**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, Dentist, Nurse Practitioner (NP), and Physician interviews the facility failed to immediately inform the physician when a resident (Resident #51) reported to the facility staff that he had oral pain and the facility staff observed a new onset of oral redness, during oral care. This was identified in 1 of 1 resident reviewed for dental care. Resident #51 was seen by a dentist on 10/28/2021 and received a recommendation for follow up dental care in 2 - 6 months. The facility failed to schedule the recommended appointment. Resident #51 reported oral pain and inflammation (redness and swelling) present for one week on 8/15/2022 (8/8/2022 through 8/15/2022) that Resident #51 and two Nursing Assistants (NA) (NA #4 and NA #5) stated was reported to the clinical staff. Interviews with two physicians (Medical Director and Physician #2) and the NP revealed they were not notified of the oral pain and inflammation during the week of 8/8/2022 through 8/15/2022. The recommended follow up care, oral pain and inflammation was identified by the surveyor and brought to the facilities attention. The facility then scheduled a dental visit on 8/17/2022 that resulted in diagnoses of two gingival abscesses (infection), dental pain and a recommendation by the dentist for a full mouth extraction (the removal of the teeth). Physician orders were provided for Tramadol (an anti-inflammatory pain medication and two antibiotics (Cleocin and Rocephin). The failure to notify the physician immediately resulted in prolonged, unresolved oral pain and infection that was left untreated. The MD and Dentist revealed infection in the mouth could lead to pneumonia due to a bacterium, weaken the overall immune system, lead to a blood infection or sepsis and can cause severe pain. Immediate Jeopardy began on 8/15/2022 when unresolved oral pain and inflammation was noted in Resident #51's mouth by the surveyor and it was discovered the facility staff had been notified by the Resident during the week of 8/8/2022 through 8/15/2022 and failed to notify the physician or NP. Immediate Jeopardy was removed on 8/27/2022 when the facility implemented a credible allegation of immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D, that is not actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses that included a tracheostomy, aphonia (the loss of the ability to speak through disease or damage to the larynx or mouth), protein calorie malnutrition, hemiplegia, and a gastrostomy. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #51 was assessed to have cognitive impairment, no issues with his teeth, no pain, and no refusal of care. A review of the staffing schedule for Resident #51, for the dates of 8/8/2022 through 8/25/2022, was conducted with the Director of Nursing (DON) on 8/25/2022. The nurses that worked during the dates were identified as Nurse #3 - Nurse #10. Phone numbers were provided for Nurse #4 - #7 and Nurse #9. Seventeen nursing assistants (NA) were identified to work with the Resident during the dates and phone numbers were provided for NA #2 - NA#10. A call was placed to NA#2, NA #10, Nurse #4, Nurse #6, and Nurse #9 without success. A telephone interview was conducted with NA #4 and NA #5. An interview was conducted with NA #4 on 8/25/2022 at 3:22 p.m. and she revealed she had worked with Resident #51 on multiple occasions and had worked with him over the past month. She stated she did oral mouth care each shift she worked and about two weeks ago, the week of 8/8/2022 through 8/15/2022, the Resident began to shake his head and pull away when she tried to clean his mouth. She stated she reported this information to the hall nurse but did not recall the nurse's name because she was with an agency. An interview was conducted with NA #5 on 8/25/2022 at 3:44 p.m. and she stated she had worked with Resident #51 numerous times. She added that she swabbed his mouth, during oral care, with a lemon swab. She stated that recently he had begun to shake his head, No, or pull away when she tried to clean his mouth and she asked the Resident if he had pain and he nodded, Yes. She added that she observed a red area to the right side of his mouth and reported the redness to an agency hall nurse because the night shift supervisor had been out of work due to an injury. She revealed this had begun two weeks ago. An observation was conducted on 8/15/2022 at 10:54 a.m. of Resident #51's teeth and revealed the upper right half of the palette was red with an inflamed swollen area to a front tooth and gum area. A review of Resident #51's electronic medical record and nurse progress notes for 60 days, did not include documentation for oral pain or inflammation. An interview was conducted on 8/16/2022 at 3:20 p.m. with the MDS Director. The MDS Director reviewed the Resident's dental exam notes from the 10/28/2021 visit, that documented the Resident had multiple missing teeth, 7 teeth that were root tips, and two non-restorable teeth. The surveyor and the MDS Director walked to Resident #51's bedside for an observation of his oral cavity. The MDS Director requested the Resident open his mouth for an observation and then she stated she observed he had inflamed gums to the top right side with multiple tooth fragments and obvious black areas on his teeth. An interview was conducted on 8/16/2022 at 4:02 p.m. with the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the MDS director, the social worker (SW) and the regional consultant present in the office. The administrative team was made aware of the concerns the surveyor had discovered during the investigation for Resident #51. The DON and Administrator revealed they both had not been aware the Resident had oral pain or inflammation in his mouth. The DON revealed the Resident can communicate his pain and had communicated his gastrointestinal pain in the past. The administrative staff all stated they will schedule a follow up dental appointment, ensure his pain was assessed, and as needed pain medication provided as ordered. A review of the nursing progress notes had been conducted on 8/25/2022 and revealed a nurse progress note written by the ADON on 8/17/2022 for the date of 8/16/2022. The progress note read Resident #51 was assessed for oral pain and denied the pain three times with a head shake. An interview was conducted with Dentist #1 on 8/26/2022 at 3:03 p.m. and he revealed he had conducted a dental assessment of Resident #51 on 8/17/2022 because the facility called his practice on 8/16/2022 to schedule the appointment. He stated the Resident had two areas with purulent exudate (any fluid or semisolid that has exuded out of a tissue because of injury or inflammation) and when the two areas were probed (pressed on with a device) the Resident squeezed his hand to indicate pain. He added, the concern with not being notified sooner about the dental pain, was that infection in the mouth could lead to pneumonia due to a bacterium, weaken the overall immune system, lead to a blood infection or sepsis and can cause severe pain. He revealed it was his expectation for the dentist or medical provider to be notified of oral changes that include redness or pain at the time the changes were identified. He revealed on 8/17/2022 he verbally ordered peridex (an antiseptic) oral rinse, swab the mouth twice a day x 14 days, Acetaminophen for pain in combination with ibuprofen intermittently and provided a referral to an oral surgeon for a full mouth extraction (removal of teeth). An interview was conducted on 8/25/2022 at 1:40 p.m. with the Nurse Practitioner (NP) and she revealed each of her visits to Resident #51, in the past two months had been acute visits related to another health concern and she had not conducted an oral exam. She revealed Resident #51's dental situation had been reported to her on 8/25/2022. She revealed it was her expectation for the facility staff to report any clinical changes that included inflammation or pain at the time the Resident reported this to a staff member. An interview was conducted with Physician #2 on 8/25/2022 at 2:54 p.m. via telephone and he revealed he had been at the facility on 8/17/2022 and had been in to see Resident #51 just to check on him. He stated this was not a scheduled visit and he had not conducted an oral exam of the Resident because this was a visit to follow up for other conditions. He added that Resident #51 does not communicate with him and prefers other providers for care. He stated he had not been informed of the Resident's reported oral pain or inflammation during the week of 8/8/2022 through 8/15/2022. An interview was conducted on 8/26/2022 at 1:37 p.m. with the Medical Director (MD) and He revealed he had not been informed of Resident #51's oral pain or inflammation during the week of 8/8/2022 through 8/15/2022. He added, in relation to Resident #51's dental exam on 8/17/2022, that the concern with an abscess/dental infection, or any infection, would be that it can spread to the bloodstream and lead to sepsis. He stated the infection contains bacteria that could be a contributor to the Resident's possible aspiration pneumonia, diagnosed on [DATE]. He stated on the date of 8/16/2022, when the Resident expressed, he had pain of a 5 on a scale of 0 to 10, his expectation was for the Resident to be offered and provided his breakthrough, as needed medication or the provider notified for further instructions. He added, it was his expectation that when the pain and inflammation was reported to the facility staff, a provider should (physician, nurse practitioner, or dentist) be notified of the change in condition. An interview was conducted with the ADON on 8/25/2022 at 10:07 a.m. and she revealed she had been present during the meeting with the administrative team on 8/16/2022 at 4:02 p.m. She revealed the statement that this was when the facility first learned of the oral pain and the need to schedule a follow up appointment was accurate and on the date of 8/16/2022. An interview was conducted with the ADON on 8/25/2022 at 10:42 a.m. and she revealed she had written a late entry progress note after the survey team had exited the facility on 8/17/2022 that stated she had conducted an oral investigation on 8/16/2022. When asked why she conducted an oral investigation prior to learning the Resident had oral pain and inflammation she stated, but I did, I promise! The Administrator was notified of immediate jeopardy on 8/26/2022 at 4:45 p.m. The facility provided a credible allegation of immediate jeopardy removal dated 8/27/2022. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: The facility failed to immediately inform the physician or dentist when resident #51 reported to the staff that he had pain in his mouth with redness that resulted from two gingival abscesses. On 8/16/22 the in-house dental provider, was contacted by the Social Worker regarding resident #51 and the need for emergency dental services. The in-house dental provider conducted an on-site evaluation and developed a treatment plan on 8/17/22. The Dentist recommended that resident #51 be seen by oral surgeon for extraction of the remaining teeth. The Facility worked with the Medical Director from 8/17 until 8/25, to find a location for resident #51's tooth extractions, due to resident #51 having a tracheostomy tube and tubing feeding there are challenges involved with this procedure. On 8/25/22 the facility located an oral surgeon in [NAME], NC to schedule an appointment for tooth extraction. The resident was seen on 8/17 by in-house Dentist who ordered acetaminophen for pain and Peridex. The Nurse Practitioner (NP) saw resident #51 for possible pneumonia on 8/25/2022 and examine resident #51's mouth. Upon examination NP wrote orders for Tramadol 50 mg twice a day as needed for pain not controlled by acetaminophen, and the NP ordered: 1) Cleocin 300 mg four times a day x 7 days for potential aspiration pneumonia, and stated this would also cover a dental infection, and 2) Rocephin 1-gram IV everyday x 7 days for pneumonia. A chest x-ray on 8/26/2022 shows no signs of pneumonia. The antibiotic was continued for the dental issues. On 8/25/2022, the Director of Nursing and administrative nurses conducted an Oral Health visual observation and assessment for all current facility residents to identify if any other resident(s) that could be having any dental issues/concerns. The DON and administrative nurses also completed an Oral Health questionnaire, which included the following questions. 1) Are you having any issues with your teeth 2) Are you having dental pain 3) Are you having trouble eating. Any identified issues or concerns will be addressed, and dental consultations will be initiated to ensure residents are treated appropriately utilizing the in-house dental services if recommended by the attending physician. Director of Nursing and/or Nurse managers completed review of 24-hour reports for last 60 days for any other concerns that require physician notification as of 8/26/2022. 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. As of 8/26/22 the Director of Nursing and Administrative Nurses, were educated by the Regional Nurse Consultant regarding the responsibility of physician notification regarding the resident change of condition, related to dental concerns. The Director of Nursing and/or Administrative Nurses will be responsible for notification of the residents' attending physician of dental recommendations and any emergent dental care needs. As of 8/26 the Director of Nursing and Administrative Nurses provided education to the licensed nurses and nursing assistants, including the contract nursing staff, on completing oral cavity observations for red swollen gums, foul odor, and/or other abnormal teeth issues on admission, during routine care, and when residents complain of mouth pain. They were instructed to report any identified concerns to the attending physician for future treatment orders. Additionally, any identified concerns will be reported to the Director of Nursing and/or administrative nurses, by documenting on the 24-hour report. Employees who have not received training from the Director of Nursing, Assistant Director of Nursing, or designee will not be permitted to work until education has been completed. The Staff Development Nurse and RN Weekend Supervisor will track and monitor staff training for completeness. As of 8/26/22, Regional Nurse Consultant also completed education with Director of Nursing, Assistant Director of Nursing and administrative nurses, related to their responsibility to review twenty-four-hour report daily Monday- Friday during the clinical meeting for any noted concerns for physician notification. Alleged Date of IJ removal: 8/27/2022 Validation of the Credible Allegation occurred on 9/2/2022 and was evidenced by Resident, Dentist, and Physician interviews, observation, and facility training. The resident interviews and observations included an oral assessment of all residents that identified 6 additional residents in need of dental care. The notification of the dentist and medical provider was verified. The facility training included an Inservice for the responsibility of physician notification regarding a change in condition and focused on dental concerns. The facility policies for notification of changes, and dental services were reviewed with all clinical staff. The Resident had an oral surgery appointment scheduled. The immediate jeopardy was removed on 8/27/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, Dentist, Nurse Practitioner (NP), and Physician interviews the facility failed to ensure a resident's well-being by not providing care and services to prevent oral abscesses and unresolved dental pain for 1 of 1 resident (Resident #51) reviewed for dental care. Resident #51 was seen by the dentist on 10/28/2021 and received a recommendation for follow up dental care in 2 - 6 months. The facility failed to schedule the recommended appointment. Resident #51 reported oral pain and inflammation (redness and swelling) present for one week on 8/15/2022 (8/8/2022 through 8/15/2022) that Resident #51 and two Nursing Assistants (NA) (NA #4 and NA #5) stated was reported to the clinical staff. Resident #51 reported pain to facility staff on 8/16/2022 and did not receive a dose of his ordered, breakthrough as needed, pain medication. The recommended follow up care, oral pain and inflammation was identified by the surveyor and brought to the facilities attention. The facility then scheduled a dental visit on 8/17/2022 that resulted in diagnoses of two gingival abscesses (infection), dental pain and a recommendation by the dentist for a full mouth dental extraction (the removal of teeth). Immediate Jeopardy began on 8/15/2022 when unresolved oral pain and inflammation was noted in Resident #51's mouth by the surveyor and it was discovered the follow up dental appointment had not been scheduled in the timeframe recommended, that resulted in two gingival abscesses, pain, and a recommendation for a full mouth dental extraction. 0Immediate Jeopardy was removed on 8/27/2022 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and level of D-that is not actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses that included a tracheostomy, aphonia (loss of ability to speak through damage to the larynx or mouth), protein calorie malnutrition, hemiplegia, and a gastrostomy. A review of the dental exam notes for the past 12 months revealed Resident #51 was seen by Dentist #1 on 10/28/2021, the facility Dental Service Provider. Resident #51 was assessed to have heavy calculus (a form of hardened dental plaque) and heavy inflammation. He was missing several teeth, had 7 root tips, 3 restorations and 2 non-restorable teeth present. A recommendation was made for a cleaning in 2-6 months and to receive oral dental exams. The 10/28/2021 dental exam was his only dental visit and he had not been seen by the hygienist. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #51 was assessed to have no issues with his teeth, cognitive impairment, no speech, and no pain present. The assessment indicated the Resident had no behaviors or rejection of care. A review of Resident #51's care plan, dated 4/6/2022, revealed a focused area that read, Resident required assistance with activities of daily living (ADL) related to limited mobility due to a cerebrovascular accident with left hemiplegia, use of a percutaneous endoscopic gastrostomy {PEG) tube and a tracheostomy with a speech impairment. The interventions included oral care daily and as needed, routine dental assessment and dental consults as needed. A review of the physician orders for Resident #51 revealed: 1) Scheduled Acetaminophen 325 milligram (mg), take two tablets by PEG tube three times a day for pain ordered on 7/18/2022 and 2) Acetaminophen 160 mg/5 milliliters (ml) liquid, take 20 ml via peg tube every 4 hours as needed for pain, ordered on 7/4/2022. A review of the staffing schedule for Resident #51, for the dates of 8/8/2022 through 8/25/2022, was conducted with the Director of Nursing (DON) on 8/25/2022. The nurses that worked during the dates were identified as Nurse #3 - Nurse #10. Phone numbers were provided for Nurse #4 - #7 and Nurse #9. Seventeen nursing assistants (NA) were identified to work with the Resident during the dates and phone numbers were provided for NA #2 - NA#10. A call was placed to NA#2, NA #10, Nurse #4, Nurse #6, and Nurse #9 without success. A telephone interview was conducted with NA #4 and NA #5. An interview was conducted with NA #4 on 8/25/2022 at 3:22 p.m. and she revealed she had worked with Resident #51 on multiple occasions and had worked with him over the past month. She stated she did oral mouth care each shift she worked and about two weeks ago, the week of 8/8/2022 through 8/15/2022, the Resident began to shake his head and pull away when she tried to clean his mouth. She stated she reported this information to the hall nurse but did not recall the nurse's name because she was with an agency. An interview was conducted with NA #5 on 8/25/2022 at 3:44 p.m. and she stated she had worked with Resident #51 numerous times. She added that she swabbed his mouth, during oral care, with a lemon swab. She stated that recently he had begun to shake his head, No, or pull away when she tried to clean his mouth and she asked the Resident if he had pain and he nodded, Yes. She added that she observed a red area to the right side of his mouth and reported the redness to an agency hall nurse because the night shift supervisor had been out of work due to an injury. She revealed this had begun two weeks ago. An interview and observation were conducted with Resident #51 on 8/15/2022 at 10:24 a.m. The Resident responded through a nod and required lip reading when he mouthed a response. When asked if he received dental visits, he shook his head no multiple times. The Resident then opened his mouth and pointed at the front right side and to a tooth. When asked if this area hurt, he nodded yes, several times. When asked if he had reported the oral pain, he shook his head yes and mouthed to the nurses. An observation was conducted on 8/15/2022 at 10:54 a.m. of Resident #51's teeth and revealed the upper right half of the palette was red with an inflamed swollen area to a front tooth and gum area. A review of Resident #51's electronic medical record and nurse progress notes for July and August 2022 did not include documentation for oral pain or inflammation. An interview was conducted on 8/16/2022 at 3:20 p.m. with the MDS Director. The MDS Director reviewed the Resident's dental exam notes from the 10/28/2021 visit, that documented the Resident had multiple missing teeth, 7 teeth that were root tips, and two non-restorable teeth. The surveyor and the MDS Director walked to Resident #51's bedside for an observation of his oral cavity. The MDS Director requested the Resident open his mouth for an observation and then she stated she observed he had inflamed gums to the top right side with multiple tooth fragments and obvious black areas on his teeth. The MDS Director was not observed to offer anything for pain. An interview was conducted on 8/16/2022 at 3:21 p.m. with Resident #51. The MDS Director was present at the bedside. The Resident indicated his pain was a 5 on a scale of 0-10 with 0 being no pain and 10 being the worst pain ever. A review of the August Medication Administration Record (MAR) revealed there was no administration documented for the ordered as needed Acetaminophen 1) when the NA's reported this to the hall nurses the week of 8/8/2022 through 8/15/2022 or 2) when the Resident reported to the MDS Director that he had pain at a 5 out of 10, on the date, 8/16/2022. On the date of 8/16/2022 the last dose of scheduled acetaminophen had been provided at 1:00 p.m. An interview was conducted on 8/16/2022 at 4:02 p.m. with the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the MDS director, the social worker (SW) and the regional consultant present in the office. The administrative team was made aware of the concerns the surveyor had discovered during the investigation. The DON and Administrator revealed the facility had not been aware Resident #51 had a dental recommendation for follow up in 2-6 months. They both stated the facility had not been aware the Resident had oral pain or inflammation in his mouth. The DON revealed the Resident can communicate his pain and had communicated his gastrointestinal pain in the past. The administrative staff all stated they will schedule a follow up dental appointment, ensure his pain was assessed, and as needed pain medication provided as ordered. An interview was conducted with the Dentist #1 on 8/17/2022 at 12:00 p.m. and he revealed his practice received a call on 8/16/2022 to schedule the visit due to the Resident reporting pain in his mouth. He said an assessment was completed on 8/17/2022 with Resident #51 and there was a change from the previous visit in October 2021. He stated the Resident now had two gingival abscesses, located on the upper right and lower left of the mouth. He revealed the failure to schedule a follow up visit per his recommendation on 10/28/2021 was very concerning to him. A review of the August MAR for the date of 8/17/2022 revealed Resident #51 had not been provided his breakthrough as needed pain medication as ordered and his last dose of scheduled Acetaminophen, prior to the dental exam had been at 9:00 a.m. The Resident was documented to receive his next dose of Acetaminophen at 1:00 p.m. A review of the nursing progress notes had been conducted on 8/25/2022 and revealed a nurse progress note written by the ADON on 8/17/2022 for the date of 8/16/2022. The progress note read Resident #51 was assessed for oral pain and denied the pain three times with a head shake. An interview was conducted with Resident #51 on 8/25/2022 at 1:06 p.m. and he revealed he had pain in his jaw and the pain had been present for a week before the first interview with the surveyor on 8/15/2022. An interview was conducted with the MDS Director on 8/25/2022 at 10:22 a.m., with the Director of Nursing present, and she was read the 8/16/2022 interview statement of her observation of Resident #51 and what was reported to her. She acknowledged the statement was accurate. When asked what she did with the information that the Resident had pain a 5 out of 10 she revealed she did not offer or provide Resident #51's ordered as needed pain medication. She added she reported this information, regarding the oral redness and pain to the administrative nursing team during the time the surveyor revealed the multiple concerns discovered during the investigation. She stated she was unaware of what the administrative nursing team did with the reported information. She revealed she had not written a progress note, as of 8/25/2022, to document what she observed or what the Resident reported. She added she would document a late entry progress note to reflect what she observed, what was reported to her and the staff she reported to about the pain. An interview was conducted with the Director of Nursing (DON) on 8/25/2022 at 10:31 a.m., in reference to the MDS Director interview on 8/25/2022 at 10:22 a.m. The DON stated to the MDS Director she did not recall the MDS director reporting the Resident had pain a 5 out of 10 that had not been reported to the hall nurse for pain medication to be provided. She stated this had not been clearly communicated to the team. She then stated it was the hall nurse that should receive this information with a follow up report to the administrative nursing team that there was a change of condition to a resident. The DON was read the summarized statement from 8/16/2022 at 4:02 p.m. and she revealed the statement was accurate that this was when the team first learned the Resident had oral pain and redness and had a recommendation that had not been scheduled. A second interview was conducted with Dentist #1 on 8/26/2022 at 3:03 p.m. and he revealed on 8/17/2022 Resident #51 had two areas with purulent exudate (any fluid or semisolid that has exuded out of a tissue because of injury or inflammation) and when the two areas were probed (pressed on with a device) the Resident squeezed his hand to indicate pain. He stated facility staff had been present at the bedside when Resident #51 expressed he had pain. He revealed he recommended Acetaminophen for pain in combination with ibuprofen intermittently. He stated the reason he had previously, on 8/17/2022, stated the failure to schedule a recommended follow up visit was concerning to him was because the lack of care can lead to dental issues that included infection. He added when taking care of dental infection, the concern was that it could lead to pneumonia due to bacteria, weaken the overall immune system, and lead to a blood infection or sepsis. He revealed dental abscesses cause severe pain. An interview was conducted on 8/25/2022 at 1:37 p.m. with the Nurse Practitioner (NP) and she revealed each of her visits to Resident #51 in the last two months had been acute visits related to another health concern and she had not conducted an oral exam. The NP then walked, with the Surveyor, to the Resident's room to assess Resident #51's mouth. She asked the Resident if he hurt and where the pain was located. The Resident pointed to the right side of his jaw and when asked about his pain he indicated his pain was a 5 out of 10 on a 0-10 pain scale. When asked if the pain was in his mouth, he nodded yes. She revealed the dental situation had been reported to her on 8/25/2022, by the administrative nursing team. She ordered Tramadol 50 mg twice a day as needed for pain not controlled by acetaminophen and ordered 1) Cleocin, an anti-infective medication, 300 mg four times a day x 7 days for aspiration pneumonia and stated this would also cover a dental infection and 2) Rocephin, an antibiotic, 1 gram intravenous (IV) everyday x 7 days for pneumonia. She stated she preferred the Dentist make a recommendation and add for a follow up visit with the primary care physician within a time frame to reevaluate the gums and pain. An interview was conducted with Physician #2 on 8/25/2022 at 2:54 p.m. via telephone and he revealed he had been at the facility on 8/17/2022 and had been in to see Resident #51 just to check on him. He stated this was not a scheduled visit and he had not conducted an oral exam of the Resident because this was a visit for other conditions. He added that Resident #51 does not communicate with him and prefers other providers for care. A telephone interview was conducted with the Dental Provider services, [NAME] President (VP) of operations and the Director of Dental Services on 8/25/2022 at 4:53 p.m. and a referral was made by the Dentist #1 on 8/17/2022 that read, Patient (Resident #51) had pain and an abscess present with infection. A recommendation was made for a full mouth extraction at an outside oral surgeon. An interview was conducted on 8/26/2022 at 1:37 p.m. with the Medical Director (MD) and he revealed, in relation to Resident #51's dental exam on 8/17/2022, that the concern with an abscess/dental infection, or any infection would be that it can spread to the bloodstream and lead to sepsis. He stated the infection contains bacteria that could be a contributor to the Resident's possible aspiration pneumonia, diagnosed on [DATE]. He stated on the date of 8/16/2022, when the Resident expressed, he had pain of a 5 on a scale of 0 to 10, his expectation was for the Resident to be offered and provided his breakthrough, as needed medication or the provider notified for further instructions. He added the lack of dental care that was recommended could be a contributor to the infection the Resident had been diagnosed with. An interview was conducted with the ADON on 8/25/2022 at 10:07 a.m. and she revealed she had been present during the meeting with the administrative team on 8/16/2022 at 4:02 p.m. She revealed the statement that this was when the facility first learned of the oral pain and the need to schedule a follow up appointment was accurate and on the date of 8/16/2022. An interview was conducted with the ADON on 8/25/2022 at 10:42 a.m. and she revealed she had written a late entry progress note after the survey team had exited the facility on 8/17/2022 that stated she had conducted an oral investigation on 8/16/2022. When asked why she conducted an oral investigation prior to learning the Resident had oral pain and inflammation she stated, but I did, I promise! An interview was conducted with the Administrator on 8/25/2022 at 5:58 p.m. and he stated it was his expectation that the facility policy and procedures overcome human error. This error with not getting the hygienist scheduled per the dental recommendation 10/28/2021 was an error from an outside agency. He stated it was his expectation that agency nurses and outside organizations meet the facility policy and protocols in place for the delivery of care at the facility. He revealed if a nurse received a new report of pain, he expected this information to be passed on to the MD and the administrative nursing team along with documentation. The Administrator was notified of immediate jeopardy on 8/26/2022 at 4:45 p.m. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: The facility failed to ensure that a resident (Resident #51) received treatment and care, when the facility failed to schedule the recommended follow up dental care which resulted in two gingival abscesses (infection) and pain. There was a delay in reporting a change in condition of a resident (Resident #51) when the facility failed to report pain, changes, or redness to the Dentist or Medical Director when it was first discovered by the clinical staff. The resident was seen on 8/17 by in-house Dentist who ordered acetaminophen for pain and Peridex. The Nurse Practitioner (NP) saw resident #51 for possible pneumonia on 8/25/2022 and examine resident #51's mouth. Upon examination NP wrote orders for Tramadol 50 mg twice a day as needed for pain not controlled by acetaminophen, and the NP ordered: 1) Cleocin 300 mg four times a day x 7 days for potential aspiration pneumonia, and stated this would also cover a dental infection, and 2) Rocephin 1-gram IV everyday x 7 days for pneumonia. A chest x-ray on 8/26/2022 shows no signs of pneumonia. The antibiotic was continued for the dental issues. On 8/16/2022 Assistant Director of Nursing completed an oral assessment of resident #51 after the Director of Nursing informed her of resident prior complaint of pain. The Assistant Director of Nursing, on 8/16/2022, ask resident #51 3 times if he had any mouth pain, and resident # 51 responded no with a head nod. On 8/17/2022 the physician was contacted by the Director of Nursing to see resident #51 regarding the dental examination, and the residents' complaint of oral pain. Resident #51 refused to allow the physician to examine him at that time 8/17/22. What are we doing about this part This resident often refuses treatment from the attending physician. The Nurse Practitioner (NP) was asked by the Director of Nursing on 8/25/2022 to examine resident #51 regarding for this resident's complaint of pain during her weekly visit. Upon examination the NP wrote an order for Tramadol 50 mg twice a day as needed for pain not controlled by acetaminophen and ordered: 1) Cleocin 300 mg four times a day x 7 days for potential aspiration pneumonia, and stated this would also cover a dental infection, and 2) Rocephin 1-gram IV everyday x 7 days for pneumonia. On 8/25/2022 the Director of Nursing and Unit Managers conducted an Oral Health observation via visual inspection, and assessment for all current residents to identify if any other resident was having any dental issues/pain. The DON and administrative nurses also completed an Oral Health questionnaire, which included the following questions. 1) Are you having any issues with your teeth 2) Are you having dental pain 3) Are you having trouble eating. Any identified issues or concerns will be addressed, and a dental consultation will be initiated to ensure residents are treated appropriately utilizing the in-house dental services or community dentist if recommended by the attending physician 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. As of 8/26 the Director of Nursing and Administrative Nurses provided re-education to licensed nurses and nursing assistants, including contract nursing staff which included reporting pain, signs of infections, notifying physician, as well as the monitoring of pain and the effectiveness of the pain treatment. Any identified concerns will be reported to the Director of Nursing and/or administrative nurses, by documenting on the 24-hour report. Employees who have not received training from the Director of Nursing, Assistant Director of Nursing or Unit Manager/designee will not be permitted to work until education has been completed. The Staff Development Nurse and RN Weekend Supervisor will track and monitor staff training for completeness. As of 8/26/22, Regional Nurse Consultant also completed education with Director of Nursing, Assistant Director of Nursing and administrative nurses, related to their responsibility to review the twenty-four-hour report daily, Monday-Friday, during the clinical meeting for any noted concerns to include reports of any dental issues. Alleged IJ Removal Date 8/27/22 Validation of the Credible Allegation occurred on 9/2/2022 and was evidenced by Resident, Dentist, and Physician interviews, observation, and facility training. The resident interviews and observations included an oral assessment of all residents that identified 6 additional residents in need of dental care. The notification of the dentist and medical provider was verified. The facility training included an Inservice for the responsibility of physician notification regarding a change in condition and focused on dental concerns. The facility policies for notification of changes, and dental services were reviewed with all clinical staff. A review of the August MAR was conducted to verify the ordered medication were being administered to Resident #51, as ordered, with no concerns identified. The Resident had an oral surgery appointment scheduled. The immediate jeopardy was removed on 8/27/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, Dentist and Medical Director interviews, the facility failed to schedule a dental cleaning and examination for Resident #51 after he had a recommendation from Dentist #1 on 10/28/2021 for a routine follow up in 2-6 months. Ten months after the recommendation, an 8/17/22 dental assessment identified two gingival abscesses, infection, and pain. A week later, a diagnosis of possible aspiration pneumonia was added. This was present in 1 of 1 resident reviewed for dental care. Immediate Jeopardy began on 8/15/22 when dental pain and swollen areas were noted in Resident #51's mouth and it was discovered the follow-up dental appointment had not been schedule in the timeframe recommended. Immediate Jeopardy was removed on 8/28/22 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D to implement corrections for Resident #51, ensure the monitoring of the systems put into place and to complete facility employee training. The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses that included a tracheostomy, aphonia, protein calorie malnutrition, hemiplegia, and a gastrostomy. A review of the Dental exam notes for the past 12 months revealed Resident #51 was seen by Dentist #1 on 10/28/2021, the facility Dental Service Provider. Resident #51 was assessed to have heavy calculus (a form of hardened dental plaque) and heavy inflammation. He was missing several teeth, had 7 root tips, 3 restorations and 2 non-restorable teeth present. A recommendation was made for a cleaning in 2-6 months and to receive oral dental exams. The 10/28/2021 dental exam was his only dental visit and he had not been seen by the hygienist. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #51 was assessed to have no issues with his teeth, cognitive impairment, no speech and no pain present. A review of the physician orders for Resident #51 revealed: 1) Scheduled Acetaminophen 325 milligram (mg), take two tablets by peg tube three times a day for pain ordered on 7/18/2022 and 2) Acetaminophen 160 mg/5 milliliters (ml) liquid, take 20 ml via peg tube every 4 hours as needed for pain, ordered on 7/4/2022. An interview was conducted with Nursing Assistant (NA) #4 on 8/25/2022 at 3:22 p.m. and she revealed she had worked with Resident #51 on multiple occasions and had worked with him over the past month. She stated she did oral mouth care each shift she worked and about two weeks ago, the Resident began to shake his head and pull away when she tried to clean his mouth. She stated she reported this information to the hall nurse but did not recall the nurse's name because she was with an agency. An interview was conducted with NA #5 on 8/25/2022 at 3:44 p.m. and she stated she had worked with Resident #51 numerous times. She added that she swabbed his mouth, during oral care, with a lemon swab. She stated that recently he had begun to shake his head, No, or pull away when she tried to clean his mouth and she asked the Resident if he had pain and he nodded, Yes. She added that she observed a red area to the right side of his mouth and reported the redness to an agency hall nurse because the night shift supervisor had been out of work due to an injury. She revealed this had begun two weeks ago. An interview and observation were conducted with Resident #51 on 8/15/2022 at 10:24 a.m. The Resident responded through a nod and required lip reading when he mouthed a response. When asked if he received dental visits, he shook his head no multiple times. The Resident then opened his mouth and pointed at the front right side and to a tooth. When asked if this area hurt, he nodded yes, several times. An observation was conducted on 8/15/2022 at 10:54 a.m. of Resident #51's teeth and revealed the upper right half of the palette was red with an inflamed swollen area to a front tooth and gum area. A review of Resident #51's electronic medical record and nurse progress notes July and August 2022 did not include documentation for oral pain or inflammation. An interview was conducted on 8/16/2022 at 3:21 p.m. with Resident #51. The MDS director was present at the bedside. The Resident indicated his pain was a 5 on a scale of 0-10 with 0 being no pain and 10 being the worst pain ever. The MDS Director was not observed to offer anything for pain. A review of the August Medication Administration Record (MAR) revealed there was no administration documented for the as needed Acetaminophen on the date, 8/16/2022, when the Resident indicated he had pain at 5 out of 10. An interview was conducted with the Dentist #1 on 8/17/2022 at 12:00 p.m. and he revealed his practice received a call on 8/16/2022 to schedule the visit due the Resident reporting pain in his mouth. He said an assessment was completed on 8/17/22 with Resident #51 and there was a change from the previous visit in October 2021. He stated the resident now had two gingival abscesses, located on the upper right and lower left of the mouth. He added his expectation would be for the follow up to occur as recommended last October and then to receive follow up information, as needed, from the hygienist. He added the lack of scheduling of the recommendation follow up visit was a concern to him. A second interview was conducted with Dentist #1 on 8/26/2022 at 3:03 p.m. and he revealed on 8/17/2022 Resident #51 had two areas with purulent exudate and when the two areas were probed (pressed on with a device) the Resident squeezed his hand to indicate pain. He revealed he recommended Acetaminophen for pain in combination with ibuprofen intermittently. He added when taking care of dental infection, the concern was that it could lead to pneumonia due to bacteria, weaken the overall immune system, and lead to a blood infection or sepsis. He revealed dental abscesses cause severe pain. An interview was conducted with Resident #51 on 8/25/2022 at 1:06 p.m. and he revealed he had pain in his jaw and the pain had been present for a week before the first interview on 8/15/2022. An interview was conducted on 8/25/2022 at 1:37 p.m. with the Nurse Practitioner (NP) and she revealed each of her visits to Resident #51 in the last two months had been acute visits related to another health concern and she had not conducted an oral exam. The NP then walked to the Resident's room to assess Resident #51's mouth. She asked the Resident if he hurt and where the pain was located. The Resident pointed to the right side of his jaw and when asked about his pain he indicated his pain was a 5 out of 10 on a 0-10 pain scale. When asked if the pain was in his mouth, he nodded yes. She revealed the dental situation had been reported to her on 8/25/2022. She ordered Tramadol 50 mg twice a day as needed for pain not controlled by acetaminophen and ordered 1) Cleocin, an anti-infective medication, 300 mg four times a day x 7 days for aspiration pneumonia and stated this would also cover a dental infection and 2) Rocephin, an antibiotic, 1 gram intravenous (IV) everyday x 7 days for pneumonia. She stated she preferred the Dentist make a recommendation and add for a follow up visit with the primary care physician within a time frame to reevaluate the gums and pain. An effort to interview the agency nurses that worked with Resident #51 8/8/2022 through 8/15/2022 via telephone was conducted, without success. A telephone interview was conducted with the Dental Provider services, [NAME] President (VP) of operations and the Director of Dental Services on 8/25/2022 at 4:53 p.m. and a referral was made by the Dentist #1 on 8/17/2022 that read, Patient (Resident #51) had pain and an abscess present with infection. A recommendation was made for a full mouth extraction at an outside oral surgeon. The VP added their company was responsible for scheduling all follow up visits but stated they had been unable to obtain consent to treat for Resident #51. The Director of Dental Services stated a letter to acquire consent to treat had been mailed to the Resident at the facility. An interview was conducted on 8/26/2022 at 1:37 p.m. with the Medical Director (MD) and he revealed, in relation to Resident #51's dental exam on 8/17/2022, that the concern with an abscess/dental infection, or any infection would be that it can spread to the bloodstream and lead to sepsis. He stated the infection contains bacteria that could be a contributor to the Resident's possible aspiration pneumonia, diagnosed on [DATE]. He stated on the date of 8/16/2022, when the Resident expressed, he had pain of a 5 on a scale of 0 to 10, his expectation was for the Resident to be offered and provided his breakthrough, as needed medication or the provider notified for further instructions. He added the lack of dental care that was recommended could be a contributor to the infection the Resident had been diagnosed with. The Administrator was notified of immediate jeopardy on 8/26/2022 at 4:45 p.m. The facility provided a credible allegation of immediate jeopardy removal dated 8/28/2022. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: The facility must ensure all residents receive dental services as required to meet their needs. Facility failed to schedule a follow up dental appointment for resident # 51 following dental consult on 10/28/21. On 8/16/22 the inhouse dental provider, was contacted by the Social Worker regarding resident #51 and the need for emergency dental services following identification needed services. The in-house dental provider conducted an on-site evaluation and treatment plan on 8/17/22. In-house dental consultant recommended the resident be seen by an oral surgeon for the remaining teeth to be extracted. The Facility worked with the Medical Director to locate an oral surgeon for resident #51's recommended tooth extraction from August 17 to August 25, 2022. Due to resident #51 having a tracheostomy tube and tubing feeding there are challenges with this procedure. On 8/25/22 the facility working with the Medical Director located an oral surgeon in [NAME], NC. The Facility completed all required paperwork to schedule the appointment 8/25/22 for tooth extraction. The paperwork for the oral surgeon was completed by nurse practitioner and family then returned to the oral surgeon so that the appointment can be scheduled on 8/25/2022. On 8/25/2022 the Director of Nursing, Nurse Managers and administrative nurses conducted Oral Health observations, visual examinations and assessments for all current residents to identify if any other residents that were having any dental issues/concerns. The DON and Unit managers also completed an Oral Health questionnaire, which included the following questions. 1) Are you having any issues with your teeth 2) Are you having dental pain 3) Are you having trouble eating. Any identified issues or concerns that will be addressed, and dental consultations will be initiated to ensure residents are treated appropriately utilizing the in-house dental services if recommended by attending physician As of 8/27/2022 the facility social worker completed a review of dental consultant recommendations for follow up appointments and outside dental referrals for October 2021, through August 2022 to ensure that residents follow up appointments were scheduled. 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. As of 8/17/22, the Director of Nursing, Assistant Director of Nursing or designee will review the consultations to ensure they have been addressed and the appointments have been scheduled with the dental provider. The appointment schedule and, schedule book, as well orders, recommendations, consultations, and follow ups will be brought to the clinical meeting by the Director of Nursing or Assistant Director of nursing. They will be compared, to validate that the orders, recommendations, consults, and follow ups are accounted for, and match the scheduled appointments. The schedule list for the in-house dental provider will be maintained and updated by the social worker, and the outside appointment book will be maintained and updated by the transportation aide under the supervision of the Director of Nursing and Assistant Director of Nursing. As of 8/26/22 the Director of Nursing, Assistant Director of Nursing and the administrative nurses were educated by the Regional Nurse Consultant regarding the responsibility of physician notification regarding the results of the dental questionnaires. On 8/26/22 the Director of Nursing determined the Unit Manager would be accountable for physician notification. The physician will determine if an emergent dental consultation is needed, or if routine dental services are sufficient. As of 8/26/22 the Director of Nursing and nurse managers are accountable for inputting the order for consultation into the electronic medical record and will oversee the schedule process which will be completed by the transportation aide. Emergent dental consultations will be sent to In-house Dental Services by Social Worker or Director of Nursing following recommendation by physician, or the resident will be sent to an appropriate outside dental service provider as determined by the medical provider. On 8/26/22 the Director of Nursing, Assistant Director of Nursing and administrative nurses provided education to nurses and nursing assistants, including contract nursing staff, to complete oral cavity observations for red swollen gums, foul odor, and/or other abnormal teeth issues on admission, during routine care, and with residents that complain of mouth pain. Any identified concerns will be reported to the Director of Nursing, Assistant Director of Nursing or Unit Manager by the nurse or nursing assistant. Assessments completed with any identified issues will be reported to physician by charge nurse for further recommendations related to treatments. Employees who have not received training from the Director of Nursing, Assistant Director of Nursing or Unit Manager/designee will not be permitted to work until education has been completed. The Staff Development Nurse and RN Weekend Supervisor will track and monitor staff training for completeness. The Administrator will validate current employees and agency staff have been educated on 8/26/22. The Administrator will also validate all clinical employees, including agency staff, are educated prior to working. As of 8/26/22 Regional Nurse Consultant also completed education to include, the Director of Nursing, Assistant Director of Nursing and Unit Manager, related to their responsibility to review Dental Consults and recommendations daily Monday- Friday during the clinical meeting Alleged Date of IJ Removal: 8/28/2022 Validation of the Credible Allegation occurred on 9/2/2022 and was evidenced by Resident, Dentist, and Physician interviews, observation, and facility training. The resident interviews and observations included an oral assessment of all residents that identified 6 additional residents in need of dental care. The notification of the dentist and medical provider was verified. The facility training included an Inservice for the responsibility of physician notification regarding a change in condition and focused on dental concerns. The facility policies for notification of changes, and dental services were reviewed with all clinical staff. A review of the August MAR was conducted to verify the ordered medication were being administered to Resident #51, as ordered, with no concerns identified. The Resident had an oral surgery appointment scheduled. The immediate jeopardy was removed on 8/28/2022.