**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Nurse Practitioner interviews, the facility failed to provide care in a safe manner for 1 of 2 residents reviewed for supervision to prevent accidents (Resident #132). The resident fell out of a raised bed onto the floor during incontinence care which resulted in the resident being transported to the local hospital and diagnosed with distal femoral (upper leg bone) fracture, proximal tibial (lower leg bone) fracture and fractured humerus (upper arm bone). The findings included: Resident # 132 was admitted to the facility on [DATE] and readmitted on [DATE]. Here diagnoses included cerebral vascular accident or stroke, muscle weakness, left hand contracture with splint and type II diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #132 was moderately cognitively impaired and required extensive assistance of 2 staff to accomplish activities of daily living (ADL) to include bed mobility, dressing, toileting, and personal hygiene. The Care Area Assessment (CAA) summary indicated Resident #132 was at risk for falls due to muscle weakness, medication use, impaired mobility and incontinence and limited range of motion in her bilateral lower extremities. A nursing progress note dated 03/10/2022 at 4:01 AM indicated NA #1 was changing Resident #132 at 3:30 AM when Resident #132 lost her grip on the bed rail and fell onto the floor. Resident #132 was assisted back into bed using a mechanical lift. Pain medication and acetaminophen were administered for complaints of pain. Resident #132 continued to complain of pain and requested to be sent to the hospital. Emergency Medical Services (EMS) was notified, Resident #132's responsible party (RP) was notified and requested the resident be sent out to the hospital closest to the family. The resident's pupils were round and equally reactive to light (pupils reaction to light being shined - pupils will become smaller with light and larger with darkness) and accommodation (pupils reaction to objects up close and distant) and the resident had no head injury. Resident #132's respirations were regular and unlabored, and staff remained with the resident until EMS arrived to transport her to the hospital emergency room (ER). Nursing Assistant (NA) #1's statement dated 03/10/2022 indicated on 03/10/22 at approximately 3:30 AM Resident #132 activated her call light at which point NA #1 entered the room and the resident requested to be changed. NA #1 walked away to get a towel, washcloths, and brief, then wet the washcloths before returning to the bedside. NA #1 turned the resident towards the window onto her left side as she grabbed the bed rail with her right arm. At that point NA #1 began cleaning her bottom but she continued to have a bowel movement while wiping her bottom. NA #1 turned away from the resident to get the brief and cream for her bottom from the chair in her room at the end of the bed when the resident fell from the bed which had been raised waist high during care onto the floor. NA #1 left the room to notify her nurse and one of the nurses came into the room to assess the resident and assist with lifting the resident via mechanical lift back in her bed. An interview on 08/10/22 at 6:58 AM with Nursing Assistant (NA) #1 indicated she was changing Resident #132's brief when she fell from the bed onto the floor. She stated she had raised the bed to waist level and provided peri care to Resident #132 on her front side and turned her onto her left side towards the window to clean her bottom. NA #1 further stated there was a paper pad on top of the resident's air mattress and under her bottom. NA #1 explained she began cleaning Resident #132's bottom when she continued to have a bowel movement and finally had her clean. NA #1 further explained she turned away from the resident and walked approximately 6 feet to get the clean brief to put on the resident when Resident #132 slipped off the bed and onto the floor. NA #1 said she turned back around with the brief and did not see the resident but heard her moaning and noticed she was on the floor with her head at the foot of the bed. NA #1 indicated she left the room immediately to go get the nurse and when she returned to the room the resident was moaning oh, oh and Resident #132 stated her left leg and left shoulder were hurting. NA #1 further indicated Nurse #1 and Nurse #2 came into the room and Nurse #2 assessed the resident while Nurse #1 left the room to contact the physician on call and notify the responsible party (RP) of the resident's fall. Nurse #2 assessed the resident and NA #1 along with NA #2, NA #3, and Nurse #2 assisted Resident #132 back into the bed with the mechanical lift. Resident #132 requested to be sent to the hospital and Nurse #2 called EMS and the resident was transferred to a local hospital ER for evaluation and treatment. Nurse #1's statement dated 03/10/22 revealed she was notified at approximately 3:30 AM on 03/10/22 that Resident #132 had fallen out of bed onto the floor during incontinence care being performed by Nursing Assistant (NA) #1. Nurse #1 stated when she entered the room the resident was on the floor on the left side of the bed with her head at the foot of the bed. She further stated Nurse #2 was in the room assessing the resident when she entered the room. A phone interview on 08/10/22 at 6:07 PM with Nurse #1 revealed she had been notified by Nursing Assistant (NA) #1 on 03/10/22 at approximately 3:30 AM that Resident #132 had fallen from her bed onto the floor. Nurse #1 said when she went into the resident's room, Resident #132 was lying in the floor with her head at the foot of the bed and her feet at the head of the bed. Nurse #1 stated Nurse #2 was already in the room assessing the resident, so she left the room to call the on-call provider and responsible party (RP) to notify them of the fall and get paperwork ready to send her out to the hospital ER for evaluation and treatment. Nurse #1 indicated initially Resident #132 had not complained of pain but once they moved her back to bed, she was complaining of left leg pain and left shoulder pain, so they medicated her, and EMS came and transported her to the hospital ER for evaluation and treatment. Nurse #1 further indicated she had provided one on one education to NA #1 about the resident's care [NAME] and stated she was a seasoned nursing assistant and should have known to have another person in the room with her while providing Resident #132's incontinence care. Nurse #1 stated because of Resident #132's fall, all residents on air mattresses now are required to have a 2-person assist with bed mobility. Nurse #2's statement dated 03/10/22 revealed she was notified by Nursing Assistant (NA) #1 at approximately 3:30 AM on 03/10/22 that Resident #132 had fallen out of bed. Nurse #2 stated when she entered the room the resident was observed lying on her back in the floor beside of her bed. Resident #132 requested to get out of the floor and back on her bed. Nurse #2 further stated she assessed the resident, and her pupils were equally round and reactive to light and accommodation (pupils reaction to moving object up close and distant), she had no respiratory distress and her range of motion to all 4 extremities was within her normal limits. The resident denied hitting her head and NA #1 stated she had not heard the resident hit her head. Resident #132 had no visible injuries noted so she was assisted back to bed via mechanical lift with the assistance of NA #1, NA #2, and NA #3. Once in the bed, Resident #132 requested pain medication and was given pain medication as ordered. Resident #132 then became adamant about going to the hospital ER, so EMS was contacted, and the resident sent to the hospital ER for evaluation and treatment. A phone interview on 08/10/22 at 7:12 PM with Nurse #2 revealed Nursing Assistant (NA) #1 notified her right away of Resident #132's fall. Nurse #2 stated when she went into the room the resident was lying on her back with her head at the foot of the bed. Nurse #2 said initially Resident #132 was laughing and talking with them but after being lifted to bed she started complaining of pain in her left shoulder. Nurse #2 further stated she had assessed Resident #132 prior to them lifting her back to bed and did not recall one leg being shorter than the other or externally rotated but said her feet were naturally turned outward. Nurse #2 indicated Nurse #1 had called the provider and because the resident was complaining of pain, they decided to send her out to the hospital ER for evaluation and treatment. Nurse #2 stated NA #1 was a seasoned NA and should have known to have another person with her while toileting a total care resident. Nurse #2 further stated now if a resident is on an air mattress it requires a 2-person assist with bed mobility. Nurse #2 indicated there should have been 2 NAs providing incontinence care to Resident #132 on 03/10/22. An interview on 08/11/22 at 9:32 AM with the Director of Rehabilitation revealed she was familiar with Resident #132, and they had provided occupational therapy (OT) treatment to her. The Director of Rehabilitation stated she was aware of the residents fall on 03/10/22 and said because of her fall the facility now required all residents on air mattresses have a 2-person assist with bed mobility and toileting. A review of the hospital discharge summary revealed Resident #132 was admitted to the hospital on [DATE] and discharged to another facility on 03/31/22. Her admitting diagnoses included displaced closed distal femur fracture, closed proximal tibial fracture and 2-part displaced closed fracture of the humerus. Resident #132 was placed on bedrest with non-weight bearing to the left extremity and a sling was applied to the left arm. The resident's pain was difficult to manage during her hospital stay due to her blood pressure being low, so she was taken off all antihypertensives and eventually accomplished pain control. Resident #132 was discharged from the hospital on [DATE] to another facility with non-weight bearing to the left extremity and under Palliative Care (which she had prior to hospital admission). An interview on 08/11/22 at 4:35 PM with the Nurse Practitioner (NP) revealed she had been notified of Resident #132's fall at the facility. She stated she had been told staff were changing the resident and she had fallen out of the bed. The NP further stated Resident #132 had hemiplegia on her left side from a previous stroke and could not possibly assist with holding on with her left side but could have possibly held onto a bedrail with her right side. The NP indicated although the resident may have been able to assist with her right hand holding onto the bedrail if she had been assessed by nursing staff as needing 2-staff assistance with bed mobility and toileting she would have expected there to have been 2 staff in the room assisting the resident. An interview on 08/11/22 at 5:37 PM with the Director of Nursing (DON) revealed Resident #132 had been assessed as needing 2-person assistance with bed mobility and transfers and stated she would have expected there to have been 2 staff members in the room providing her care. She stated it was Nursing Assistant (NA) #1's first night off orientation and NA #1 had stated she was not aware the care [NAME] for the resident was inside her closet, so NA #1 was provided additional one on one education by Nurse #1 on the night of the incident. The facility was notified of Immediate Jeopardy at past non-compliance on 08/19/22 at 5:08 PM. The facility provided the following credible allegation of complaince with a compliance date of 03/11/22. The facility's corrective actions implemented after the accident to prevent a reoccurrence included the following: 1. Resident #132 was immediately assessed after the fall by a licensed nurse and transported to the ER for further evaluation. 2. The Director of Rehab/Designee completed a 100% audit of all residents in the facility to ensure appropriate bed mobility assistance was accurate in comparison to the resident's MDS and NA alerts. Any discrepancy was corrected and any resident that required further evaluation was referred to therapy. 3. On 03/11/22, education was given to all nursing department (active nurses and NAs) of where to find bed mobility status of one or two person for each resident in alerts section of point of care (POC). Any nursing staff on leave received the required education prior to their first shift. The education was added to the nursing staff orientation. 4. Therapy staff and DON and/or designee reviewed any bed mobility changes during morning meeting five times a week. 5. When a resident had a change in bed mobility it was documented on the nursing 24-hour report and in the residents electronic medical record (EMR). 6. The weekend manager on duty or weekend nursing supervisor obtained report from the nurses regarding any changes in resident mobility status and reported to the DON. 7. DON and/or designee conducted random weekly observations for 12 weeks and validated resident's bed mobility status was being followed. Any non-compliance was addressed, and further education provided as needed. 8. The frequency of weekly observations was: 10 residents reviewed/observed for weeks 1-4 to ensure bed mobility POC alerts. 5 residents reviewed/observed for weeks 5-8 to ensure bed mobility POC alerts. 3 residents reviewed/observed for weeks 9-12 to ensure bed mobility POC alerts. 9. The Administrator and Quality Assurance/Performance Improvement (QAPI) committee analyzed the data are reported any patterns/trends to the Regional Operations Manager for immediate correction. Findings of the QAPI committee were reviewed monthly for 3 months to ensure continued compliance. 10. The QAPI committee will continue to evaluate the above plan and make additional recommendations for interventions based on the audits to ensure continued compliance. Allegation of compliance (AOC) date: 03/11/222. On 08/11/22 the facility's Plan of Correction was validated by the following: audits conducted by the facility were reviewed and were found to be completed according to the plan of correction. All nurses and nursing assistants were educated on where to find bed mobility status in the alerts section of POC. The training topic was transfers, bed mobility and alerts and the content included: 1. Proper transfers, bed mobility and where to find alerts for each resident. 2. If resident requires air mattress or is not able to assist with care, utilize 2-person assist for ADLs. Director of Nursing (DON)/Staff Development Coordinator (SDC)/Assistant Director of Nursing (ADON) was responsible for ensuring all staff were trained on proper care to prevent falls. The corrective action plan was validated to be completed as of 03/11/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, Nurse Practitioner (NP), facility staff, and resident interviews, the facility failed to ensure resident's well-being by not providing care and services to prevent oral abscesses, unresolved dental pain and chewing difficulty for 1 of 1 resident (Resident #68). On 10/19/21 was seen by the in-house dentist who noted Resident #68 was in pain due to a tooth infection and referral was made for outside dental treatment and antibiotics were recommended. The antibiotics were ordered the next day by the Nurse Practitioner. Resident #68 was seen by a dentist on 11/21/21 who wrote a referral for an oral surgeon for extraction of all remaining teeth. Resident #68 was seen by an oral surgeon on 12/07/21 and the plan was to remove all upper and lower teeth during two appointments using nitrous oxide which she asked to defer until January 2022 when her Medicaid would take effect. On 3/27/22 Resident #68's diet order was changed to regular diet with mechanical soft meat. On 05/10/22 physician orders were written for antibiotics for a dental abscess. From 5/10/22 through 5/13/22, Resident #68 reported a pain level ranging from 6 to 7 (on a scale of 1-10 with 10 being the worst pain). Antibiotics were prescribed on 6/9/22 for a dental infection. From 06/09/22 through 06/15/22, Resident #68 reported pain level ranging from 5 to 7 (on a scale of 1-10 with 10 being the worst pain). On 7/8/22 Resident #68 diet order was changed to regular diet with chopped meat. On 7/28/22 Resident #68 was seen by the NP who noted a dental abscess. This infection required 14 days of antibiotics and oxycodone for the pain. From 8/4/22 through 8/11/22, Resident #68 reported a pain level ranging from 6 to 9. Resident #68 oral surgeon consultation appointment was scheduled on 08/10/22 (after the survey started) for 08/15/22. Immediate jeopardy began on 05/10/22 when Resident #68 was treated for a tooth abscess and the facility failed to obtain dental services for Resident #68 for the extraction of all remaining teeth. The immediate jeopardy was removed on 8/12/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: Resident #68 was admitted to the facility on [DATE] and a readmitted on [DATE] with diagnoses to include Type 2 Diabetes, end stage renal failure, heart disease and malignant neoplasm of right ovary and overlapping sites of female genital organs and left kidney. Review of admission minimum data set (MDS) dated [DATE] revealed Resident #68 was coded as having no issues or concerns with oral care Review of Resident #68's revised care plans revealed no approach for oral care. Review of in-house dental note dated 10/19/21 revealed Resident #68 was in pain due to tooth infection and referral was made for outside dental treatment and recommended antibiotics such as Amoxicillin 500 MG (milligrams) 1 tablet every 8 hours for 10 days or Clindamycin 300 MG 1 tablet every 8 hours for 10 days if appropriate due to overall health condition. Review of nursing progress note dated 10/20/21 revealed Nurse Practitioner (NP) evaluated Resident #68 related to tooth infection with new order as follows: Amoxicillin 50 milligrams (MG) by mouth daily for 7 days. Resident #68 is her own responsible person and is aware of new orders. Review of Physician order dated 10/20/21 for Amoxicillin 500 MG 1 tablet by mouth every 8 hours (2pm, 10pm, 6am) for tooth infection. Review of outside dental note dated 11/21/21 revealed Resident #68 required oral surgery for extractions of all remaining teeth. The outside dental practice wrote a referral for Resident #68 to be seen by an oral surgeon for teeth extraction due to the teeth being broken and all root tips with tissue covering the teeth. Review of oral surgeon note dated 12/07/21 revealed plan to remove all upper and lower teeth for Resident #68 during two appointments using nitrous oxide; however, the resident requested to wait until January 2022 when her Medicaid would take effect. Per telephone interview with Transportation Coordinator on 08/11/22 at 03:19 PM revealed she called the oral surgeon practice in January 2022 to make Resident #68 an appointment to have her teeth extracted and the oral surgeon who had agreed to do the extractions had retired. The oral surgeon who took over the practice could not see anyone until August 2022 and did not accept Medicaid. Review of dietary order dated 03/27/22 revealed new order for regular diet with mechanical soft meat. Rehab Director interview was conducted on 08/11/22 at 10:15 AM revealed she was familiar with Resident #68 and her on-going dental issues. She stated speech and occupational therapy have been working with Resident #68 since March 2022 trying to accommodate her diet and texture needs for her dental issues. She revealed Resident #68 goes back and forth with what types of textures are easiest for her to eat according to her how her mouth and teeth are feeling. The Rehab Director stated that she lets them know if she needs something chopped or ground or if it is soft enough for her to eat as is, they go by her preferences for each meal. Currently she is on a regular diet with chopped meats, currently she likes things soft and lots of soups due to her current dental issues. She stated that she does not recall a discussion during a morning meeting of not being able to find a dentist for Resident #68 teeth extractions who will accept her insurance but does not recall the date of the meeting or which staff member was discussing the matter. Review of in-house dental note for 04/28/22 visit revealed Resident #68 was seen by facility dentist for routine dental visit. Facility dental note stated could not perform extractions for Resident #68 in house due to all teeth being root tips and tissue had completely covered her teeth and the procedure would need to be surgical. Resident #68 had been referred out for dental treatment, and the attached referral provided dentist's recommendations in case the resident would like to proceed with the treatment plan through a provider that accepts their current coverage. It was recommended the facility contact the resident's Medicaid provider for a list of accepted dental offices. There was no documentation as to whether the staff or the Social Worker contacted Medicaid for a list of oral surgeons as recommended by the in-house dentist. The facility could not produce any documentation of anyone contacting oral surgeon practices to inquire if they took Resident #68 Medicaid. Review of nursing progress note dated 05/10/22 revealed new orders for Resident #68 to receive Clindamycin 300 MG 1 tablet by mouth every 8 hours for dental abscess. Resident #68 was made aware. Review of Physician order dated 05/10/22 revealed Resident #68 to receive Clindamycin 300 MG 1 tablet by mouth every 8 hours (12AM, 8AM, 4PM) for 7 days for dental infection. Resident #68 had been ordered Acetaminophen 325 MG 2 tablets by mouth every 4 hours as needed for pain on 04/28/22. Review of medication administration record (MAR) for May 2022 revealed Resident #68 received Clindamycin 300 MG 1 tablet every 8 hours (12AM, 8AM, 4PM) as ordered beginning on 05/10/22 and ending on 05/16/22. Resident #68 received Acetaminophen 325 MG related to tooth pain at a level of 6 on a scale of 1 to 10 (ten being the worst pain) on 05/10/22 at 01:06 PM, tooth pain at a level of 7 on 05/12/22 at 05:42 AM and 03:59 PM, and tooth pain at a level of 7 on 05/13/22 at 04:02 AM and 12:30 PM all with effective results. Review of Physician order dated 06/07/22 revealed an order for a consult for oral surgery for teeth extractions for Resident #68. Review of nursing progress note dated 06/09/22 revealed new orders for oral surgery consult for teeth extractions, Clindamycin 300 MG 1 tablet by mouth every 8 hours for 7 days for dental abscess. Resident #68 was made aware. Review of Physician order dated 06/09/22 revealed Resident #68 to receive Clindamycin 300 MG 1 tablet by mouth every 8 hours (5AM, 1PM, 9PM) for 7 days for a dental infection. Review of medication administration record (MAR) for June 2022 revealed Resident #68 received Acetaminophen 325 MG related to tooth pain at a level of 5 on a scale of 1 to 10 (ten being the worst pain) on 06/10/22 at 12:53 AM and 04:09 PM, tooth pain at a level of 7 on 06/12/22 at 03:43 PM, and tooth pain at a level of 5 on 06/15/22 at 11:38 AM and 06:50 PM. Review of in-house dental note dated 06/28/22 revealed Resident #68 was seen again for a routine dental visit. The in-house dental note indicated Resident #68 he previously been referred to an oral surgeon for extractions and described Resident #68 as having severe periodontal disease (the result of infections and inflammation of the gums and bone that surround and support the teeth) with heavy calculus buildup. It was noted there was no dental abscess present today though one was detected a month ago. Review of dietary order dated 07/08/22 revealed new order for regular diet with chopped meat. Review of quarterly minimum data set (MDS) dated [DATE] revealed Resident #68 to be cognitively intact. Resident #68 was coded as having no issues or concerns with oral care or dental issues. Review of nursing progress note dated 07/26/22 revealed request for Physician/ Nurse Practitioner (NP) for complaint of pain of right-side jaw, area is swollen. NP evaluated on 07/28/22. Received physician order on 07/28/22 for oral surgery consults for extraction of teeth for dentures. Review of Physician order dated 07/28/22 revealed oral surgery consult for Resident #68 for extraction of teeth for dentures. Resident #68 was receiving antibiotics for a urinary tract infection which was completed on 08/03/22. Review of physician order dated 08/04/22 for antibiotic Clindamycin 300 MG 1 tablet by mouth every 8 hours (7PM, 3AM, 11AM) for 7 days for dental abscess, Oxycodone 5-325MG every 6 hours PRN for pain and Ibuprofen 400 MG 1 tablet by mouth 3 times daily (7PM, 3AM, 11AM) for pain. Nursing progress note dated 08/05/22 at 11:14 AM revealed Resident #68 was administered pain medication related to jaw pain at a level of 9. Result was effective. Review of Physician order dated 08/08/22 for Ibuprofen 200 MG 2 tablets by mouth 3 times daily (5AM, 1PM, 9PM) for pain. Nursing progress note dated 08/10/22 at 11:58 AM revealed Resident #68 was administered pain medication related to jaw pain at a level of 8. Result was effective. Review of Physician order dated 8/11/22 for antibiotic Clindamycin 300 MG 1 tablet every 8 hours (7PM, 3AM, 11AM) for 7 days for dental abscess, Oxycodone 5-325 MG every 6 hours PRN for pain, and Ibuprofen 200 MG 2 tablets by mouth 3 times daily for pain. Review of medication administration record (MAR) for August 2022 revealed Resident #68 received Oxycodone 5-325 MG 1 tablet by mouth every 6 hours PRN for pain on 08/04/22 at 11:44 AM for pain level of 7 with effective result and 9:20 PM for pain level of 7 with effective result for dental pain, 08/05/22 at 4:21 AM for pain level of 7 with effective result, 11:14 AM for pain level of 9 with effective result and 09:09 PM for pain level of 9 with effective result for dental pain, 08/08/22 at 11:59 AM for pain level of 6 with effective results and 9:12 PM for pain level of 9 with effective results for dental pain, 08/10/22 at 3:51 AM for pain level of 6 with effective results and 11:58 AM with pain level of 8 with effective results for dental pain, and on 08/11/22 at 3:53 AM for pain level of 8 with effective results, 10:23 AM for pain level of 7 with effective results and 08:39 PM for pain level of 7 with effective results for dental pain. Resident #68 observation and interview was conducted on 08/08/22 at 11:06 AM revealed her sitting up in her wheelchair in her room. Resident #68 right cheek was slightly swollen, and she opened her mouth to reveal gums were red and swollen and only tips of teeth were visible from swollen gums, other visible teeth were broken and chipped. Resident #68 stated the abscess in her mouth is painful and she was currently receiving an antibiotic and pain medication. She revealed she has been having dental issues since last year after she received chemo treatments, and this is her third infection. Resident #68 stated she saw the in-house dentist several months ago about her dental issues and was told the in-house dentist was not able to treat her, so she saw another dentist who recommended she have all of her teeth removed by an oral surgeon. She revealed the facility staff was supposed to be looking for an oral surgeon who will take her Medicaid. An interview was conducted with Resident #68 on 08/10/22 at 1:57 PM during which she revealed she had an abscess on the top and bottom of the right side of her mouth that she believed started 8-10 days ago. She stated she was only eating soft foods and liquids due to the pain. Observation of Resident #68 ' s teeth revealed red gums swollen over upper and lower teeth, and other teeth observed to be broken and chipped. Interview was conducted on 08/11/22 at 02:08 PM with Resident #68 revealed she received her Oxycodone 5MG between breakfast and lunch and her antibiotic for her abscesses at lunch along with two ibuprofens, so her pain scale right now was at 7. She stated her pain usually stays between a 7 with medications and 9 when she is waking up or the medications have worn off. She revealed the abscesses inside the upper right side of mouth at the base of nose caused pain up through her nose and into her eye and the abscess toward back of right side of mouth and jaw caused pain through her jawbone like she had lock jaw. Resident #68 stated this was the worst pain she had been through. She revealed her mouth hurts when she eats, and she chews on the left side and waits between bites and takes small sips of liquid through straws to prevent eating and drinking from making the pain worse. Resident #68 further revealed she has had dental issues on-going and believes at least three different times she has had abscesses since last year. She stated nursing staff, and the Social Worker were supposedly searching for a dentist who would accept her Medicaid to take out her teeth since last year. An interview was conducted with Nursing Assistant #6 on 08/10/22 at 07:15 AM revealed she worked 11PM-7AM with Resident #68 and was familiar with her care and current dental issues. She stated Resident #68 was able to perform her own oral care and staff provided set-up. She revealed Resident #68 informed her that she had abscesses in her mouth and would request pain medication stating that her mouth was hurting. The NA stated when Resident #68 complains of being in pain or is requesting pain medication, she will inform the nurse so they can assess her and administer any medication. An interview was conducted with Nurse #4 on 08/10/22 at 03:25 PM which revealed he was familiar with Resident #68 and her dental issues. He stated he observed cheek swelling on Resident #68 right side and she informed him about abscesses in her mouth. He stated he told the nurse practitioner (NP) about Resident #68 ' s cheek being swollen on the right side and having abscess in her mouth. Nurse #4 revealed Resident #68 was currently receiving antibiotics, pain medication and ibuprofen for the abscess and the facility staff were supposedly looking for an oral surgeon to remove her teeth. Social worker (SW) interview was conducted on 08/10/22 at 04:41 PM which revealed he was familiar with Resident #68 and had been working on a referral for an oral surgeon since November 2021. He stated Resident #68 was referred to an outside dental clinic in November 2021 and he recommended an oral surgeon referral. He revealed Resident #68 was sent out to oral surgeon in December 2021 and a plan was developed for the oral surgeon to extract her teeth over two appointments. The SW stated in January 2022, the transportation aide called the oral surgeon to schedule the two appointments and the oral surgeon had retired and his replacement did not have an opening until August 2022 and did not accept Medicaid. He revealed Resident #68 was seen by the in-house dentist in April 2022 and was recommended to have all teeth extracted and referred to a dental clinic. The SW stated he contacted the dental clinic in June 2022 about the status of the referral for Resident #68 and was informed they had not received the referral and it had to be refaxed. He revealed he spoke with the dental clinic again in July 2022 to inquire about the status of the referral and was informed the referral had been denied due to the dental clinic not providing oral surgery and not accepting Medicaid. The SW stated he had not documented the attempts made to contact dental practices for Resident #68 to be seen by an oral surgeon. He revealed he contacted an oral surgeon practice who takes Medicaid on 08/10/22 and has a consult appointment scheduled on 08/15/22 for Resident #68. Interview was conducted on 08/11/22 at 11:41 AM with Nurse Practitioner (NP) which revealed she was familiar with Resident #68 and her dental issues. She stated October 2021 Resident #68 was experiencing oral pain and had some broken teeth and a dental infection which required antibiotics. She revealed Resident #68 was seen by both an in-house and outside dentist who recommended all teeth to be extracted by an oral surgeon. The NP revealed she was told Resident #68 teeth extraction supposedly fell through due to insurance issues and the SW was working on finding an oral surgeon who would accept Medicaid. She stated Resident #68 had been on antibiotic therapy last October for a dental infection and this past May for a dental abscess on the left side of Resident #68 mouth, and was currently on an antibiotic, pain medication and ibuprofen due to abscesses on right side of mouth and slight swelling of right side of her face. The NP stated she felt it had taken too long and has expressed concern to the Director of Nursing (DON) and SW multiple times over the past year and kept being told it was being worked on. She revealed the dental issues had affected Resident #68's eating and she had expressed concerns to the DON and SW about the dental infection causing harm to resident due to heart issues. The NP stated she spoke with the medical director about her concerns and asked he get involved to move the referral process along. She stated the medical director ordered a consult for oral surgery on 07/28/22. The NP revealed she had no knowledge of an oral surgery consult or any consult taking this long to be completed. The Director of Nursing (DON) and Regional Nurse Consultant interview was conducted on 08/11/22 at 06:30 PM which revealed the DON was aware of the need for Resident #68 to be referred for oral surgery services. She stated the SW had been working with the in-house dental practice in getting Resident #68 seen for oral surgery services but has trouble finding a practice that would accept Medicaid. She revealed the facility had not contacted Medicaid or corporate for a list of oral surgeon providers that would accept Medicaid. The DON stated she had spoken with Resident #68 multiple times about her dental referral but was not aware of the severe pain the resident was having with her mouth due to her teeth and current abscess. The facility was notified of immediate jeopardy on 08/19/22 at 04:39 PM. F 684 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 11/23/2021, a referral to an outside oral surgeon was received from the facility contracted dental service for Resident #68 related to need for extractions of teeth due to broken, decayed teeth and mouth pain. The facility failed to schedule an oral surgeon appointment for Resident #68 who experienced unresolved tooth pain, difficulty eating, and abscesses requiring antibiotics affecting overall well-being. Resident saw oral surgeon on 8/15/20022 and is scheduled for oral surgery on 8/25/2022. On 8/10/22, the Director of Nursing (DON) performed an oral evaluation on Resident #68. Resident #68 exhibited slight redness to the mucous membrane. No overt swelling of gums. Resident #68 verbalized no pain at the time. Resident #68 stated she has had no issues with eating related to oral pain. On 8/10/22, Nursing Management (Director of Nursing, and Unit Coordinators) completed an audit of all current in-house residents to identify those with complaints of dental pain. This audit included an observation of the oral cavity for abnormalities of the teeth, redness, odor, or signs and symptoms of infection. The Physician was notified of any abnormalities, new orders for dental referrals were obtained and any dietary consult recommendations were implemented, including pain management. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete By 8/11/22, Director of Nursing and Staff Development Coordinator will educate Licensed Nurses to complete oral cavity observations for red swollen gums, odor, and/or other teeth abnormalities on admission, during routine care, and with residents that complain of mouth pain. It is the responsibility of the Nursing Aides to report any oral abnormalities and pain to the Licensed Nurse. It is the responsibility of the Licensed Nurse to report any oral abnormalities and pain to the Unit Coordinators. Unit Coordinators are responsible for notifying the Physician/Nurse Practitioner. Regarding off shifts it is the responsibility of Licensed Nurses to notify the Physician or Nurse Practitioner of any abnormalities and obtain new orders for treatments and interventions including pain management, and dietary consults if needed. Nursing staff will not be able to start their next shift prior to receiving the education, and all new hires will receive this education during orientation process. On 8/10/22, the Unit Coordinators and Licensed Nurses were notified of this responsibility by the Director of Nursing and Staff Development Coordinator during this education. By 8/11/22, the Director of Nursing will educate Licensed Nurses regarding the process for communicating new physician orders for oral cavity observations/abnormalities, treatments and interventions including pain management, and dietary consults if needed, to the Unit Coordinators. During off hours the Licensed Nurses will input orders, which will pull into Facility Activity Report-Orders and will be brought to the Daily Clinical Meeting by the Unit Coordinators. By 8/11/22, Nursing Management (Director of Nursing, Unit Coordinators) will educate the Nurse Aides to report oral cavity observations for red swollen gums, odor, and/or other teeth abnormalities on admission, during routine care, and with residents that complain of mouth pain or difficulty chewing. Issues identified will be reported to the Licensed Nurse or Unit Coordinator for follow-up. Issues identified will be reported to the Licensed Nurse or Unit Coordinator for follow-up. Nurse Aides will not be able to start their next shift prior to receiving the education, and all new hires will receive this education during orientation process. The process is as follows: 1. Licensed Nurses and Nurse Aides will complete oral cavity observations for red swollen gums, odor, and other teeth abnormalities on admission, during routine care, and with residents that complain of mouth pain, and/or difficulty chewing. Any issues identified will be reported to the Licensed Nurse, Unit Coordinator. The Unit Coordinators are responsible for notifying the Physician/Nurse Practitioner; regarding off shifts it is the responsibility of Licensed Nurses to notify the Physician or Nurse Practitioner of any oral cavity observations/abnormalities and new orders for treatments and interventions including pain management, and dietary consults if needed 2. Any dental recommendations by the Physician and Nurse Practitioner will be entered by the Licensed Nurses or Unit Coordinators. 3. The Unit Coordinators will print, review, and bring the Facility Activity Report - Orders to include new dental services referral (orders) to review with the DON and Social Services Director during the daily Clinical Morning Meeting. During Clinical Morning meeting a review will be conducted of the Facility Activity Report -Orders to include any referrals (orders) for dental services, progress notes, physician orders, pain, and infections. This review identifies any new pain, dietary concerns, and resolution of infections/abscesses. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including nursing agency staff will receive education prior to the start of their shift. On 8/10/22, the Regional Clinical Manager educated the Director of Nursing, Unit Coordinators, Social Worker, and the Administrator regarding clinical morning meeting process to review the Facility Activity Report -Orders to include any referrals (orders) for dental services, progress notes, physician orders, pain, and infections. This review identifies any new pain, dietary concerns, and resolution of infections/abscesses. The Unit Coordinators were notified during this education that they are responsible to print, review, and bring the Facility activity Report-Orders to Clinical Morning Meeting. Attendees of the Clinical Morning Meeting are Director of Nursing, Administrator, Staff Development Coordinator, Social Worker, and Unit Coordinators. Effective 8/11/22, the Director of Nursing and Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 8/12/2022 On 8/25/22 the credible allegation for the immediate jeopardy removal was validated and the removal date of 08/12/22 was confirmed. The audit tools completed by the facility on 08/10/22 were reviewed. The physician was notified of results from the audits and residents identified with dental needs were scheduled to see in house dentist and oral surgeon. On 8/10/22, the Regional Clinical Manager educated the Director of Nursing, Unit Coordinators, Social Worker, and the Administrator regarding clinical morning meeting process to review the Facility Activity Report -Orders to include any referrals (orders) for dental services, progress notes, physician orders, pain, and infections. This review identifies any new pain, dietary concerns, and resolution of infections/abscesses. Interviews with nurses, nursing assistants and Unit Coordinators revealed they received education on identifying any changes in resident condition including mouth pain, abnormal odor coming from mouth, broken teeth, bleeding gums, any abnormal areas in mouth, difficulty eating and reporting these changes to the nurses and the medical providers. Oral care handout was also provided to all nursing staff. Nursing staff contacts the Nurse Practitioner or Physician with any reports of dental issues, enters any new orders and referrals, and informs the Unit Coordinator so appointments can be scheduled. Interviews with the Unit Coordinators confirmed they had also received education on reviewing any new orders or referrals for dental issues and scheduling appointments. They will inform the Director of Nursing of the new order or referral and if an appointment was made and complete a facility report to review during daily clinical meeting. Director of Nursing (DON) was interviewed and revealed she educated nursing staff on oral care and referral process. She stated nursing assistants are responsible for performing oral care every shift and as needed and looking for any dental issues such as odor, difficulty chewing, pain and when observed to notify nursing. Nursing staff was responsible for assessing resident for dental issues and pain and inform the Unit Coordinator, Nurse Practitioner or Physician about any dental concerns. Nursing will also input any new orders or referrals related to dental issues and notify Unit Coordinator. She revealed the Unit Coordinator schedules all dental appointments and completes a tracking form that is brought to daily clinical meeting. The DON stated she was responsible for keeping a master list of all dental appointments that was reconciled daily to reflect when the resident appointment was completed and the outcome.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and Nurse Practitioner (NP), Dental Clinic Manager, facility staff, and resident interviews, the facility failed to obtain dental services from an oral surgeon for teeth extractions. Resident #68 was seen by a dentist on 11/21/21 who wrote a referral for an oral surgeon for extraction of all remaining teeth. Resident #68 was seen by an oral surgeon on 12/07/21 and the plan was to remove all upper and lower teeth during two appointments using nitrous oxide which she asked to defer until January 2022 when her Medicaid would take effect. When the oral surgeon's office was contacted in January 2022 it was communicated that the current oral surgeon did not accept Medicaid. The in-house dentist recommended referrals to an oral surgeon for extractions on 4/28/22 and 6/28/22. The Physician/Nurse Practitioner wrote orders for oral surgery consults for extraction of teeth on 6/7/22 and 7/28/22. The delay in services led to repeated dental infections, unresolved pain, and difficulty eating. Resident #68 oral surgeon consultation appointment was scheduled on 08/10/22 (after the survey started) for 08/15/22. The deficient practice occurred for 1 of 1 resident reviewed for dental services (Resident #68). Immediate jeopardy began on 05/10/22 when Resident #68 was treated for a second tooth abscess and the facility failed to obtain dental services for the extraction of all remaining teeth. The immediate jeopardy was removed on 8/12/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: Resident #68 was admitted to the facility on [DATE] and a readmitted on [DATE] with diagnoses to include Type 2 Diabetes, end stage renal failure, heart disease and malignant neoplasm of right ovary and left kidney. Review of admission minimum data set (MDS) dated [DATE] revealed Resident #68 was coded as having no issues or concerns with oral care Review of in-house dental note dated 10/19/21 revealed Resident #68 was in pain due to tooth infection and referral was made for outside dental treatment and recommended antibiotics such as Amoxicillin 500 MG (milligrams) 1 tablet every 8 hours for 10 days or Clindamycin 300 MG 1 tablet every 8 hours for 10 days if appropriate due to overall health condition. Review of nursing progress note dated 10/20/21 revealed Nurse Practitioner (NP) evaluated Resident #68 related to tooth infection with new order as follows: Amoxicillin 50 milligrams (MG) by mouth daily for 7 days. Resident #68 is her own responsible person and is aware of new order. Review of Physician order dated 10/20/21 for Amoxicillin 500 MG 1 tablet by mouth every 8 hours (2pm, 10pm, 6am). Review of outside dental note dated 11/21/21 revealed Resident #68 required oral surgery for extractions of all remaining teeth. The outside dental practice wrote a referral for Resident #68 to be seen by an oral surgeon for teeth extraction due to the teeth being broken and all root tips with tissue covering the teeth. Review of oral surgeon note dated 12/07/21 revealed plan to remove all upper and lower teeth for Resident #68 during two appointments using nitrous oxide; however, the resident requested to wait until January 2022 when her Medicaid would take effect. Per telephone interview with Transportation Coordinator on 08/11/22 at 03:19 PM, she called the oral surgeon practice in January 2022 to make Resident #68 an appointment to have her teeth extracted and the oral surgeon who had agreed to do the extractions had retired. The oral surgeon who took over the practice could not see anyone until August 2022 and did not accept Medicaid. Review of in-house dental note for 04/28/22 visit revealed Resident #68 was seen by facility dentist for routine dental visit. Facility dental note stated in house dentist could not perform extractions for Resident #68 due to all teeth being root tips and tissue had completely covered her teeth and the procedure would need to be surgical. Resident #68 had been referred out for dental treatment, and the attached referral provided dentist's recommendations in case the resident would like to proceed with the treatment plan through a provider that accepts their current coverage. It was recommended the facility contact the resident's current insurance provider for a list of accepted dental offices. There was no documentation in the medical record as to whether the staff or the Social Worker contacted Medicaid for a list of oral surgeons as recommended by the in-house dentist. The facility could not produce any documentation of anyone contacting oral surgeon practices to inquire if they took Resident #68 Medicaid. Review of nursing progress note dated 05/10/22 revealed new orders for Resident #68 to receive Clindamycin 300 MG 1 tablet by mouth every 8 hours for dental abscess. Resident #68 was made aware. Review of Physician order dated 05/10/22 revealed Resident #68 to receive Clindamycin 300 MG 1 tablet by mouth every 8 hours (12AM, 8AM, 4PM) for 7 days. Quarterly MDS dated [DATE] revealed Resident #68 was coded as having no issues or concerns with oral care. Review of Physician order dated 06/07/22 revealed an order for oral surgery consult for teeth extractions for Resident #68. Review of nursing progress note dated 06/09/22 revealed new orders for oral surgery consult for teeth extractions, Clindamycin 300 MG 1 tablet by mouth every 8 hours for 7 days for dental abscess. Resident # 68 was made aware. Review of Physician order dated 06/09/22 revealed Resident #68 to receive Clindamycin 300 MG 1 tablet by mouth every 8 hours (5AM, 1PM, 9PM) for 7 days. Review of in-house dental note dated 06/28/22 revealed Resident #68 was seen again for a routine scheduled dental visit. The in-house dental note indicated Resident #68 had previously been referred to an oral surgeon for extractions and described Resident #68 as having severe periodontal disease (the result of infections and inflammation of the gums and bone that surround and support the teeth) with heavy calculus buildup. It was noted there was no dental abscess present today though one was detected a month ago. admission MDS dated [DATE] revealed Resident #68 was coded as having no issues or concerns with oral care. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #68 to be cognitively intact. Resident #68 was coded as having no issues or concerns with oral care or dental issues. Review of nursing progress note dated 07/26/22 revealed request for Physician/ Nurse Practitioner (NP) for complaint of right-side jaw pain area is swollen. NP evaluated on 07/28/22. Received physician order on 07/28/22 for oral surgery consults for extraction of teeth for dentures. Review of Physician order dated 07/28/22 revealed an oral surgery consult for Resident #68 for extraction of teeth for dentures. Review of nursing note dated 07/28/22 revealed new orders by Medical Director for oral surgeon consult for extraction of teeth for dentures for Resident #68. Resident #68 was receiving antibiotic therapy for a urinary tract infection and received the last dose on 08/03/22. Review of physician order dated 08/04/22 for antibiotic Clindamycin 300 MG 1 tablet by mouth every 8 hours (7PM, 3AM, 11AM) for 7 days for dental abscess, Oxycodone 5-325MG every 6 hours PRN for pain and Ibuprofen 400 MG 1 tablet by mouth 3x ' s daily (7PM, 3AM, 11AM) for pain. Review of Physician order dated 08/08/22 for Ibuprofen 200 MG 2 tablets by mouth 3x ' s daily (5AM, 1PM, 9PM) for pain. Review of nursing progress note dated 08/08/22 revealed new order received from nurse practitioner (NP) to begin Ibuprofen 200 MG 2 tablet by mouth 3x's daily. Orders processed and Resident #68 was made aware of new orders. Review of Physician order dated 8/11/22 for antibiotic Clindamycin 300 MG 1 tablet every 8 hours (7PM, 3AM, 11AM) for 7 days for dental abscess, Oxycodone 5-325 MG every 6 hours PRN for pain, and Ibuprofen 200 MG 2 tablets by mouth 3x's daily for pain. Resident #68 observation and interview was conducted on 08/08/22 at 11:06 AM revealed her sitting up in her wheelchair in her room. Resident #68 right cheek was slightly swollen, and she opened her mouth to reveal gums were red, inflamed and swollen and only tips of teeth were visible from swollen gums, other visible teeth were broken and chipped. Resident #68 stated the abscesses in her mouth were painful and she was currently receiving an antibiotic and pain medication. She revealed she had been having dental issues since last year after she received chemo treatments, and this was her third infection. Resident #68 stated she saw the in-house dentist several months ago about her dental issues and was told the in-house dentist was not able to treat her, so she saw another dentist who recommended she have all of her teeth removed by an oral surgeon. She revealed the facility staff told her they were looking for an oral surgeon who would take her Medicaid. An interview was conducted with Nurse #4 on 08/10/22 at 03:25 PM which revealed he was familiar with Resident #68 and her dental issues. He stated he observed cheek swelling on Resident #68 right side and she informed him about abscesses in her mouth. He stated he told the nurse practitioner (NP) about Resident #68 ' s cheek being swollen on the right side and having abscess in her mouth. Nurse #4 revealed Resident #68 was currently receiving antibiotics, pain medication and ibuprofen for the abscess and the facility staff were supposedly looking for an oral surgeon to remove her teeth. Social worker (SW) interview was conducted on 08/10/22 at 04:41 PM which revealed he was familiar with Resident #68 and had been working on a referral for an oral surgeon since November 2021. He stated Resident #68 was referred to an outside dental clinic in November 2021 and he recommended an oral surgeon referral. He revealed Resident #68 was sent out to oral surgeon in December 2021 and a plan was developed for the oral surgeon to extract her teeth over two appointments. The SW stated in January 2022, the transportation aide called the oral surgeon to schedule the two appointments and the oral surgeon had retired and his replacement did not have an opening until August 2022 and did not accept Medicaid. He revealed Resident #68 was seen by the in-house dentist in April 2022 and was recommended to have all teeth extracted and referred to a dental clinic. The SW stated he contacted the referred dental clinic in June 2022 about the status of the referral for Resident #68 and was informed they had not received the referral and it had to be faxed. He revealed he spoke with the dental clinic again in July 2022 to inquire about the status of the referral and was informed the referral had been denied due to the dental clinic not providing oral surgery and not accepting Medicaid. The SW stated he had not documented the attempts made to contact dental practices for Resident #68 to be seen by an oral surgeon. A telephone interview was conducted with the Dental Clinic Manager on 08/11/22 at 09:48 AM which revealed the clinic received a referral on 07/27/22 for oral surgery for Resident #68. She stated the dental clinic director reviewed the referral and denied it due to Resident #68 needing oral surgery and they did not perform oral surgery. She revealed this was the only referral received by the clinic for Resident #68. The dental clinic manager revealed the facility social worker called the dental clinic on 08/10/22 and was informed the referral for Resident #68 had been denied due to the clinic not being able to perform oral surgery. Unit coordinator interview was conducted on 08/11/22 at 02:30 PM which revealed she was familiar with on-going dental issues with Resident #68 and had called dental clinic herself sometime in July and spoke with someone about oral surgery referral for Resident #68. She stated she was told the referral was in the basket and had not been reviewed yet. She revealed she informed SW of the information received from the dental clinic. The Unit Coordinator revealed she did not document or make a note of her call to the dental clinic and has no knowledge of the name of the dental clinic employee she spoke with. Telephone interview conducted with Transportation Coordinator on 08/11/22 at 03:19 PM revealed she was familiar with Resident #68 and had transported her to a dental appointment in November 2021. She stated Resident #68 was referred to an oral surgeon in December 2021 and they discussed a plan with Resident #68 to remove her teeth and she asked to wait until she received her Medicaid at the first of the year. The Transportation Coordinator revealed she contacted oral surgeon's office in January 2022 to schedule Resident #68 appointment and the oral surgeon had retired and his replacement did not accept Medicaid. She stated she called a few other dental practices in January 2022, but none of the offices accepted Medicaid. The Transportation Coordinator revealed she contacted a dental clinic in July, and they would not accept Medicaid. She further revealed she was not allowed to enter notes into electronic chart but did inform her supervisor and the Social Worker about practices she called in January and July. Interview was conducted on 08/11/22 at 11:41 AM with Nurse Practitioner (NP) which revealed she was familiar with Resident #68 and her dental issues. She stated October 2021 Resident #68 was experiencing oral pain and had some broken teeth and a dental infection which required antibiotics. She revealed Resident #68 was seen by both an in-house and outside dentist who recommended all teeth to be extracted by an oral surgeon. The NP revealed she was told Resident #68 teeth extraction supposedly fell through the cracks due to insurance issues and the SW was working on finding an oral surgeon who would accept Medicaid. She stated Resident #68 had been on antibiotic therapy last October for a dental infection and this past May for a dental abscess on the left side of Resident #68 mouth, and was currently on an antibiotic, pain medication and ibuprofen due to abscesses on right side of mouth and slight swelling of right side of her face. The NP stated she felt it had taken too long and has expressed concern to the Director of Nursing (DON) and SW multiple times over the past year and kept being told it was being worked on. She revealed the dental issues had affected Resident #68's eating and she had expressed concerns to the DON and SW about the dental infection causing harm to resident due to heart issues. The NP stated she spoke with the Medical Director about her concerns and asked he get involved to move the referral process along. She stated the Medical Director ordered a consult for oral surgery on 07/28/22. The NP revealed she had no knowledge of an oral surgery consult or any consult taking this long to be completed. The Director of Nursing (DON) and Regional Nurse Consultant interview was conducted on 08/11/22 at 06:30 PM which revealed the DON was aware of the need for Resident #68 to be referred for oral surgery services. She stated the SW had been working with the in-house dental practice in getting Resident #68 seen for oral surgery services but has trouble finding a practice that would accept Medicaid. She revealed the facility had not contacted Medicaid or corporate for a list of oral surgeon providers that would accept Medicaid. The DON stated she had spoken with Resident #68 multiple times about her dental referral but was not aware of the severe pain the resident was having with her mouth due to her teeth and current abscesses. The facility was notified of immediate jeopardy on 08/19/22 at 04:39 PM. The facility provided the following plan for IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 11/23/2021, a referral to an outside oral surgeon was received from the facility contracted dental service for Resident #68 related to the need for extractions of teeth due to broken, decayed teeth and mouth pain. The facility made multiple attempts to schedule this appointment. An appointment was scheduled for the resident with an oral surgeon on 12/7/21. The oral surgeon recommended extraction of lower and upper teeth. However, Resident #68 requested to wait until January 2022 when dental insurance would take effect. In January 2022, the transportation aide proceeded to schedule an appointment however attempts were unsuccessful. Resident #68 was seen by the facility contracted dentist on 4/28/22 and 6/28/22 with a referral to an oral surgeon for extractions. On 7/28/22, the facility received an order from the medical director to refer Resident #1 to an oral surgeon for teeth extractions and dentures. The facility failed to schedule the oral surgeon appointment subsequently Resident #68 experienced tooth pain and abscesses requiring antibiotics. Resident saw oral surgeon on 8/15/2022 and is scheduled for oral surgery on 8/25/2022. On 8/10/22, the Director of Nursing (DON) performed an oral evaluation on Resident #68. Resident #68 exhibited slight redness to the mucous membrane. No overt swelling of gums. Resident #68 verbalized no pain at the time. Resident #68 stated she has had no issues with eating related to oral pain. On 8/10/22, Nursing Management (Director of Nursing and Unit Coordinators) completed a review of all current in-house residents ' medical records to identify any outstanding referrals for dental care and ensure these have been completed. As well, to identify dental visit status, including the last dental visit, follow up recommended and validation of scheduled appointments (as applicable). Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete By 8/11/22, the Director of Nursing will educate Licensed Nurses regarding the process for communicating new physician orders for dental services to the Unit Coordinators. The Director of Nursing, Unit Coordinators, and Social Worker will be responsible for reviewing in-house dentist visit notes for recommendations, referrals, and notify MD and obtain any orders. On 8/11/22 The Regional Clinical Coordinator educated the Director of Nursing, Unit Coordinators, and Social Worker of the process. The process is as follows: 1. A licensed nurse receives the referral and inputs the orders for a referral. 2. The Unit Coordinator will print, review, and bring the Facility Activity Report - Orders to include new dental services referrals (orders) to review with the DON and Social Services Director during the daily Clinical Morning Meeting. 3. Unit Coordinators will schedule appointments. 4. Unit Coordinators will communicate with Director of Nursing if unable to schedule appointment daily 5. Director of Nursing will write the information on a master log of residents receiving dental services and update daily; Director of Nursing will reconcile this log daily by validating any outside or in-house dental appointments. When the Director of Nursing is not available the Social Worker will be responsible for filling in and updated the master log. On 8/10/22 the Regional Clinical Manager educated the Director or Nursing and Social Worker on the responsibility for the Master log and the new referral process. 6. The DON will reconcile this log daily by validating any outside or in-house dental appointments that have been completed. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including nursing agency staff will receive education prior to the start of their shift. On 8/10/22, the Regional Clinical Manager educated the Director of Nursing, Unit Coordinators, Social Worker, and the Administrator regarding the new referral process and their responsibilities on the referral process to review the Facility Activity Report -Orders to include any referrals (orders) for dental services and pain medication orders. During this education the Unit Coordinators were notified that they were responsible for printing, reviewing, and bringing the Facility Activity Report- Orders to Clinical Morning Meeting. The Director of Nursing, Unit Coordinators and Social Worker will review the Facility Activity Report - Orders during the daily Clinical Morning Meeting. Additionally, new admissions will be reviewed to identify residents with physician orders for dental services to validate dental services are scheduled and these orders completed. On 8/10/22 the Regional Clinical Manager educated the Social Worker on the responsibility for the log and the new referral process. The Director of Nursing, Unit Coordinators, and Social Worker will review documentation daily from outside dental appointments and in-house dental appointments to ensure dental service recommendations from the dental provider and physician are implemented. Effective 8/11/22, the Director of Nursing and Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 8/12/2022 On 8/25/22 the credible allegation for the immediate jeopardy removal was validated and the removal date of 08/12/22 was confirmed. The audit tools completed by the facility on 08/10/22 were reviewed. The physician was notified of results from the audits and residents identified with dental needs were scheduled to see in house dentist and oral surgeon. On 08/10/22, the Regional Clinical Manager provided education with the Administrator, Director of Nursing, Unit Coordinators and Social Worker on regarding the new referral process and their responsibilities on the referral process to review the Facility Activity Report -Orders to include any referrals (orders) for dental services and pain medication orders. During this education the Unit Coordinators were notified that they were responsible for printing, reviewing, and bringing the Facility Activity Report- Orders to Clinical Morning Meeting. The Director of Nursing, Unit Coordinators and Social Worker will review the Facility Activity Report - Orders during the daily Clinical Morning Meeting. Additionally, new admissions will be reviewed to identify residents with physician orders for dental services to validate dental services are scheduled and these orders completed. The Director of Nursing, Unit Coordinators, and Social Worker will review documentation daily from outside dental appointments and in-house dental appointments to ensure dental service recommendations from the dental provider and physician are implemented. A review of the Dental Referral Logs was completed and revealed residents with dental needs were scheduled to see the in-house dentist or oral surgeon for extractions depending on what issue was indentified. Interviews with nurses, nursing assistants and Unit Coordinators revealed they received education on identifying any changes in resident condition including mouth pain, abnormal odor coming from mouth, broken teeth, bleeding gums, any abnormal areas in mouth, difficulty eating and reporting these changes to the nurses and the medical providers. Oral care handout was also provided to all nursing staff. Nursing staff contacts the Nurse Practitioner or Physician with any reports of dental issues, enters any new orders and referrals, and informs the Unit Coordinator so appointments can be scheduled. Interviews with the Unit Coordinators revealed they also received education on reviewing any new orders or referrals for dental issues and scheduling appointments. They will inform the Director of Nursing of the new order or referral and if an appointment was made and complete a facility report to review during daily clinical meeting. Director of Nursing (DON) revealed she educated nursing staff on oral care and referral process. She stated nursing assistants are responsible for performing oral care every shift and as needed and looking for any dental issues such as odor, difficulty chewing, pain and when observed to notify nursing. Nursing staff was responsible for assessing resident for dental issues and pain and inform the Unit Coordinator, Nurse Practitioner or Physician about any dental concerns. Nursing will also input any new orders or referrals related to dental issues and notify Unit Coordinator. She revealed the Unit Coordinator schedules all dental appointments and completes a tracking form that is brought to daily clinical meeting. The DON stated she was responsible for keeping a master list of all dental appointments that was reconciled daily to reflect when the resident appointment was completed and the outcome.

Based on observations, record reviews and Nurse Practitioner (NP), Dental Clinic Manager, staff, and resident interviews Administration failed to provide leadership and oversight to facility staff to ensure dental referrals for extractions were scheduled for Resident #68 as recommended by the dentist and ordered by the Physician. The Administration failed to have an effective process that involved the interdisciplinary team and explore all options to ensure needed care and services were provided for 1 of 1 sampled resident (Resident #68). Immediate Jeopardy began on 05/10/22 when the facility failed to have systems in place to obtain dental services for Resident #68 for the extraction of all remaining teeth. The immediate jeopardy was removed on 8/11/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: This tag is cross referred to F684 and 791. F 684 - Based on observations, record reviews, Nurse Practitioner (NP), facility staff, and resident interviews, the facility failed to ensure resident's well-being by not providing care and services to prevent oral abscesses, unresolved dental pain and chewing difficulty for 1 of 1 resident (Resident #68). On 10/19/21 was seen by the in-house dentist who noted Resident #68 was in pain due to a tooth infection and referral was made for outside dental treatment and antibiotics were recommended. The antibiotics were ordered the next day by the Nurse Practitioner. Resident #68 was seen by a dentist on 11/21/21 who wrote a referral for an oral surgeon for extraction of all remaining teeth. Resident #68 was seen by an oral surgeon on 12/07/21 and the plan was to remove all upper and lower teeth during two appointments using nitrous oxide which she asked to defer until January 2022 when her Medicaid would take effect. On 3/27/22 Resident #68's diet order was changed to regular diet with mechanical soft meat. On 05/10/22 physician orders were written for antibiotics for a dental abscess. From 5/10/22 through 5/13/22, Resident #68 reported a pain level ranging from 6 to 7 (on a scale of 1-10 with 10 being the worst pain). Antibiotics were prescribed on 6/9/22 for a dental infection. From 06/09/22 through 06/15/22, Resident #68 reported pain level ranging from 5 to 7 (on a scale of 1-10 with 10 being the worst pain). On 7/8/22 Resident #68 diet order was changed to regular diet with chopped meat. On 7/28/22 Resident #68 was seen by the NP who noted a dental abscess. This infection required 14 days of antibiotics and oxycodone for the pain. From 8/4/22 through 8/11/22, Resident #68 reported a pain level ranging from 6 to 9. Resident #68 oral surgeon consultation appointment was scheduled on 08/10/22 (after the survey started) for 08/15/22. F 791 - Based on observations, record reviews, and Nurse Practitioner (NP), Dental Clinic Manager, facility staff, and resident interviews, the facility failed to obtain dental services from an oral surgeon for teeth extractions. Resident #68 was seen by a dentist on 11/21/21 who wrote a referral for an oral surgeon for extraction of all remaining teeth. Resident #68 was seen by an oral surgeon on 12/07/21 and the plan was to remove all upper and lower teeth during two appointments using nitrous oxide which she asked to defer until January 2022 when her Medicaid would take effect. When the oral surgeon ' s office was contacted in January 2022 it was communicated that the current oral surgeon did not accept Medicaid. The in-house dentist recommended referrals to an oral surgeon for extractions on 4/28/22 and 6/28/22. The Physician/Nurse Practitioner wrote orders for oral surgery consults for extraction of teeth on 6/7/22 and 7/28/22. The delay in services led to repeated dental infections, unresolved pain, and difficulty eating. Resident #68 oral surgeon consultation appointment was scheduled on 08/10/22 (after the survey started) for 08/15/22. The deficient practice occurred for 1 of 1 resident reviewed for dental services (Resident #68). Facility administration was notified of immediate jeopardy on 08/19/22 at 04:39 PM. The facility provided the following IJ removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The Administration failed to provide leadership and oversight to the facility staff to ensure that dental referral/consults were completed. There were no effective systems to manage referrals/ consults with an oral surgeon and follow through with recommendations for needed services. The lack of effective systemic process resulted in residents experiencing pain, difficulty chewing, and infection. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 8/10/22, the Regional Clinical Manager and the Regional Director of Operations educated the Administrator (NHA), Director of Nurses (DON), Unit Coordinator and Nurse Supervisor on the facility ' s revised process for managing in-house and outside dental services. On 8/10/22, the Regional Director of Operations re-educated the NHA on the requirements of F835. On 8/10/22, the Regional Director of Operations and Regional Clinical Manager educated the NHA and DON regarding the process for the Daily Stand-Up meeting where the Interdisciplinary Team (IDT) which includes Administration, Nursing, Social Services, Dietary and Therapy Services will meet and review to identify and outstanding consultations of dental referrals. This education included the daily Stand Down meeting where follow up is validated on previously identified issues. The Regional Director of Operations and Regional Clinical Manager will provide onsite support and validation for the Administrator and Director of Nursing weekly. A random observation of key facility meetings to include the daily IDT meeting and weekly Risk meeting will be conducted by the Regional Director of Operations and Regional Clinical Manager to provide ongoing validation, support, and education. Effective 8/11/22 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 8/11/2022 On 8/25/22 the credible allegation for the immediate jeopardy removal was validated and the removal date of 08/11/22 was confirmed. A root cause analysis was completed by the Regional Director of Operations which identified the following root causes for the IJ concerns identified at the survey: failure to provide leadership and oversight to the facility staff to ensure that dental referral/consults were completed and no effective systems to manage referrals/ consults. The audit tools completed by the facility on 08/10/22 were reviewed. The physician was notified of results from the audits and residents identified with dental needs were scheduled to see in house dentist and oral surgeon. On 08/10/22, the Regional Clinical Manager and Regional Director of Operations provided education with the Administrator and Director of Nursing on identifying issues with immediate jeopardy cited and discussed with them the components of the regulations for F-684, F-791, and F-835. The education also included QA (Quality Assurance) roles and responsibilities, morning stand-up, clinical stand-up, dental referral process and follow-ups, correction plans and monitoring processes. Interviews with nurses and nurse aides revealed they received education on identifying any changes in resident condition including mouth pain, abnormal odor coming from mouth, broken teeth, bleeding gums, any abnormal areas in mouth, difficulty eating and reporting these changes to the nurses and the medical providers. Oral care handout was also provided to all nursing staff. An QAPI (Quality Assurance and Performance Improvement) meeting was conducted on 08/22/22 with the following key personnel in attendance: Regional Clinical Manager, Administrator, Director of Nursing, and Medical Director. They discussed weekly risk meetings, morning stand-up, clinical stand-up, dental referral process and follow-ups, correction plans and monitoring processes.