoses which included diabetes mellitus type 2, congestive heart failure (CHF) and hypothyroidism (underactive thyroid). The MDS dated [DATE] documented Resident #2 was usually understood, usually understands, and was moderately cognitively impaired. The Physician's Orders printed 12/3/ 2021 documented active orders for Metformin ER (extended release) (medication used to control high blood sugars) 500mg po BID for DM; Lantus Insulin (injection used to treat DM)100U/ML (units per millimeter) 30 units subcutaneous (SQ- beneath the skin) once daily (QD) for DM. Additionally, Resident #2 had active treatment orders for Magic Mixture Compound (combination of medications)100,000-0.1 topical TID AM/AF(afternoon)/HS) to bilateral posterior (back) thighs, wounds; off load pressure to heels when in bed every shift (QS) when in bed; off load pressure to Right ischium (lower part of hip bone) with repositioning in accordance with assessed needs QS; Skin prep (protective barrier) to bilateral heels QD (AM). Review of the Medication Record dated 12/2021 documented Metformin ER 500mg po BID with administration time of 8:00 AM and 8:00 PM: Lantus 30units SQ QD for DM at 8:00 AM. Review of the Medications/Treatments Administered document dated 12/1/21 revealed Metformin ER and Lantus were administered at 1:02 PM. Resident #2 was administered their 8:00 AM medications 3 hours and 2 minutes after the medication administration window of the physician ordered AM dose. Review of the Treatment Record dated 12/2021 for Resident #2 documented on 12/1/21 treatment orders for the Magic mixture compound, off- loading of pressure to heals and ischium, and skin prep were not signed revealing the resident's treatment was not completed as scheduled for the AM, Afternoon and 6:00 AM-2:00 PM shift. d.) Resident #3: Resident #3 had diagnoses which included hypertensive heart disease with heart failure, DM and dementia. The MDS dated [DATE] documented Resident #3 was usually understood, usually understands, and was severely cognitively impaired. Review of the Physician's Orders printed 12/3/21 documented active orders for Metoprolol Succinate ER (used to treat heart failure and high blood pressure) 100mg tab-100mg po QD; Lisinopril (used to treat hypertension (HTN) and heart failure) 20mg tab po QD; Cartia XT (extra time) (used to treat HTN) 180mg capsule po QD; Lantus 100U/ML insulin 20 units SQ BID and Metformin 1000 mg po BID. Review of the Medication Record dated 12/2021 documented Metoprolol Succinate ER 100mg po QD with administration time of AM (7:00-10:00 AM); Lisinopril 20mg po QD with administration time of AM; Cartia XL 180mg po QD with administration time of AM; Metformin 1000mg po BID with administration time of 8:00 AM and 8:00 PM; Lantus 20 units SQ QD for DM at 8:00 AM and 8:00 PM. Review of the Medications/Treatments Administered document dated 12/1/21 revealed Metoprolol Succinate ER, Lisinopril 20mg, Cartia XL 180mg were administered at 11:58 AM, this was 1 hour and 58 minutes after the window of administration. Metformin 1000mg, and Lantus were administered at 11:58 AM, this was 3 hours and 58 minutes after the scheduled administration time. Additional review of the Medication Records dated 12/1/21 for Resident's #1, 2, 3, 14, 26, 34, 43, 54, 67 and 85 revealed the scheduled and AM medications had not been administered within the time frames of the administration window. Additional review of the Treatment Records dated 12/1/21 for Resident's #26, 41, 43, 49, 64, 67, 73, 84, 306 and 307 revealed treatments had not been completed within the time frames of the administration window. During an interview on 12/1/21 at 2:21 PM, RNS #3 stated the reality was that there was a staffing crisis and residents were not getting their medications on time. RNS #3 stated that medications and treatments were not administered within medication administration window because the RNS was pulled off unit several times to complete supervisory duties which included: tracking down and completing five employee COVID-19 swabs for testing (waiting 15 minutes with each), attending three resident care plan meetings, staying with maintenance while they repaired the narcotic cabinet in the medication room, collection of emergency drug boxes for pharmacy to pick up and being interrupted to answer phone calls and assist staff. During a telephone interview on 12/1/21 at 3:44 PM, the Nurse Practitioner (NP) stated they were not aware that medications were being administered outside of the administration window. During a telephone interview on 12/2/21 at 8:37 AM, LPN #4 (who works the Lake unit) stated that medications take priority over treatments. Medication administration may be late, and at times they do not get all the residents treatments completed. There is just not enough time due to staffing. During an interview on 12/2/21 at 9:24 AM, RNS #4 stated that when they take a medication cart and supervise the building, they were unable to administer scheduled medications to residents on time. During an interview on 12/2/21 at 10:00 AM, the Administrator stated they were partially aware of the problem as they round within the facility every 2 hours and assumed the medications were going to be late. The Administrator stated they spoke with RNS #3 first thing in the morning to call if they were falling behind and stated, I expect them to call and get assistance via going up the ladder. Based on the survey team's observations of staffing levels, timely medication pass and staff interviews verifying in-service education was completed, the survey team declared the facility removed the immediacy as of 12/03/21 at 10:00 AM. Corrective actions the facility took to remove the immediacy included: - Evaluated and adjusted current staffing needs of the facility to include an additional day time supervisor and a nurse for the Lake Unit. - Immediate education provided to nursing supervisors to check in with each unit nurse to evaluate completion of ordered meds and treatments. Nursing Supervisors instructed to call Administrator or DON in the event of anticipated delays. Instruction to nursing staff to communicate ability to complete med pass and treatments as ordered for residents, to evaluate workloads and anticipate needs so that support can be arranged, and a plan can be made to assist and notification to administration. 415.12(l)(2)(ii)