Every finding on record at Carolina Care Health and Rehabilitation

Based on record review and staff interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 1 of 19 residents reviewed for advanced directives (Resident #62). Findings included: Resident #62 was admitted to the facility on [DATE]. Review of Resident #62's electronic medical record revealed a Medical Orders for Scope of Treatment (MOST) form dated [DATE] that indicated her preference for Cardiopulmonary Resuscitation (CPR) to be attempted in the event she had no pulse and was not breathing. The Code book for 100 hall was observed at the Nurses station. Review of the Code Book revealed Resident #62's a Medical Orders for Scope of Treatment (MOST) form dated [DATE] that indicated her preference for a Do Not Resuscitate (DNR) status in the event she had no pulse and was not breathing. The form was signed by Resident #62's Responsible Party. Further review of Resident #62's electronic medical record revealed a progress note written by the Social Worker dated [DATE] 2:42 PM that read in part: Optum NP reviewed plan of care and current MOST form with resident and resident's responsible party. New MOST form completed to indicate Do Not Resuscitate (DNR) order with limited additional interventions, New MOST scanned to residents' chart and copy placed in MOST form book at nursing desk. Review of Resident #62's electronic medical record revealed the following care conference notes from Resident #62's care plan meetings: A note dated [DATE] that read in part: advanced directives discussed and no changes at this time. A note dated [DATE] read in part: Social went over advanced directives and wants resident to remain a Full code. A note dated [DATE] read in part: Social went over advanced directives and wants resident to remain a Full code. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #62 was cognitively intact. During an interview on [DATE] at 10:20 am NA #3 stated residents code status could be found in the code book. NA #3 stated the code book is kept at the nurse's desk, and that each unit had a code book. During an interview on [DATE] at 10:44 am Nurse #2 stated the code book is where the resident's code status could be found, and the book was the most updated. Nurse #2 stated it was the Social Worker's responsibility to update the forms in the code book. During an interview on [DATE] at 11:42 am the Social Worker stated advanced directives were discussed with residents upon admission and reviewed at quarterly care plan meetings. The Social Worker stated he was responsible and received completed MOST forms to be scanned and uploaded into the electronic medical record, then placed in the code book. The Social Worker stated the code books had the residents' most up to date code status. The Social Worker stated he normally filled out the MOST forms with the resident or resident representative, but sometimes the Nurse Practitioner from Optum completed the form and then he was responsible to upload the form and place the most updated form into the code book. The Social Worker verified Resident #62's MOST form in the code book did not match the MOST form in the electronic medical record or the status documented in care conference notes. The Social Worker was not sure why the form from [DATE] was not in the electronic medical record. During an interview on [DATE] at 1:27 pm, the Director of Nursing (DON) stated on admission the Nurse Practitioner or nurse fills out the MOST form with residents. The DON stated the Social Worker made sure the MOST forms were correct and was responsible to upload the MOST form into the electronic medical record and to make sure the completed MOST form was placed into the code book at the nurse's station. The DON stated she expected the resident's code status to match throughout the electronic chart and the Code Book. During an interview [DATE] at 1:27 pm the Administrator stated advanced directives were completed and discussed with residents on admission and at quarterly care plan meetings. The Administrator stated Optum Nurse Practitioners could complete the MOST forms with the residents. The Administrator stated completed forms were given to the Social Worker to be uploaded to the electronic medical record and placed into the code book at the nurse's station. The Administrator expected the code status to match throughout the resident record.

Based on observations, record review, and staff interviews, the facility failed to provide toenail care to 1 of 2 residents (Resident #82) who were dependent on staff for assistance with activities of daily living (ADL). Findings included: Resident #82 was admitted on [DATE] with diagnoses that included muscle wasting and atrophy. The care plan for ADL that initiated on 11/14/23 revealed Resident #82 required ADL assistance related to impaired mobility and muscle weakness. The goal was to reach his highest level of independence with ADL through the next review date. Interventions included using clear and simple instructions or cues when providing care, and monitoring, documenting and reporting declines in functions to the physician as indicated. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #82 with severely impaired cognition. He needed supervision or touching assistance for personal hygiene, and partial to moderate assistance for putting on or taking off footwear and shower. Resident #82 did not exhibit behavior of rejecting evaluation or care during the 7-day assessment period. A review of Resident #82's shower records revealed he was scheduled to receive shower twice weekly on Wednesday and Saturday during the first shift. The shower records indicated that he received a shower provided by Nurse Aide (NA) #2 last Saturday on 02/22/25. An observation conducted on 02/24/25 at 12:47 PM revealed all of Resident #82's bilateral toenails were extended between 4-5 millimeters (mm) beyond the tip of his toes. The right big toenail was cracked with sharp edges and brownish substances were visible underneath this toenail. During an interview conducted on 02/24/25 at 12:49 PM, Resident #82 stated he was not diabetic. He could not trim his toenails as he had difficulty reaching his lower extremities. He did not know how long it had been since his toenails had been trimmed and indicated the staff did not offer to trim them when he received showers in the past week. He wanted his toenails to be trimmed immediately as it bothered him, especially when wearing his cowboy boots. A subsequent observation conducted on 02/25/25 at 1:14 PM revealed Resident #82's bilateral toenails remained untrimmed. The right big toenail was cracked with sharp edges and dirty. During a joint observation conducted on 02/25/25 at 3:15 PM with NA #1 and Nurse #1, Resident #82's toenails remained untrimmed with both big toenails cracked with sharp edges. Brownish substances were seen underneath the right big toenail. An interview was conducted with NA #1 on 02/25/25 at 3:18 PM. She stated she had provided care for Resident #82 frequently, but she did not notice his long, cracked, dirty toenails. She added Resident #82's toenails needed to be trimmed to ensure comfort and safety. During an interview conducted on 02/25/25 at 3:20 PM, Nurse #1 explained she did not provide care for Resident #82 frequently and was not aware of his long, cracked, and dirty toenails. She confirmed Resident #82 was not a diabetic and his toenails could be trimmed by a NA. She stated Resident #82 was dependent on the staff for nail care and acknowledged that his toenails needed to be trimmed immediately. An interview was conducted with NA #2 on 02/26/25 at 10:54 AM. She stated she was a member of the shower team and recalled giving a shower to Resident #82 last Saturday on 02/22/25. She did not notice Resident #82 with long, cracked, and dirty toenail during the shower. Otherwise, she would have offered to trim and clean his toenails. During a joint interview conducted on 02/26/25 at 11:44 AM, the Director of Nursing and the Administrator expected all the nursing staff to be more attentive to residents' skin conditions including toenails when providing care or shower and offer nail care as indicated. It was their expectation for all the dependent residents to receive nail care as needed or indicated in a timely manner.

Based on record review, and interviews with staff, Consultant Pharmacist, and Nurse Practitioners, the facility failed to respond to identified drug irregularities related to the use of as needed (PRN) psychotropic drug (drug that affects mental state) and provide follow up recommendations for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #83). The findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included Metabolic encephalopathy, cognitive communication deficit, unspecified dementia, and anxiety disorder. A physician's order dated 10/25/2024 indicated Lorazepam one (1) milligram (mg) by mouth three times a day PRN (as needed) for anxiety/agitation, hold for sedation was ordered for Resident #83. The order did not contain a stop date. Rationales for extended therapy beyond 14 days were not found in Resident #83's medical records. A review of the October, November and December 2024 and January 2025 medication administration record (MAR) revealed Resident #83 had received no doses of PRN Lorazepam in October and November of 2024, and Resident #83 received 2 doses of PRN Lorazepam in December 2024 and received 5 doses of PRN Lorazepam in January 2025. 12/14/2024- 1 dose 12/30/2024- 1 dose 1/3/2025- 1 dose 1/6/2025- 1 dose 1/14/2025- 1 dose 1/15/2025- 1 dose 1/23/2025- 1 dose A review of Resident #83's medical record revealed the Consulting Pharmacist had conducted a medication regimen review (MRR) for Resident #83 on 11/29/2024. The Consulting Pharmacist sent a recommendation to the provider on 11/29/2024 that read: Resident has a PRN (as needed) Lorazepam order on MAR. Per guidelines, this medication would need to have a 14 day stop date added or a progress note to document a longer duration on MAR. Whichever is appropriate. Review of the November recommendations to provider form revealed on 12/04/2024 the facility Nurse Practitioner (NP) wrote continue under the section Physician response to recommendation. Review of medication regimen reviews dated 12/29/2024 and 01/24/2025 revealed the Consulting Pharmacist made no recommendations. During an interview conducted on 02/27/25 at 9:48 AM, the Nurse Practitioner (NP) stated that the Psychiatric NP usually wrote the orders for psychotropic medications and that the orders normally had a 14 day stop date, then the orders would have to be renewed. The NP verified she had signed the November pharmacist recommendation form for Resident #83 and wrote Continue under the rationale section. NP stated the Psychiatric NP normally completed the pharmacy recommendation forms for antipsychotic and psychotropic medications and could not explain why she had addressed the recommendation and not the Psychiatric NP. During a telephone interview on 02/27/25 at 12:02 PM, the Consulting Pharmacist verified he had completed the MMR for Resident #83 on 11/29/24. The Consulting Pharmacist verified he had sent a recommendation to the provider that read: Resident has a PRN (as needed) Lorazepam order on MAR. Per guidelines, this medication would need to have a 14 day stop date added or a progress note to document a longer duration on MAR. Whichever is appropriate. The Consulting Pharmacist verified the response from the provider was continue. The Consulting Pharmacist stated the response of continue received from the Nurse Practitioner on the pharmacist recommendation form was sufficient since his recommendation had been acknowledged and a response was sent. The consulting pharmacist stated he would have followed up with it again in a couple months if needed. During a telephone interview on 02/27/25 at 12:55 PM the Psychiatric Nurse Practitioner (NP) stated she was familiar with Resident #83 and was aware she had an order for Lorazepam. The Psychiatric NP stated if she had received the pharmacy recommendation form from 11/29/24, regarding the Lorazepam order written 10/25/24 and known the resident had not received any Lorazepam she would have discontinued the order. The Psychiatric NP stated she normally responded to all the pharmacy recommendations regarding antipsychotic or psychotropic medications, but sometimes the facility NP or Medical Director received and responded to the pharmacy recommendation forms. An interview was conducted with the Director of Nursing (DON) on 02/27/2025 at 10:08 AM and the DON expected PRN psychotropic medications to be written for 14 days, or for the provider to write the specific rationale for why the order needed to be extended for more than 14 days, which the DON verified is part of the facility psychotropic policy. During an interview on 02/27/2025 at 10:59 AM the Administrator stated he expected orders for PRN psychotropic medications to be written per the facility policy.

Based on record review, and interviews with staff and Nurse Practitioners, the facility failed to ensure physician's orders for as needed (PRN) psychotropic drug (drug that affects mental state) was time limited in duration and provided rationales for therapy exceeding 14 days for 1 of 5 sampled residents reviewed for unnecessary medications (Residents #83). The findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included Metabolic encephalopathy, cognitive communication deficit, unspecified dementia, and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #83 with severe cognitive impairment and indicated she had received antianxiety medications in the 7-day assessment period. Review of Resident #83's medical record revealed a physician's order dated 10/25/2024 that indicated Lorazepam 1mg (milligram) three times a day PRN (as needed) for Anxiety/Agitation, Hold for sedation was ordered for Resident #83. The order did not contain a stop date. This order was discontinued on 02/14/2025 due to non-use, and the rationales for extended therapy beyond 14 days were not found in Resident #83's medical records. A review of the December 2024 and January 2025 medication administration record (MAR) revealed Resident #83 had received 7 doses of PRN Ativan in December 2024 and January 2025. 12/14/2024- 1 dose 12/30/2024- 1 dose 1/3/2025- 1 dose 1/6/2025- 1 dose 1/14/2025- 1 dose 1/15/2025- 1 dose 1/23/2025- 1 dose On 02/24/25 at 11:49 AM an attempt to interview Resident #83 was unsuccessful. She was unable to engage in the interview. During an interview on 02/27/25 at 9:33 AM Nurse #3 stated she just recently became a nurse. Nurse #3 knew there was a policy regarding PRN (as needed) psychotropic medications. Nurse #3 did know recall the specific policy but knew she could get help finding it from the nurses in administration. During an interview on 02/27/25 at 9:44 AM Nurse #4 stated she was aware of the facility's policy for psychotropic medication use and stated that PRN orders for psychotropics had to have a 14 day stop date. During an interview conducted on 02/27/25 at 09:48 AM, the Nurse Practitioner (NP) stated that the Psychiatric NP usually writes the orders for Psychotropic medications and that the orders normally have 14 day stop date, then the orders have to be renewed. During a telephone interview on 02/27/25 at 12:55 PM the Psychiatric Nurse Practitioner (NP) stated she was familiar with Resident #83 and was aware she had an order for Lorazepam. The Psychiatric NP stated if she had received the pharmacy recommendation form from 11/29/24, regarding the Lorazepam order written 10/25/24 and known the resident had not received any Lorazepam she would have discontinued the order. An interview was conducted with the Director of Nursing (DON) on 02/27/2025 at 10:08 AM and the DON expected orders for PRN psychotropic medications to be written for 14 days, which the DON verified was part of the facility psychotropic medication policy. During an interview on 02/27/2025 at 10:59 AM the Administrator stated he expected orders for PRN psychotropic medications to be written per the facility policy.

Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR), level II was completed after a readmission with mental health diagnoses for 1 of 3 residents (Resident #40) reviewed for PASRR. The findings include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] and a PASRR level I was completed. The resident was diagnosed with other schizoaffective disorder on 4/13/21, anxiety disorder on 4/13/21, and mood affective disorder on 06/03/21. Resident #40 was readmitted to the facility on [DATE]. No PASRR level II was completed. During an interview on 2/27/25 at 10:05 AM with the Social Worker (SW) he revealed a PASRR level II should be completed upon admission for residents with a mental health diagnosis and when a resident has had a change of condition or a newly added mental health diagnosis. He stated in December 2023 and January 2024 he and the Administrator completed a PASRR audit for all residents with mental health diagnosis including Resident #40 but could not locate her current PASRR letter to show if a level II PASRR had been completed. During an interview on 2/27/25 at 11:40 AM with the Administrator he revealed PASRR level II should be completed in a timely manner upon the admission of a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. He stated in December 2023 and January 2024 he and the SW completed a PASRR audit for all residents with mental health diagnosis and PASRR level II referrals were sent into the PASRR office for any resident found to have a mental health diagnosis with no level II PASRR. He revealed this included Resident #40 and according to the PASRR audit documentation, Resident #40's name was checked off and labeled addressed for a level II referral being completed. The Administrator stated Resident #40's current PASRR letter could not be located to show if a level II PASRR had been completed.

2. Resident #55 was admitted to the facility on [DATE]. Review of Resident #55's facility face sheet dated 6/30/23 revealed Resident #55 had a designated responsible party (RP). Review of the Nurse Practitioner's (NP) order dated 2/11/25 at 8:21 PM revealed Resident #55 was sent to the hospital for evaluation and treatment. Review of Resident #55's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the discharge was coded as an unplanned discharge to hospital with return anticipated. Review of Resident #55's electronic medical record revealed no written notification was given to Resident #55 or her RP of her transfer to the hospital. Resident #55 returned to the facility on 2/14/25. Attempted to contact Resident #55's RP and was unable to be reached. An interview was conducted with the Social Worker (SW) on 02/27/2025 at 9:15 AM. The SW stated that the facility did not notify residents or their responsible parties (RP) in writing regarding transfers to the hospital. The SW also stated that the facility had never notified residents or their RPs in writing about hospital transfers and he was not aware of the regulation. The Administrator was interviewed on 02/27/2025 at 10:30 AM. The Administrator stated he did not notify residents or their RP's in writing of transfers to the hospital. The Administrator also stated that the facility did not have a process for written notification of transfers. The Administrator also stated that he was aware of the regulation, but the facility was not meeting the regulation. Based on record review, resident, staff, and responsible party (RP) interviews the facility failed to notify the resident and the Responsible Party in writing of transfers to the hospital for 2 of 2 residents reviewed for facility initiated discharge (Resident #6 and Resident #55). The findings included: 1. Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's facility face sheet dated 12/09/2024 revealed Resident #6 was her own responsible party. Review of the Nurse Practitioner's (NP) order dated 12/19/2024 at 10:52 AM revealed Resident #6 was sent to the hospital for evaluation and treatment. Review of Resident #6's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the discharge was coded as an unplanned discharge to hospital with return anticipated. Review of Resident #6's electronic medical record revealed no written notification was given to Resident #6 of her transfer to the hospital. Resident #6 returned to the facility on [DATE]. An interview was conducted with Resident #6 on 02/27/2025 at 8:10 AM. Resident #6 stated she did not receive any notification in writing prior to being transferred to the hospital in December 2024. An interview was conducted with the Social Worker (SW) on 02/27/2025 at 9:15 AM. The SW stated that the facility did not notify residents or their responsible parties (RPs) in writing regarding transfers to the hospital. The SW also stated that the facility had never notified residents or their RPs in writing about hospital transfers and he was not aware of the regulation. The Administrator was interviewed on 02/27/2025 at 10:30 AM. The Administrator stated he did not notify residents or their RPs in writing of transfers to the hospital. The Administrator also stated that the facility did not have a process for written notification of transfers. The Administrator also stated that he was aware of the regulation, but the facility was not meeting the regulation.

Based on observations, record review and staff interviews, the facility failed to ensure items stored ready for use were labeled and dated and/or failed to remove expired food items in 1 of 2 nourishment rooms (300 Hall). These practices had the potential to affect food served to residents. Findings included: An observation of the 300 Hall nourishment room and interview with the restorative Nurse on [DATE] at 10:30 AM revealed in the nourishment room three thick and clear lemon-flavored liquid cups with use by date [DATE] and nine thick and liquid lemon-flavored cups with the use by date [DATE]. The restorative Nurse further revealed dietary was responsible for checking nourishment refrigerators daily, but staff had been educated to throw away according to the use by date. The Nurse indicated items stored should have been already discarded. An interview conducted with the Dietary Manager (DM) on [DATE] at 2:28PM revealed dietary staff stocked the nourishment rooms and the items had gotten pushed back into a bottom drawer out of the way. The interview further revealed dietary was responsible for removing the items and cleaning out the refrigerator once items expired daily. The DM indicated staff should have been checking the entire refrigerator for dates and removing expired items. An interview conducted with the Administrator on [DATE] at 6:15 PM revealed he expected nourishment rooms to be checked consistently. The Administrator stated expired items in the nourishment rooms refrigerators needed to be discarded.

Based on record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation surveys that occurred on 08/12/21 and 08/25/22. This was for one deficiency cited in August 2021 and August 2022 in the area of Accuracy of Assessments and subsequently cited on the current recertification and complaint investigation survey of 01/05/24. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referred to: F641: Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of hospice services, seizure disorder, and discharge for 3 of 6 residents whose MDS assessments were reviewed (Resident #15, #205 and #83) During the recertification and complaint investigation survey conducted on 08/25/22, the facility failed to accurately code the MDS assessments in the areas of hospice services, level of assistance needed for eating, oral/dental status, and cognition for 10 of 18 sampled residents whose MDS was reviewed. During the recertification and complaint investigation survey conducted on 08/12/21, the facility failed to accurately code the Minimum Data Set (MDS) assessment reviewed for the areas of hospice to reflect prognosis for 1 of 1 resident reviewed for hospice and the number of falls for 1 of 3 residents reviewed for falls. During an interview on 01/05/24 at 5:05 PM with the Administrator, he reported his quality assurance team met monthly and included the Medical Director who comes quarterly, the pharmacist who attends every other month, the registered dietician who attends quarterly and all the department heads who attend monthly. He reported they currently had Process Improvement Plans (PIPs) addressing falls, weight loss, and wound care and said they would be adding another PIP for MDS compliance. The Administrator stated he felt like they had resolved the issue by hiring a second MDS coordinator but said she had recently been out on maternity leave for 12 weeks and it was clear now that one MDS coordinator could not handle the workload. He further stated they would be monitoring for MDS compliance and said that human error did occur.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the areas of hospice services, seizure disorder, and discharge for 3 of 6 residents whose MDS assessments were reviewed (Resident #15, # 205 and #83). Findings Include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included end stage renal failure. Review of Resident #15's care plan initiated on 11/09/23 for Hospice care with interventions that included Hospice services provided, facility to work with Hospice team and continue to make Resident #15 comfortable. The admission MDS assessment dated [DATE] indicated Resident #15 was moderately cognitively impaired. He was not coded for receiving Hospice services both while a resident and while not a resident. An interview with the MDS Coordinator on 01/04/24 at 2:04 PM revealed Resident #15 was admitted to the facility on Hospice care and continued to receive Hospice care while at the facility and his MDS currently did not reflect him receiving Hospice care but should. She stated Resident #15's MDS not reflecting him receiving Hospice care was an oversight based on human error and a correction would need to be made. A telephone interview with the Hospice Nurse on 01/05/24 at 11:34 AM revealed that Resident #15 had been admitted to the facility under Hospice care and had continued to receive Hospice care while a resident at the facility. The Director of Nursing (DON) and Administrator were interviewed on 01/05/24 at 5:49 PM who revealed Resident #15 was receiving Hospice services prior to coming to the facility and currently while at the facility. They stated their process would be for the MDS to reflect current orders and to be accurate and they felt it was just an oversight based on human error on the part of the MDS Coordinator. 40476 2. Resident #205 was admitted to the facility on [DATE] with diagnoses that included seizure disorder. A hospital discharge summary dated 12/20/23 revealed Resident #205 had a history of epileptic seizures. The admission MDS assessment dated [DATE] indicated Resident #205 was cognitively intact. Resident #205 was not coded for a seizure disorder during the assessment. Review of Resident #205's Medication Administration Record (MAR) dated December 2023 revealed the following order, Keppra 1,000 milligrams twice a day for non-epileptic seizures. An interview with the MDS Coordinator on 01/04/24 at 2:04 PM revealed Resident #205 was admitted into the facility on [DATE] with a diagnosis listed of seizure disorder. She stated she normally would look at the hospital discharge summary to obtain a diagnosis list, however, did not see it at the time she completed the MDS assessment. The MDS Coordinator stated she had missed the diagnosis by mistake. 3. Resident #83 was admitted to the facility on [DATE] with diagnoses that included hypertension and cardiomyopathy. The discharge MDS assessment dated [DATE] indicated Resident #83 was cognitively intact. Resident #83 was coded as discharged to the hospital. A discharge summary dated 10/12/23 revealed Resident #83 was discharged home with home health services. An interview with the MDS Coordinator on 01/04/24 at 2:04 PM revealed Resident #83 had a planned discharge home with home health services. She stated she had coded the discharge MDS in error. The interview revealed the MDS should have been coded that Resident #83 was discharged to the community and not the hospital.

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 [MEDICATION(S)] 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICATION(S)] 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 [MEDICATION(S)] 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.

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 [MEDICATION(S)] 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICATION(S)] 500 MG (milligrams) 1 tablet every 8 hours for 10 days or [MEDICATION(S)] 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: [MEDICATION(S)] 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of outside dental note dated 11/21/21 revealed Resident #68 required oral surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] 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 [MEDICATION(S)]; 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 [MEDICATION(S)] 300 MG 1 tablet by mouth every 8 hours for dental abscess. Resident #68 was made aware. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Quarterly MDS dated [DATE] revealed Resident #68 was coded as having no issues or concerns with oral care. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing progress note dated 06/09/22 revealed new orders for oral surgery consult for teeth extractions, [MEDICATION(S)] 300 MG 1 tablet by mouth every 8 hours for 7 days for dental abscess. Resident # 68 was made aware. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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, 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 [MEDICATION(S)] 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICATION(S)] 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICATION(S)] 500 MG (milligrams) 1 tablet every 8 hours for 10 days or [MEDICATION(S)] 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: [MEDICATION(S)] 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of outside dental note dated 11/21/21 revealed Resident #68 required oral surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICATION(S)]; 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 [MEDICATION(S)] 300 MG 1 tablet by mouth every 8 hours for dental abscess. Resident #68 was made aware. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] Review of nursing progress note dated 06/09/22 revealed new orders for oral surgery consult for teeth extractions, [MEDICATION(S)] 300 MG 1 tablet by mouth every 8 hours for 7 days for dental abscess. Resident #68 was made aware. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #68 was receiving antibiotics for a urinary tract infection which was completed on 08/03/22. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICATION(S)] 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/ 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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.

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 [CONDITION(S)] 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 on to 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 Kardex 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 03/10/22 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 03/31/22 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 [CONDITION(S)] 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 Kardex 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.

Based on observations and staff interviews, the facility failed to refrigerate an unopened insulin vial, date opened insulin vials and discard expired medications available for use in 3 of 5 medication carts (Medication Cart 2, Medication Cart 4, and Medication Cart 1). The findings included: a. An observation of Medication Cart 2 with Nurse #3 on 8/11/22 at 10:28 AM revealed an undated and unopened vial of Insulin detemir available for use in the top drawer and labeled with Resident #36's name. The vial had a pharmacy sticker which indicated it was sent to the facility on [DATE]. Insulin detemir is a long-acting insulin used to treat diabetes. An interview with Nurse #3 on 8/11/22 at 10:35 AM revealed she didn't know who placed the unopened vial of Insulin detemir in the medication cart but whoever did it probably did not realize that Resident #36 had another vial in the medication cart that was available. Nurse #3 stated the vial should have been kept in the refrigerator until ready to be opened and used because it was only good for 42 days after being taken out of refrigeration. Nurse #3 further stated she didn't notice the insulin because she didn't have to give it and it was scheduled to be given only at bedtime. b. An observation of Medication Cart 4 with Medication Aide (MA) #1on 8/11/22 at 10:38 AM revealed an opened and undated vial of Insulin detemir labeled with Resident #4's name and an opened and undated vial of [MEDICATION(S)] labeled with Resident #14's name. [MEDICATION(S)] is a short-acting insulin product used to help control blood sugar. An interview with MA #1 on 8/11/22 at 10:38 AM revealed Nurse #4 was assigned to give all the insulins from Medication Cart 4, and she did not have anything to do with the insulins on the medication cart. MA #1 checked both insulin vials and verified that both did not have an open date. An interview with Nurse #4 on 8/11/22 at 11:09 AM revealed he hadn't gotten around to giving the insulins in Medication Cart 4 and had not seen the insulin vials that were undated. Nurse #4 stated both insulins should have been dated when they were opened because Insulin detemir was only good for 42 days after it was opened while [MEDICATION(S)] was good for 28 days after being opened. c. An observation of Medication Cart 1 with Nurse #4 on 8/11/22 at 11:01 AM revealed a bottle of Magic Mouthwash with an expiration date of 7/17/22 and approximately 150 ml (milliliters) left in the bottle available for use. There was another bottle of Magic Mouthwash with an expiration date of 8/3/22 and approximately 75 ml left for use. Both bottles of Magic Mouthwash were labeled as belonging to Resident #37. Magic Mouthwash is a mouth-rinse mixture used to relieve pain from mouth and throat sores. An interview with Nurse #4 on 8/11/22 at 11:06 AM revealed he was not sure why the expired bottles of Magic Mouthwash had not been discarded off the medication cart and that he had meant to take them out of the medication cart but had just not gotten around to doing it. An interview with the Director of Nursing (DON) on 8/11/22 at 5:08 PM revealed the insulins should be stored in the refrigerator until ready to be used and should be dated when opened. The DON stated the expired bottles of Magic Mouthwash should have been taken off the medication cart when they expired. The DON further stated that all the nurses who were on the medication carts were responsible for checking each medication cart. The medication aides were also educated on checking all the medications including the insulins so they should make sure all insulins were dated and not expired.

Based on observations, record reviews, resident, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place. This was for three (3) deficiencies in the areas of Accuracy of Assessments and Care Plan Timing and Revision which were originally cited on the 08/12/21 recertification investigation survey and Infection Control which was originally cited on the 08/12/21 and 09/22/20 recertification investigation surveys. These areas were cited again on the current recertification survey with an exit date of 09/01/22. The continued failure of the facility during the three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This citation is cross referred to: 1. F641: Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of hospice (Resident #14), level of assistance required for eating (Resident #37, Resident #80, Resident #33, Resident #9, Resident #51 and Resident #23), oral/dental status (Resident #68) and cognition (Resident #34 and Resident #59) for 10 of 18 sampled residents whose MDS were reviewed. During the recertification survey completed on 08/12/21 the facility was cited for not accurately coding the MDS assessment reviewed for the areas of Hospice to reflect prognosis for 1 of 1 resident reviewed for hospice and the number of falls for 1 of 3 residents reviewed for falls. 2. F657: Based on record review, observation, and resident and staff interviews, the facility failed to update care plans to reflect dental issues for 1 of 1 resident reviewed for dental care (Resident #68). During the recertification survey completed on 08/12/21 the facility failed to revise a resident's care plan to reflect the level of assistance required by the staff when repositioning in bed for 1 of 3 residents reviewed for falls. 3. F880: Based on record reviews, observation and staff interviews, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) recommended practices when 1 of 1 staff member (Nurse Aide #5) failed to change gloves and perform hand hygiene during incontinence care on 1 of 3 residents (Resident #37) reviewed for infection control. During the recertification survey completed on 08/12/21 the facility was cited for not placing an unvaccinated resident on enhanced droplet contact precautions according to CDC guidance, staff not using all personal protective equipment (PPE), staff not changing PPE between rooms and nurses not cleaning glucometers after use according to the manufacture's recommendations. During the recertification survey completed on 09/22/20 the facility was cited for staff working on the isolation unit for staff not performing hand hygiene before entering and after exiting a resident room, staff not disposing of used gloves properly, staff not wearing face mask on the isolation unit, staff not wearing PPE correctly on the isolation unit and staff failing to follow CDC guidance and their own policy and procedure for cleaning and disinfecting resident care equipment after use on the isolation unit. An interview with the Director of Nursing (DON) who was also the Infection Preventionist on 8/11/22 at 2:43 PM revealed they were constantly educating staff on infection control procedures and needed to do more training on infection control during procedures. She stated they needed to do more audits of infection control guidelines during various procedures and more education on principles of infection control across all staff members and include all aspects in the orientation process for new hires. A phone interview on 08/11/22 at 6:04 PM with the Administrator revealed their implemented procedures had not held strong and they had had an influx of admissions and it was difficult for one person to keep up with the workload. He explained they were in the process of recruiting another nurse with experience to help with the MDS workload. He further explained he would be taking a more proactive role in the clinical meeting as well as the stand-up meeting held daily. The Administrator stated he would continue meeting with the administrative team to discuss concerns and look at ways to resolve them in the best interest of the residents. He further indicated they would seek assistance from corporate in recruiting for the MDS position to help alleviate the workload on one person and utilizing their expertise in educating staff on infection control principles.

Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of hospice (Resident #14), level of assistance required for eating (Resident #37, Resident #80, Resident #33, Resident #9, Resident #51 and Resident #23), oral/dental status (Resident #68) and cognition (Resident #34 and Resident #59) for 10 of 18 sampled residents whose MDS were reviewed. The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospice Certification signed by the Hospice Physician on 5/23/22 indicated Resident #14 had a terminal illness with a life expectancy of six months or less for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated a No to a question which asked if Resident #14 had a condition or chronic disease that may result in a life expectancy of less than 6 months. In addition, hospice care was not coded on this MDS. An interview with the MDS Coordinator on 8/11/22 at 3:59 PM revealed she was responsible for coding the prognosis on Resident #14's admission MDS assessment dated [DATE]. The MDS Coordinator stated she did not code that Resident #14 had a life expectancy of less than 6 months because the Hospice Certification was not available in the medical record when she completed the admission MDS assessment, but she should have obtained it from hospice. She stated Resident #14 was admitted to hospice on 5/20/22 and she should have coded hospice care on the admission MDS assessment. An interview with the Director of Nursing (DON) on 8/11/22 at 5:08 PM revealed the MDS Coordinator should have coded hospice care and Resident #14's prognosis according to what the hospice physician had indicated in her Hospice Certification. The DON stated if the hospice certification was not located in the medical record while the MDS Coordinator was completing Resident #14's assessment then she should have called and obtained the certification from hospice. 2. Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #37 required extensive assistance by two+ persons physical assist with eating. An interview with the MDS Coordinator on 8/11/22 at 3:59 PM revealed Resident #37 was able to feed herself sometimes and at other times, her family member assisted her. The MDS Coordinator stated Resident #37 did not require the assistance of two people with eating and that she had coded the MDS in error. She explained that she based the coding on the documentation made by the nurse aides on what level of assistance required by Resident #37 and she did not catch the error. An interview with the Director of Nursing on 8/11/22 at 5:08 PM revealed Resident #37 did not require the assistance of two people with eating and that the MDS Coordinator should have verified the documentation by the nurse aides and made alterations as necessary in order to code the MDS correctly. 3. Resident #80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #80 required supervision from two+ persons physical assist with eating. An interview with the MDS Coordinator on 8/11/22 at 3:59 PM revealed Resident #80 was able to feed herself and did not require the assistance of two people with eating. The MDS Coordinator stated that she had coded the MDS in error. She explained that she based the coding on the documentation made by the nurse aides on what level of assistance required by Resident #80 and she did not catch the error. An interview with the Director of Nursing on 8/11/22 at 5:08 PM revealed Resident #80 did not require the assistance of two people with eating and that the MDS Coordinator should have verified the documentation by the nurse aides and made alterations as necessary in order to code the MDS correctly. 4. Resident #33 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 required extensive physical assistance with eating from two or more persons. An interview with the MDS Coordinator on 08/11/22 at 3:59 PM revealed Resident #33 was assisted with meals by one person and did not require the assistance of two people with eating and this had been an error. She explained she based the information included on the assessment from the documentation made by the nurse aides on what level of assistance was required by Resident #33 and she had not caught the error. An interview with the Director of Nursing on 08/11/22 at 5:08 PM revealed Resident #33 did not require the assistance of two people with eating and said the MDS Coordinator should have verified the documentation by the nurse aides and made alterations as necessary to code the MDS accurately. 5. Resident #9 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 required supervision from two or more persons physical assist with eating. An interview with the MDS Coordinator on 08/11/22 at 3:59 PM revealed Resident #9 was able to feed herself and did not require the assistance of two people with eating. The MDS Coordinator stated she had coded the MDS in error. She explained she based the coding on the documentation made by the nurse aides on what level of assistance was required by Resident #9 and she had not caught the error. An interview with the Director of Nursing on 08/11/22 at 5:08 PM revealed Resident #9 did not require the assistance of two people with eating and said the MDS Coordinator should have verified the documentation by the nurse aides and made alterations as necessary to code the MDS accurately. 6. Resident #51 was admitted to the facility on [DATE]. Review of quarterly minimum data set (MDS) assessment dated [DATE] indicated Resident #51 required extensive assistance of two or more persons physical assist with eating. Review of revised care plan dated 7/26/22 revealed a goal for Resident #51: eats meals independently with use of adaptive equipment device. Interventions include provide assistance as needed during eating and drinking. An interview with Resident #51 on 08/10/22 at 02:10 PM revealed Resident #51 received help from staff with setting up her tray and opening her drink, but she can eat by herself with no issues. An interview with the MDS Coordinator on 8/11/22 at 4:18 PM revealed Resident #51 did not require two-person assistance for eating and she had noted the information in error. She stated she reviewed documentation from nursing assistants for the level of mealtime assistance required for Resident #51 but did not observe Resident #51 for mealtime assistance herself. An interview with Director of Nursing (DON) on 8/11/22 at 5:12 PM revealed Resident #51 did not require two-person physical assistance with eating and the MDS should reflect correct level of mealtime assistance required for the resident. 7. Resident #23 was readmitted to the facility on [DATE]. Review of quarterly minimum data set (MDS) assessment dated [DATE] indicated Resident #23 required extensive assistance of two or more persons physical assist with eating. An interview with Nurse Assistant (NA) # dated 08/09/22 at 12:10 PM revealed Resident #23 required some assistance with her meals. She stated one staff would sit at the table with Resident #23 to supervise and encourage her to eat. She revealed Resident #23 was able to eat on her own, but staff would assist with feeding her if needed. Observation on 08/09/22 at 12:28 PM of Resident #23 sitting at dining room table with one staff member sitting next to her. Resident #23 was able to drink and take small bites of food on her own with use of adaptive mealtime equipment. An interview with the MDS Coordinator on 8/11/22 at 4:18 PM revealed Resident #23 did not require two-person assistance for eating and she had noted the information in error. She stated she reviewed documentation from nursing assistants for level of mealtime assistance required for Resident #23 but did not observe Resident #23 for mealtime assistance herself. An interview with Director of Nursing (DON) on 8/11/22 at 5:12 PM revealed Resident #23 did not require two-person physical assistance with eating and the MDS should reflect correct level of mealtime assistance required for the resident. 8. Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE]. a. Review of a quarterly minimum data set (MDS) assessment dated [DATE] indicated no dental issues or concerns had been identified for Resident #68. b. Review of an admission MDS assessment dated [DATE] indicated no dental issues or concerns had been identified for Resident #68. c. Review of a quarterly MDS assessment dated [DATE] indicated no dental issues or concerns had been identified for Resident #68 Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a dietary order dated 7/08/22 revealed a new order for a regular diet with chopped meat due to dental issues. An interview with Resident #68 was conducted on 8/08/22 at 11:06 AM. She revealed she had been having dental issues and infections since last year after receiving [CONDITION(S)] treatments. An observation of Resident #68 was made during the interview on 8/08/22 at 11:06 AM. Her right cheek was observed as slightly swollen. She opened her mouth to reveal gums which were red, inflamed, and swollen with only the tips of some teeth visible. Other teeth were broken and chipped. An interview was conducted on 8/11/22 at 2:08 PM with Resident #68. She stated she received an [MEDICATION(S)] tablet (pain medication) between breakfast and lunch, the antibiotic for her dental infection at lunch along with two ibuprofen tablets (pain medication), so her current pain level was moderate to severe and usually remained at this level with medications. She stated the pain could be severe when the medication wore off, like when she wakes up in the morning. She revealed the abscesses inside the upper right side of her mouth at the base of her nose caused pain up through her nose and into her eye and the abscess toward back of the right side of her 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 had dental issues on-going and believed at least three different times she had abscesses since last year. She stated nursing staff, and the Social Worker told here they were searching for a dentist who would accept her insurance to take out her teeth since last year. An interview with the MDS Coordinator on 8/11/22 at 4:27 PM revealed she should have included information about Resident #68 ' s broken teeth and dental pain on the admission and two quarterly MDS assessments and this had been an error. She stated she received information on dental care from nursing staff but did not follow up and assess Resident #68 herself. An interview with the Director of Nursing (DON) on 8/11/22 at 5:14 PM revealed she was aware of Resident #68 having missing and broken teeth and past and present dental infections. She stated the MDS should reflect correct dental information for Resident #68. 9. Resident #34 was admitted to the facility on [DATE]. Resident #34's admission Minimum Data Set (MDS) dated [DATE] revealed she had clear speech and sometimes understood others. The Brief Interview for Mental Status (BIMS, a structured interview assessing cognition) assessment noted she should be interviewed but it had been left blank and the Staff Assessment for Mental Status had been completed instead. An interview conducted with the Social Worker (SW) on 8/11/22 at 5:00 PM revealed he had completed the BIMS portion of Resident #34's admission MDS assessment. The SW explained Resident #34 answered questions to the best of her ability, but her answers did not make any sense. The SW stated he felt like the interview was incomplete and interviewed staff instead. The SW stated the resident interview for the BIMS assessment should have been completed and not left blank. An interview conducted with the Director of Nursing (DON) and the Regional Nurse on 8/11/22 at 5:15 PM revealed Resident #34's BIMS assessment should have been completed and not left blank. 10. Resident #59 was admitted to the facility on [DATE]. Resident #59's admission Minimum Data Set (MDS) dated [DATE] revealed they had unclear clear speech and usually understood others. The Brief Interview for Mental Status (BIMS, a structured interview assessing cognition) assessment noted they should be interviewed but it had been left blank and the Staff Assessment for Mental Status had been completed instead. An interview conducted with the Social Worker (SW) on 8/11/22 at 5:00 PM revealed he had completed the BIMS portion of Resident #59's admission MDS assessment. The SW explained Resident #59 answered questions, but he could not understand their speech. The SW stated he interviewed staff instead. The SW stated the resident interview for the BIMS assessment should have been completed and not left blank. An interview conducted with the Director of Nursing (DON) and the Regional Nurse on 8/11/22 at 5:15 PM revealed Resident #59's BIMS assessment should have been completed and not left blank.

Based on record review, observation, and resident and staff interviews, the facility failed to update care plans to reflect dental issues for 1 of 1 resident reviewed for dental care (Resident #68). The findings include: Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly minimum data set (MDS) assessment dated [DATE], an admission MDS assessment dated [DATE], and a quarterly MDS assessment dated [DATE], all indicated no dental issues or concerns had been identified for Resident #68. Review of revised care plans dated 05/27/22, 06/30/22 and 07/25/22 revealed no goals or interventions for dental care. Review of an in-house dental note dated 04/28/22 revealed Resident #68 was seen by the facility dentist for a routine dental visit. The note indicated the in-house dentist could not perform extractions due to all teeth being root tips, covered with tissue, and requiring surgery. Review of a nursing progress note dated 05/10/22 revealed a new order for Resident #68 to receive [MEDICATION(S)] (an antibiotic) 300 milligrams (mg) 1 tablet by mouth every 8 hours for a dental abscess. Review of a nursing progress note dated 06/09/22 revealed new orders for an oral surgery consult for teeth extractions, [MEDICATION(S)] 300 mg 1 tablet by mouth every 8 hours for 7 days for a dental abscess. Review of an in-house dental note dated 06/28/22 revealed Resident #68 was seen for a routine scheduled dental visit. The 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 (plaque) buildup. The note also indicated Resident #68 had missing natural teeth and root tips. An interview with Resident #68 was conducted on 08/08/22 at 11:06 AM. She revealed she had been having dental issues and infections since last year after receiving [CONDITION(S)] treatments. An observation of Resident #68 was made during the interview on 08/08/22 at 11:06 AM. Her right cheek was observed as slightly swollen. She opened her mouth to reveal gums which were red, inflamed, and swollen with only the tips of some teeth visible. Other teeth were broken and chipped. An interview with the MDS Coordinator on 08/11/22 at 04:27 PM revealed Resident #68 should have had a care plan for dental care to include dental infections and treatment, oral surgery recommendations, and missing or broken natural teeth. She revealed Resident #68 not having a care plan for dental care was an error on her part. She stated she received information on dental care from nursing staff to complete the care plans and did not follow up or assess Resident #68 herself. An interview with the Director of Nursing (DON) on 08/11/22 at 05:14 PM revealed she was aware of Resident #68 having missing and broken teeth and past and present dental infections over the past year. She stated Resident #68 ' s care plan should reflect goals for dental care.

Based on record review, observations, resident and staff interviews, the facility failed to provide nail care to 1 of 6 residents (Resident #80) reviewed for assistance with activities of daily living. The findings included: Resident #80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #80's care plan dated 7/26/22 indicated Resident #80 had an ADL (activities of daily living) self-care performance deficit related to decreased mobility. She prefers nails long and polished and refuses to let staff cut nails short. Interventions included to encourage resident to allow staff to assist with nail care and monitor fingernails for cleanliness and need to be groomed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #80 was severely cognitively impaired, had no rejection of care behaviors and required extensive physical assistance with personal hygiene. An observation and interview of Resident #80 was made on 8/8/22 at 11:08 AM. Resident #80's fingernails were observed being at least a half inch longer than the tips of her fingers and there were jagged and cracked edges. Resident #80 stated that she wanted her fingernails trimmed and that the staff were supposed to trim them today. A second observation of Resident #80 on 8/9/22 at 10:35 AM revealed her sitting in her wheelchair in her room beside her bed. Her fingernails were still a half inch longer than the tips of her fingers. Resident #80 stated she had asked the staff to clip her fingernails, but they didn't do it. A third observation of Resident #80 on 8/10/22 at 8:55 AM revealed her eating breakfast with her left hand while using a fork. Her fingernails continued to be a half inch longer than the tips of her fingers. A fourth observation of Resident #80 on 8/11/22 at 11:11 AM revealed her lying in bed. Her fingernails continued to be long and had jagged and cracked edges. Resident #80 stated she received a shower the day before and she wanted them cut then, but staff never did, and no one had offered to trim her fingernails. An interview with Nurse Aide (NA) #4 on 8/11/22 at 10:18 AM revealed she gave Resident #80 a shower on 8/10/22 and she noticed that her fingernails were long and needed to be trimmed. NA #4 stated Resident #80 would not let the staff cut her fingernails in the past, but she didn't ask her on 8/10/22 if she could cut her fingernails. An interview with Medication Aide (MA) #1 on 8/11/22 at 11:13 AM revealed she had noticed Resident #80's long nails when she gave her medications this morning but Resident #80 wouldn't let the staff cut her fingernails and she had refused before to have them trimmed. MA #1 stated she didn't ask Resident #80 if she could cut her fingernails this morning. A follow-up interview with MA #1 on 8/11/22 at 2:24 PM revealed Resident #80 let her trim her fingernails. MA #1 stated she noticed the jagged and cracked edges and that Resident #80's fingernails were very thin, and they broke once she started cutting them. An interview with the Director of Nursing on 8/11/22 at 5:08 PM revealed staff should still offer to trim Resident #80's fingernails even though she had refused nail care in the past.

Based on record reviews, observation and staff interviews, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) recommended practices when 1 of 1 staff member (Nurse Aide #5) failed to change gloves and perform hand hygiene during incontinence care on 1 of 3 residents (Resident #37) reviewed for infection control. The findings included: The Centers for Disease Control and Prevention (CDC) guidance entitled, Hand Hygiene in Healthcare Settings, last reviewed on 1/8/21 indicated the following information: Change gloves and perform hand hygiene during patient care, if moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. The facility's infection control policy entitled, Handwashing/Hand Hygiene, revised in August 2015 indicated the following statements: Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with blood or bodily fluids. An observation of incontinence care by Nurse Aide (NA) #5 on Resident #37 was made on 8/9/22 at 10:53 AM. NA #5 was observed using hand sanitizer to both hands prior to putting gloves on before starting the procedure. NA #5 proceeded to unfasten Resident #37's brief and turned her towards her right side. While Resident #37 held on to the side rail, NA #5 started to clean stool off Resident #37's buttocks with a disposable wipe using her left hand while the right hand supported Resident #37's back. Without removing her gloves, NA #5 reached into Resident #37's drawer with her right hand for a jar of moisture barrier cream, opened the lid with her left hand, and applied the cream to Resident #37's buttocks with her left hand. She placed a new brief underneath Resident #37's bottom and then rolled her onto her back and proceeded to wipe her front perineal area with a disposable wipe using her left hand. She fastened the new brief, replaced Resident #37's covers and re-adjusted her bed. NA #5 placed the trash in a plastic bag and removed gloves from both hands. She discarded the trash and then used hand sanitizer to both hands. An interview with NA #5 on 8/9/22 at 2:15 PM revealed she normally did perineal care from front to back but if the resident had a bowel movement, she would wipe the bowel movement off the buttocks first. NA #5 stated she probably should have changed her gloves prior to reaching for the barrier cream in the drawer and before wiping Resident #37's front perineal area. NA #5 stated this was what she had been educated to do when doing incontinence care and she just forgot to change her gloves and do hand hygiene in between touching contaminated and clean surfaces. An interview with the Director of Nursing (DON) who was also the Infection Preventionist on 8/11/22 at 2:43 PM revealed NA #5 should have started doing incontinence care from the front perineal area and then to the back. She should have never reached inside the drawer with contaminated gloves, and she should have taken off her gloves and washed her hands when touching between dirty and clean surfaces. The DON stated she needed to do more education with incontinence care and infection control.

Based on observations, record review and staff interviews, the facility failed to post the correct daily nurse staffing information for 1 out of 4 days of the recertification survey and failed to post the correct census number for 4 out of 4 days of the recertification (August 8 through 11, 2022). The findings included: Observations made during the recertification survey on 8/09/2022 at 8:10 AM and 4:45 PM revealed the posted daily nurse staffing information was dated 8/08/2022 for the previous day. Observations made during the recertification survey on 8/08/2022 at 10:55 AM, 8/09/2022 at 8:10 AM and 4:45 AM, 8/10/2022 at 8:50 AM, and 08/11/2022 at 2:00 PM revealed incorrect information for the census number for the facility. On 8/11/2022 at 3:48 PM an interview was conducted with the Staffing Coordinator (SC) who was responsible for the scheduling of the nursing department. The SC stated she was responsible for filling out and posting the daily nurse staffing hours with the census. She revealed she completed the daily nurse staffing information a week ahead of time and would make changes as needed to the hours or the census number. The SC stated she posted the daily nurse staffing on the bulletin board outside of the nursing station on the 100 and 200 halls in the mornings and when she was not working one of the nurses on duty was responsible. She revealed the incorrect census number on the daily nurse staffing information was an error and should have reflected the correct daily census number for the facility. The SC stated the posting on 8/09/2022 of the previous day daily nurse staffing was an error and the correct date and information should be posted each day. Interview was conducted with Director of Nursing (DON) on 8/11/2022 at 5:33 PM revealed the SC was responsible for printing off the daily nurse staffing information and posting it in the facility. She stated the SC was completing the information a week ahead of time and would make changes to reflect the daily census in the facility and staffing changes. She revealed she was not aware the daily nurse staffing information posted on 8/09/2022 was the previous day nor was she aware the census was not correct. She stated the daily nurse staffing information should reflect the correct date and number of hours and the correct census number.

Based on observations, record review, resident interviews and staff and Nurse Practitioner (NP) interviews it was determined that the facility failed to protect a resident's right to be free of sexual abuse for 2 of 3 (Residents #2 and #3) residents reviewed for abuse. Resident #2, a cognitively impaired resident, was observed having oral sex with Resident #1. Resident #3, a cognitively impaired resident, was observed to have her breast squeezed by Resident #1. Residents #2 and #3 were assessed at the facility and found to have no physical injuries. Immediate Jeopardy began on 10/28/18 when Resident #1 rolled Resident #2 in her wheel chair to her room and the residents were observed by staff having oral sex. Immediate Jeopardy began on 11/28/18 for Resident #3 when Resident #1 rolled her in her wheel chair to his room and he was observed by staff to squeeze her breast. Immediate Jeopardy was removed on 11/30/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he scored a 13 on the brief interview of mental status (BIMS) indicating that he had no cognition impairments. No inappropriate behaviors were noted during the assessment period. He required set up help only with walking in corridor. The resident was also as assessed as having no limitations with range of motion. Review of Resident #1's care plan revealed the following Problem which was initiated on 10/14/16 and was reviewed by staff on 9/06/18: Mr. (Resident #1's last name) was previously reported by staff and then his own self admission of inappropriate touching of female residents. He has signed a behavioral contract that he will not engage in such behavior or risk discharge. The goal was for Resident #1 will not exhibit socially inappropriate/disruptive behavior. Care plan approaches included; Assess whether the behavior endangers the resident and/or others. Intervene if necessary, If Mr. (Resident #1) begins to become socially inappropriate redirect him immediately and inform him that such behavior will not be tolerated at CCC (abbreviation for facility name). and Observe and report socially inappropriate/disruptive behaviors when around others. Further review of Resident #1's care plan revealed the following Problem which was initiated on 10/24/16 and was most recently reviewed by staff on 9/06/18: Mr. (Resident #1's last name) took a female resident who had significant physical limitation outside of facility when he had been told that until this issues was decided by ADMINISTRATION he was not to take any female outside of facility. The goal was for Resident #1 not to harm others secondary to inappropriate behavior. A care plan approach included; Staff will do an adjustment to his previous behavioral contract and all parties will sign. Review of Resident #1's behavioral contact that was signed by Resident #1, his Power of Attorney and facility staff members on 10/26/16 specified the following; I (Resident #1's name) understand that my previous behavioral agreement signed 4/15/16 remains in effect as long as I am a resident here. That agreement was that I understood that if I touched any female in an inappropriate manner that I would be discharged from Carolina Care Center. Today I understand that I am signing an addendum to that agreement. I agree that I will not take any female resident outside of facility. I understand that I am free to socialize with other residents in public areas inside the facility with their consent. I understand that I can attend supervised out of facility events with other residents. I understand that inappropriate touching of females and taking females outside of facility without administration consent could result in discharge from Carolina Care Center. a. Review of Resident #1's progress notes revealed a nursing note dated 10/28/18 at 5:33 PM, written by Nurse #1 which stated, CNA (certified nursing assistant) reported resident feeling on another female residents breasts (Resident #2) and then whispered in her ear and took her to her room. Nurse went to room and female resident was sitting up in wheelchair in front of bathroom with head moving back and forth and resident was standing in front of her with his zipper open, penis out and residents penis was in her mouth. When I asked them what they were doing she states, 'I'm just doing what all other adults do.' He didn't say anything but 'yeah.' Asked resident to leave room at this time. Educated resident he was not allowed to go back down to her room and that he had violated his behavior contract. Resident walked out of room at this time and went to his room. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Resident #2 [DIAGNOSES REDACTED]. Review of Resident #2's quarterly MDS dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 8 (which indicated moderately impaired cognition), required supervision with set up help only with locomotion on the unit, required extensive assistance with one person physical assistance with transfers and used a wheelchair as a mobility device. Review of Resident #2's care plan revealed the following Problem was initiated on 10/16/18: Decision making: (Resident #2's first name) has difficulty making her own safe/appropriate decisions, long and short term memory deficit is noted. The goal specified, (Resident #2's first name) will suffer no loss of dignity due to memory loss. Approaches included; Assist to reminisce and redirect as much as possible to decrease further decline in cognition. Review of Resident #2's progress notes revealed a nursing note, written by Nurse #1, on 10/28/18 at 5:18 PM which specified the following; CNA (certified nursing assistant) reported another resident feeling on residents breasts and then whispered in her ear and took her to her room. Nurse went to room and resident was sitting up in wheelchair in front of bathroom with head moving back and forth and the other resident standing in front of her with his zipper open, penis out and residents penis was in her mouth. When I asked them what they were doing she states, 'I'm just doing what all other adults do.' Asked other resident to leave room at that time. She states, 'I wanted to do it and then grabbed his arm and was telling him to come back to her bed later.' Explained to resident he was not allowed to go back down to her room. Removed other resident at this time. Sitting up in her room NAD (no apparent distress). The note also specified Resident #2's family was made aware. Review of the facility's Investigation Report signed by the Director of Nurses (DON) revealed Resident #1 was alert and oriented in all spheres with a BIMS of 13 with no short term or long term memory problems. Resident #2 was assessed as having a BIMS of 8 with short term and long term memory problems. The investigation specified that Resident #1 was interviewed by the police on 10/28/18 and he admitted to being in female resident's room and having inappropriate contact with resident. The investigation report specified Resident #2 was unable to remember the incident when interviewed by the police. Observations and an interview with Resident #1 on 11/28/18 at 3:55 PM revealed he was able to ambulate independently and was able to verbally answer questions. During the interview with Resident #1 he stated he remembered he had inappropriate contact with a female resident a month or so ago, but denied inappropriately touching of any female residents since this incident which occurred a month ago. Observations of Resident #2 on 11/28/18 at 4:15 PM revealed she was seated in her wheel chair and was pleasantly confused. Resident #2 did not recall what day it was or what she ate for lunch that day. Resident #2 also did not recall any incidents of inappropriate behaviors being exhibited by male residents or staff members towards her. Interview with the facility's Social Worker (SW) on 11/30/18 at 12:40 PM revealed Resident #1 was alert and oriented and could consent to engage in sexual activity, but Resident #2 was cognitively impaired and was unable to consent to sexual activity. Review of an Investigation-employee statement written by Nurse Aide (NA) #1 dated and signed 10/28/18 stated NA #1 saw Resident #1 bending over Resident #2 and touching Resident #2's breasts in the hallway and started rolling to her room in her wheelchair and immediately reported it to her supervisor. During interview on 11/30/18 at 12:05 PM with NA #1 she stated on 10/28/18 she observed Resident #1 rolling Resident #2 in her wheelchair in the hallway. She specified that she was seeing the residents from behind, so she could not see if Resident #1 was touching Resident #2's breasts, but his hand was draped over her shoulder. She stated she did not verbally tell Resident #1 to stop rolling Resident #2 in her wheel chair because they were too far ahead of her, but she followed them and found them together in Resident #2's room. NA #1 stated she could hear the residents from the room's open doorway and it sounded like they were having oral sex. NA #1 stated she peeked in the doorway and she could not directly see what they were doing because they were around the corner in the room, but from what she could hear it sounded like they were engaged in oral sex. NA #1 stated she was so shocked from what she heard and could see that she did not say anything to the residents or attempt to stop them, but immediately went to report it to the Unit Manager (Nurse #1). NA #1 stated the Unit Manager (Nurse #1) quickly responded to her request to check on Resident #1 and Resident #2. NA #1 stated she was now aware that she should have immediately interrupted and stopped Resident #1 and Resident #2, separated the residents and then reported their activity to the Unit Manager. During an interview on 11/30/18 at 3:32 PM with Nurse #1 (Unit Manager) she stated that during the evening of 10/28/18 NA #1 asked her to go to Resident #2's room because she saw Resident #1 touching Resident #2's breasts in the hallway and they were now in Resident #2's room. Nurse #1 stated she went to the room, knocked on the room's opened door and when she entered Resident #2's room she observed Resident #1's and Resident #2 engaged in oral sex. Nurse #1 stated she observed Resident #1's penis in Resident #2's mouth. Nurse #1 stated she asked the residents what they were doing and they stopped. Nurse #1 stated she told Resident #1 to go to his room and she immediately reported this to the Director of Nursing (DON) and administrator. Interview with the facility's DON on 11/28/18 at 4:35 PM revealed during the evening of 10/28/18 Nurse #1 called her and informed her that Resident #1 and Resident #2 were observed having oral sex in Resident #2's room. The DON stated Resident #1 had previously exhibited inappropriate touching of a female resident and he was aware of his actions. So, the facility placed Resident #1 on 1 on 1 direct staff observation for 24 hours to monitor his behaviors in an effort to protect Resident #2 and other residents. The DON specified the facility started an abuse investigation and the local police department was notified about the incident. Interview with the DON on 11/29/18 at 4:30 PM revealed staff are trained if they see abuse in any form they are to keep the resident safe, ask the abuser to leave and not leave the resident alone. The DON stated NA #1 should have immediately stopped Resident #1 and Resident #2 on 10/28/18 when the residents were alone in a room together and NA #1 thought they were engaged in sexual activity. Review of the police incident/investigation report revealed the police responded in reference to a report of a sexual assault at the facility on 10/28/18 at 6:21 PM. The report specified; Suspect engaged in a sex act with victim and listed Resident #2 as the victim. During interview with the Administrator on 11/29/18 at 8:40 AM she stated when she was informed of Resident #1 and Resident #2's being observed engaged in oral sex in Resident #2's room on 10/28/18 she immediately came to the facility. The administrator stated the police were notified of the incident during the evening of 10/28/18 and an officer came to the facility to investigate. The administrator stated Resident #1's family was notified and they took him home for the night. Upon his return to the facility on [DATE] the resident was placed on 1 on 1 direct staff to resident monitoring for the first 24 hours and then was placed on 15 minute staff checks to monitor the resident's behaviors. During another interview with the administrator on 11/29/18 at 4:05 PM, the administrator stated, on 10/28/18 NA #1 should have stopped Resident #1 and Resident #2 when she heard the residents together in Resident #2's room and she thought they were having inappropriate relations instead of going to report what she thought the residents were doing to Nurse #1. The administrator stated, Resident #1 should not be allowed to roll resident's in their wheel chairs and if he was observed doing this staff should stop him. She stated Resident #1's inappropriate behaviors had been shared with department managers at morning stand up meetings which are attended by department managers. The administrator stated her expectation was for the department managers to share any concerns, such as Resident #1's inappropriate behaviors of touching female residents and rolling other residents in their wheel chairs, with the employees in their department to protect the residents in the facility. The administrator stated Resident #1 would remain on 1 on 1 direct staff monitoring until he is discharged from the facility to an assisted living facility. b. Review of Resident #1's progress notes revealed a social service note dated 11/28/18 at 12:15 PM which specified, Resident family notified of incident with female resident (Resident #3) at approximately 9:55 am. Family was told this was grounds for immediate discharge and that he needed to be picked up today. Daughter states she is at work, but she would call his sister. At approximately 12:15 PM, resident was interviewed regarding incident. He was notified that this is reportable to the state, the police were called, and this was grounds for immediate discharge. Resident states understanding. RP (responsible party) was also notified that it was reported and that the police were called. Review of Resident #3's medical record revealed she was admitted on [DATE]. Resident #3 had [DIAGNOSES REDACTED]. Review of Resident #3's Annual MDS dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 7 (which indicated severely impaired cognition), the activity of walking in room and corridor did not occur, she utilized a wheel chair as a mobility device and required supervision with one person physical assistance with locomotion on and off the unit. Review of Resident #3's progress notes revealed a social services note dated 11/28/18 at 2:17 PM which specified. Resident interviewed regarding incident with male resident this morning. Resident was notified that we reported to state and the police were called. Resident agreed to speak with police when they came. RP (responsible party) was notified of incident and also made aware that it was reported to state and police came to speak with resident. RP appreciative of notification at this time. Review of the facility's initial allegation report revealed on 11/28/18 at 9:45 AM a male resident (Resident #1) pushed female resident (Resident #3) in his room and Licensed Nurse went directly behind them and (Resident #1) was bending over female resident sitting in wheel chair fondling her breast. Nurse immediately removed female resident from situation. Review of the facility's investigation revealed an interview the Social Worker conducted with Resident #3 on 11/28/18 which revealed the following; Resident states the she was in her room, male resident came to her room and wanted to show her a picture in his room. Male resident pushes her in her wheelchair to his room. At this time, (Resident #3's name) states the male resident asked if he could kiss her, and she gave him permission to kiss her on the forehead. Male resident kissed her on the forehead, and nurse came in and pushed her out of the room. At this time, she remembers going to BINGO but does not recall who pushed her there. Observations of Resident #3 on 11/29/18 at 10:24 AM revealed she was seated in her wheel chair and was pleasantly confused. Interview with Resident #3 at this time revealed she did not recall any incidents where a male resident had acted or touched her inappropriately. Review of the facility's investigation revealed an interview the facility's Social Worker conducted with Resident #1 on 11/28/18 which revealed the following; Resident states that female resident showed interest in seeing the Christmas tree in his room, so he went to get her out of her room and pushed her to his room and states that 'nothing else happened'. Nurse (Nurse #2's first name) walked in and said (Resident #3's first name) in exasperated tone, and nurse went to (DON's first name) (DON) office and Mr. (Resident #1's last name) went to BINGO alone. When asked, Mr. (Resident #1's last name) states that he did not touch female resident in anyway. Observations and an interview with Resident #1 on 11/28/18 at 3:55 PM revealed he was able to ambulate independently and was able to verbally answer questions. During the interview with Resident #1 he stated he remembered he had inappropriate contact with a female resident a month or so ago, but denied inappropriately touching of any female residents since this incident which occurred a month ago. Resident #1 did admit to pushing a female resident in her wheel chair from her room to his room during the morning of 11/28/18, but stated that he did not touch the female resident inappropriately while the female resident was in his room. On 11/30/18 at 2:40 PM an interview was conducted with the facility's Social Worker (SW), who interviewed Residents #1 and Resident #3 as part of the facility's investigation. The SW stated Resident #1 was alert and oriented and could consent to engage in sexual activity, but Resident #3 was cognitively impaired and was unable to consent to sexual activity. The SW stated that when she interviewed Resident #1 he denied touching Resident #3 inappropriately on 11/28/18, but admitted to pushing Resident #3 in her wheel chair into his room on 11/28/18. The SW stated the facility was in the process of finding placement for Resident #1 at an assisted living facility. Review of the facility's investigation revealed a written statement from Nurse #2 which specified, Informed by therapist she noticed (Resident #1's name) pushing a female resident into his room. Went immediately to room. Door was open and noted (Resident #1's name) standing on the left side of female resident's wheel-chair leaning over her. Walked in and noted hand fondling her right breast. Asked (Resident #1) what he was doing. He jerked his hand away quickly and stepped back away from woman. Stated 'we were getting ready to go to Bingo.' (Resident #1's name) reached over picked banana up and gave to this nurse and stated 'here this is for you.' Instructed both residents they were not to be in the room and immediately afterward removed female resident from room. Reported to DON (Director of Nursing). Interview with Nurse #2 on 11/29/18 at 11:30 AM revealed on 11/28/18 Therapy staff #1 reported to her that Resident #1 had rolled Resident #3 into his room. Nurse #2 stated she immediately responded and when she entered Resident #1's room Resident #1 was standing to the side of Resident #3's wheel chair and was straightening a blanket that was on Resident #3's lap. Nurse #2 stated she then observed Resident #1 use his left hand to squeeze Resident #3's right breast twice. Nurse #3 stated she then asked Resident #1 what he was doing and he immediately stepped away from Resident #3 and he said they were getting ready for bingo. Nurse #2 stated Resident #1 then picked up a banana and gave it to her. Nurse #2 stated she informed the residents that they should not be in the room together and she removed Resident #3 from Resident #1's room and reported the incident to the DON. Review of the facility's investigation revealed a written statement from Therapy staff #1 which specified, on 11/28/18 at 9:15 am she was passing by room [ROOM NUMBER] which was occupied by Resident #3 and Resident #5 and Resident #1 was standing inside the room with both residents in the room. The statement specified therapy staff #1 reported to nursing on the hall to make aware of situation and later returned to the room and asked Resident #1 if he was there to take resident to BINGO. Resident #1 stated yes and the staff member remained in the room until Resident #1 pushed Resident #3 out of room toward the 100 hall. The statement specified; When I checked to see if that the resident (Resident #1's name) was headed in the right direction toward BINGO, resident was not, resident (Resident #1 name) pushed resident (Resident #3's name) into his room. I then reported to staff with staff removing resident (Resident #3's name) from residents (Resident #1's name) room. Interview with Therapy staff #1 on 11/29/18 at 11:55 AM revealed she did not see Resident #1 act inappropriately, but thought it was odd for a male resident to be in the room occupied by two female residents, so she reported it to the nursing staff. Therapy staff #1 stated she was unaware Resident #1 had a history of [REDACTED].#2) on 10/28/18. Therapy staff #1 stated she also was not aware Resident #1 should not be pushing other residents in their wheelchairs. An interview with the Nurse Practitioner (NP) on 11/29/18 at 2:10 PM revealed Resident #1 was alert and oriented and was aware of his actions. The NP stated following the 10/30/18 incident where Resident #1 and Resident #2 were observed having inappropriate contact Resident #1 he was placed on 1:1 staff to resident monitoring for a 24 hour period and following the initial 24 hour period he was then placed on 15 minute checks by staff to monitor his behaviors. The NP stated she was involved with the decision to place Resident #1 on 15 minute staff monitoring and was in agreement with this decision. The NP stated since Resident #1 had a second occurrence of having inappropriate contact with another female resident (Resident #3) on 11/28/18 he was placed back on 1:1 staff monitoring which would continue until he was discharged to an assisted living facility because Resident #1 no longer required skilled level care. Interview with the Director of Nursing (DON) on 11/28/18 at 4:35 PM revealed Resident #1 should not be allowed to push any resident in their wheelchairs. The DON stated Resident #1 had previously exhibited inappropriate touching of a female resident and he was aware of his actions. The DON stated if staff observed Resident #1 pushing another resident in their wheel chair the staff member should instruct him to stop pushing the resident and report the behavior to a nurse. Interview with the administrator on 11/29/18 at 8:40 AM revealed on 11/28/18 Resident #1 was placed back on 1:1 staff monitoring after he rolled Resident #3 in her wheel chair into his room and was observed by a nurse to touch the female resident's breast. During another interview with the administrator on 11/29/18 at 4:05 PM, the administrator stated Resident #1 should not be allowed to roll resident's in their wheel chairs and if he was observed doing this staff should stop him. She stated Resident #1's inappropriate behaviors had been shared with department managers at morning stand up meetings which are attended by department managers. The administrator stated her expectation was for the department managers to share any concerns, such as Resident #1's inappropriate behaviors of touching female residents and rolling other residents in their wheel chairs, with the employees in their department to protect the residents in the facility. The administrator stated Resident #1 would remain on 1 on 1 direct staff monitoring until he is discharged from the facility to an assisted living facility. On 11/30/18 at 8:32 AM the administrator was informed of the Immediate Jeopardy. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 11/30/18 at 8:40 PM. The facility's credible allegation of IJ removal indicated: Carolina Care Health and Rehabilitation Credible Allegation of Immediate Jeopardy removal For the purpose of this allegation Carolina Care Health and Rehabilitation (CCHR) is not in substantial compliance with the regulation set forth, this plan of correction constitutes CCHR credible allegation of Immediate Jeopardy removal. On (MONTH) 28, (YEAR) Resident # 1 took resident # 2 to her room and resident # 2 performed oral sex on resident # 1. Nurse # 1 removed resident #1 from resident # 2's room. Nurse completed head to toe assessment to ensure no physical harm. Resident # 2 will be monitored by staff to be free from contact from resident # 1. Family for Resident # 2 notified of incident on (MONTH) 28, (YEAR). Police called and notified of incident on (MONTH) 28, 2019 in regards to resident # 2. Resident # 2 will be protected from abuse. On (MONTH) 28, (YEAR) resident # 1 was seen with resident # 3 touching her breast. Nurse #2 removed resident #3 from resident #1's room. Nurse completed head to toe assessment to ensure no physical harm. Resident # 3 will be monitored by staff to be free from contact from resident # 1. Family for Resident # 3 notified of incident on (MONTH) 28, (YEAR). Police called and notified of incident on (MONTH) 28, 2019 in regards to resident # 3. Resident # 3 will be protected from abuse. Facility identified other residents to be at risk as all female residents due to the nature of the allegation. Social worker/ appointed designee's interviewed all interviewable female residents throughout facility as of (MONTH) 29, 2019. All non interviewable residents will be monitored by nursing staff to ensure they are free from abuse. All non interviewable residents will be assessed head to toe by Director of Nursing or designee by (MONTH) 30, (YEAR). Family took resident #1 home for the night to avoid further incident. Upon return to the facility on 0otober 29, (YEAR) Administrator started resident on one to one supervision for 24 hours. Facility then started 15 minute checks ongoing on resident # 1 whereabouts. Social worker/designee in serviced all facility staff on (MONTH) 29, (YEAR) on action plan to monitor resident #1 in regards to being around female residents. Social Worker/ designee in serviced staff on (MONTH) 30, (YEAR) on facility abuse policy in regards to sexual abuse and resident right to be free from any abuse at all times. Administrator issued 30 day discharge notice to resident # 1 on (MONTH) 29, (YEAR) in regards to being a danger to himself and others as well as resident level of care no longer requires Skilled Nursing Care . Family appealed. Discharge notice appeal held on (MONTH) 8, (YEAR) with decision still pending. Social Worker will attempt to find safe location for transfer. Effective (MONTH) 28, (YEAR) Administrator amended plan to 1:1 supervision for resident # 1. Administrator will ensure that a staff member is assigned to resident # 1 at all times until other placement is secured. Nursing will monitor residents daily to ensure they are free from abuse. Rehab Director in serviced all rehab staff in regards to resident # 1 being around or pushing female residents in wheelchair. Administrator or designee will randomly question 4 female residents 5 times per week for any potential abuse and reporting to include if resident has ever experienced abuse at facility for 1 month then 3 days per week for 1 month then 1 time per week for 1 month and 2 times per month for 3 months. Administrator reviewed findings to QAPI committee on (MONTH) 30, (YEAR) for any further corrections. Social working will update Administrator and QAPI committee of any contacts for placement. CCHR will continue to review action plan and make any necessary adjustments until placement of accused resident is obtained. Administrator updated QAPI Committee to change of 1:1 supervision on (MONTH) 30, (YEAR). Facility will remove Immediate Jeopardy as of (MONTH) 30, (YEAR). The facility's credible allegation of IJ removal was verified on 11/30/18 at 9:05 PM. Observations revealed Resident #1 had 1 on 1 direct staff monitoring in place and no inappropriate resident or staff behaviors were observed in the facility, Interviews with residents revealed that they felt safe in the facility, interviews with facility staff revealed they had received inservice training on resident abuse and were aware they should immediately stop any form of resident abuse they observe, separate the residents involved to protect the residents and then report the abuse, review of facility documentation revealed resident skin audits were completed as specified on the credible allegation which revealed no suspicious bruising or injuries and review of resident interviews conducted by staff revealed residents felt safe at the facility and had not been mistreated.

Based on observations, record review, resident interviews, staff and Nurse Practitioner (NP) interviews the facility failed to implement the facility's abuse policies to protect and prevent resident to resident sexual abuse for 2 of 3 sampled residents reviewed for abuse. Resident #2, a cognitively impaired resident, was observed having oral sex with Resident #1. Resident #3, a cognitively impaired resident, was observed to have her breast squeezed by Resident #1. Residents #2 and #3 were assessed at the facility and found to have no physical injuries. The facility also failed to implement its policy for reporting abuse by not reporting an incident of resident to resident sexual abuse to the state agency within two hours for 1 of 3 sampled residents reviewed for abuse (Resident #2). Immediate Jeopardy began on 10/28/18 when staff observed Resident #1 roll Resident #2 in her wheel chair to her room and the residents were observed by staff having oral sex in her room which was not immediately stopped by the staff member. Immediate Jeopardy began on 11/28/18 for Resident #3 when staff observed Resident #1 rolling her in her wheel chair to his room and he was observed by staff to squeeze her breast. Immediate Jeopardy was removed on 11/30/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. Example #2 was cited at a scope and severity of a D where a plan of correction is required. The findings included: 1. Review of the facility's Abuse Prevention Program policy statement, which was dated revised (MONTH) 2006, revealed the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal property and involuntary seclusion. The Policy Interpretation and Implementation specified the following: 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Review of the facility's policy statement for Preventing Resident Abuse, which was revised (MONTH) 2014, revealed the following: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. The policy's Interpretation and Implementation specified; 1. The facility's goal is to achieve and maintain an abuse-free environment. 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: j. Assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he scored a 13 on the brief interview of mental status (BIMS) indicating that he had no cognition impairments. No inappropriate behaviors were noted during the assessment period. He required set up help only with walking in corridor. The resident was also as assessed as having no limitations with range of motion. Review of Resident #1's care plan revealed the following Problem which was initiated on 10/14/16 and was reviewed by staff on 9/06/18: Mr. (Resident #1's last name) was previously reported by staff and then his own self admission of inappropriate touching of female residents. He has signed a behavioral contract that he will not engage in such behavior or risk discharge. The goal was for Resident #1 will not exhibit socially inappropriate/disruptive behavior. Care plan approaches included; Assess whether the behavior endangers the resident and/or others. Intervene if necessary, If Mr. (Resident #1) begins to become socially inappropriate redirect him immediately and inform him that such behavior will not be tolerated at CCC (abbreviation for facility name). and Observe and report socially inappropriate/disruptive behaviors when around others. Further review of Resident #1's care plan revealed the following Problem which was initiated on 10/24/16 and was most recently reviewed by staff on 9/06/18: Mr. (Resident #1's last name) took a female resident who had significant physical limitation outside of facility when he had been told that until this issues was decided by ADMINISTRATION he was not to take any female outside of facility. The goal was for Resident #1 not to harm others secondary to inappropriate behavior. A care plan approach included; Staff will do an adjustment to his previous behavioral contract and all parties will sign. Review of Resident #1's behavioral contact that was signed by Resident #1, his Power of Attorney and facility staff members on 10/26/16 specified the following; I (Resident #1's name) understand that my previous behavioral agreement signed 4/15/16 remains in effect as long as I am a resident here. That agreement was that I understood that if I touched any female in an inappropriate manner that I would be discharged from Carolina Care Center. Today I understand that I am signing an addendum to that agreement. I agree that I will not take any female resident outside of facility. I understand that I am free to socialize with other residents in public areas inside the facility with their consent. I understand that I can attend supervised out of facility events with other residents. I understand that inappropriate touching of females and taking females outside of facility without administration consent could result in discharge from Carolina Care Center. a. Review of Resident #1's progress notes revealed a nursing note dated 10/28/18 at 5:33 PM, written by Nurse #1 which stated, CNA (certified nursing assistant) reported resident feeling on another female residents breasts (Resident #2) and then whispered in her ear and took her to her room. Nurse went to room and female resident was sitting up in wheelchair in front of bathroom with head moving back and forth and resident was standing in front of her with his zipper open, penis out and residents penis was in her mouth. When I asked them what they were doing she states, 'I'm just doing what all other adults do.' He didn't say anything but 'yeah.' Asked resident to leave room at this time. Educated resident he was not allowed to go back down to her room and that he had violated his behavior contract. Resident walked out of room at this time and went to his room. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Resident #2 [DIAGNOSES REDACTED]. Review of Resident #2's quarterly MDS dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 8 (which indicated moderately impaired cognition), required supervision with set up help only with locomotion on the unit, required extensive assistance with one person physical assistance with transfers and used a wheelchair as a mobility device. Review of Resident #2's care plan revealed the following Problem was initiated on 10/16/18: Decision making: (Resident #2's first name) has difficulty making her own safe/appropriate decisions, long and short term memory deficit is noted. The goal specified, (Resident #2's first name) will suffer no loss of dignity due to memory loss. Approaches included; Assist to reminisce and redirect as much as possible to decrease further decline in cognition. Review of Resident #2's progress notes revealed a nursing note, written by Nurse #1, on 10/28/18 at 5:18 PM which specified the following; CNA (certified nursing assistant) reported another resident feeling on residents breasts and then whispered in her ear and took her to her room. Nurse went to room and resident was sitting up in wheelchair in front of bathroom with head moving back and forth and the other resident standing in front of her with his zipper open, penis out and residents penis was in her mouth. When I asked them what they were doing she states, 'I'm just doing what all other adults do.' Asked other resident to leave room at that time. She states, 'I wanted to do it and then grabbed his arm and was telling him to come back to her bed later.' Explained to resident he was not allowed to go back down to her room. Removed other resident at this time. Sitting up in her room NAD (no apparent distress). The note also specified Resident #2's family was made aware. Review of the facility's Investigation Report signed by the Director of Nurses (DON) revealed Resident #1 was alert and oriented in all spheres with a BIMS of 13 with no short term or long term memory problems. Resident #2 was assessed as having a BIMS of 8 with short term and long term memory problems. The investigation specified that Resident #1 was interviewed by the police on 10/28/18 and he admitted to being in female resident's room and having inappropriate contact with resident. The investigation report specified Resident #2 was unable to remember the incident when interviewed by the police. Observations and an interview with Resident #1 on 11/28/18 at 3:55 PM revealed he was able to ambulate independently and was able to verbally answer questions. During the interview with Resident #1 he stated he remembered he had inappropriate contact with a female resident a month or so ago, but denied inappropriately touching of any female residents since this incident which occurred a month ago. Observations of Resident #2 on 11/28/18 at 4:15 PM revealed she was seated in her wheel chair and was pleasantly confused. Resident #2 did not recall what day it was or what she ate for lunch that day. Resident #2 also did not recall any incidents of inappropriate behaviors being exhibited by male residents or staff members towards her. Interview with the facility's Social Worker (SW) on 11/30/18 at 12:40 PM revealed Resident #1 was alert and oriented and could consent to engage in sexual activity, but Resident #2 was cognitively impaired and was unable to consent to sexual activity. Review of an Investigation-employee statement written by Nurse Aide (NA) #1 dated and signed 10/28/18 stated NA #1 saw Resident #1 bending over Resident #2 and touching Resident #2's breasts in the hallway and started rolling to her room in her wheelchair and immediately reported it to her supervisor. During interview on 11/30/18 at 12:05 PM with NA #1 she stated on 10/28/18 she observed Resident #1 rolling Resident #2 in her wheelchair in the hallway. She specified that she was seeing the residents from behind, so she could not see if Resident #1 was touching Resident #2's breasts, but his hand was draped over her shoulder. She stated she did not verbally tell Resident #1 to stop rolling Resident #2 in her wheel chair because they were too far ahead of her, but she followed them and found them together in Resident #2's room. NA #1 stated she could hear the residents from the room's open doorway and it sounded like they were having oral sex. NA #1 stated she peeked in the doorway and she could not directly see what they were doing because they were around the corner in the room, but from what she could hear it sounded like they were engaged in oral sex. NA #1 stated she was so shocked from what she heard and could see that she did not say anything to the residents or attempt to stop them, but immediately went to report it to the Unit Manager (Nurse #1). NA #1 stated the Unit Manager (Nurse #1) quickly responded to her request to check on Resident #1 and Resident #2. NA #1 stated she was now aware that she should have immediately interrupted and stopped Resident #1 and Resident #2, separated the residents and then reported their activity to the Unit Manager. During an interview on 11/30/18 at 3:32 PM with Nurse #1 (Unit Manager) she stated that during the evening of 10/28/18 NA #1 asked her to go to Resident #2's room because she saw Resident #1 touching Resident #2's breasts in the hallway and they were now in Resident #2's room. Nurse #1 stated she went to the room, knocked on the room's opened door and when she entered Resident #2's room she observed Resident #1's and Resident #2 engaged in oral sex. Nurse #1 stated she observed Resident #1's penis in Resident #2's mouth. Nurse #1 stated she asked the residents what they were doing and they stopped. Nurse #1 stated she told Resident #1 to go to his room and she immediately reported this to the Director of Nursing (DON) and administrator. Interview with the facility's DON on 11/28/18 at 4:35 PM revealed during the evening of 10/28/18 Nurse #1 called her and informed her that Resident #1 and Resident #2 were observed having oral sex in Resident #2's room. The DON stated Resident #1 had previously exhibited inappropriate touching of a female resident and he was aware of his actions. So, the facility placed Resident #1 on 1 on 1 direct staff observation for 24 hours to monitor his behaviors in an effort to protect Resident #2 and other residents. The DON specified the facility started an abuse investigation and notified the local police department about the incident. Review of the police incident/investigation report revealed the police responded in reference to a report of a sexual assault at the facility on 10/28/18 at 6:21 PM. The report specified; Suspect engaged in a sex act with victim and listed Resident #2 as the victim. During interview with the Administrator on 11/29/18 at 8:40 AM she stated when she was informed of Resident #1 and Resident #2's being observed engaged in oral sex in Resident #2's room on 10/28/18 she immediately came to the facility. The administrator stated the police were notified of the incident during the evening of 10/28/18 and an officer came to the facility to investigate. The administrator stated Resident #1's family was notified and they took him home for the night. Upon his return to the facility on [DATE] the resident was placed on 1 on 1 direct staff to resident monitoring for the first 24 hours and then was placed on 15 minute staff checks to monitor the resident's behaviors. During another interview with the administrator on 11/29/18 at 4:05 PM, the administrator stated, on 10/28/18 NA #1 should have stopped Resident #1 and Resident #2 when she heard the residents together in Resident #2's room and she thought they were having inappropriate relations instead of going to report what she thought the residents were doing to Nurse #1. The administrator stated, Resident #1 should not be allowed to roll resident's in their wheel chairs and if he was observed doing this staff should stop him. She stated Resident #1's inappropriate behaviors had been shared with department managers at morning stand up meetings which are attended by department managers. The administrator stated her expectation was for the department managers to share any concerns, such as Resident #1's inappropriate behaviors of touching female residents and rolling other residents in their wheel chairs, with the employees in their department to protect the residents in the facility. The administrator stated Resident #1 would remain on 1 on 1 direct staff monitoring until he is discharged from the facility to an assisted living facility. b. Review of Resident #1's progress notes revealed a social service note dated 11/28/18 at 12:15 PM which specified, Resident family notified of incident with female resident (Resident #3) at approximately 9:55 am. Family was told this was grounds for immediate discharge and that he needed to be picked up today. Daughter states she is at work, but she would call his sister. At approximately 12:15 PM, resident was interviewed regarding incident. He was notified that this is reportable to the state, the police were called, and this was grounds for immediate discharge. Resident states understanding. RP (responsible party) was also notified that it was reported and that the police were called. Review of Resident #3's medical record revealed she was admitted on [DATE]. Resident #3 had [DIAGNOSES REDACTED]. Review of Resident #3's Annual MDS dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 7 (which indicated severely impaired cognition), the activity of walking in room and corridor did not occur, she utilized a wheel chair as a mobility device and required supervision with one person physical assistance with locomotion on and off the unit. Review of Resident #3's progress notes revealed a social services note dated 11/28/18 at 2:17 PM which specified. Resident interviewed regarding incident with male resident this morning. Resident was notified that we reported to state and the police were called. Resident agreed to speak with police when they came. RP (responsible party) was notified of incident and also made aware that it was reported to state and police came to speak with resident. RP appreciative of notification at this time. Review of the facility's initial allegation report revealed on 11/28/18 at 9:45 AM a male resident (Resident #1) pushed female resident (Resident #3) in his room and Licensed Nurse went directly behind them and (Resident #1) was bending over female resident sitting in wheel chair fondling her breast. Nurse immediately removed female resident from situation. Review of the facility's investigation revealed an interview the Social Worker conducted with Resident #3 on 11/28/18 which revealed the following; Resident states the she was in her room, male resident came to her room and wanted to show her a picture in his room. Male resident pushes her in her wheelchair to his room. At this time, (Resident #3's name) states the male resident asked if he could kiss her, and she gave him permission to kiss her on the forehead. Male resident kissed her on the forehead, and nurse came in and pushed her out of the room. At this time, she remembers going to BINGO but does not recall who pushed her there. Observations of Resident #3 on 11/29/18 at 10:24 AM revealed she was seated in her wheel chair and was pleasantly confused. Interview with Resident #3 at this time revealed she did not recall any incidents where a male resident had acted or touched her inappropriately. Review of the facility's investigation revealed an interview the facility's Social Worker conducted with Resident #1 on 11/28/18 which revealed the following; Resident states that female resident showed interest in seeing the Christmas tree in his room, so he went to get her out of her room and pushed her to his room and states that 'nothing else happened'. Nurse (Nurse #2's first name) walked in and said (Resident #3's first name) in exasperated tone, and nurse went to (DON's first name) (DON) office and Mr. (Resident #1's last name) went to BINGO alone. When asked, Mr. (Resident #1's last name) states that he did not touch female resident in anyway. Observations and an interview with Resident #1 on 11/28/18 at 3:55 PM revealed he was able to ambulate independently and was able to verbally answer questions. During the interview with Resident #1 he stated he remembered he had inappropriate contact with a female resident a month or so ago, but denied inappropriately touching of any female residents since this incident which occurred a month ago. Resident #1 did admit to pushing a female resident in her wheel chair from her room to his room during the morning of 11/28/18, but stated that he did not touch the female resident inappropriately while the female resident was in his room. On 11/30/18 at 4:45 PM an interview was conducted with the facility's Social Worker (SW), who interviewed Residents #1 and Resident #3 as part of the facility's investigation. The SW stated Resident #1 was alert and oriented and could consent to engage in sexual activity, but Resident #3 was cognitively impaired and was unable to consent to sexual activity. The SW stated that when she interviewed Resident #1 he denied touching Resident #3 inappropriately on 11/28/18, but admitted to pushing Resident #3 in her wheel chair into his room on 11/28/18. The SW stated the facility was in the process of finding placement for Resident #1 at an assisted living facility. Review of the facility's investigation revealed a written statement from Nurse #2 which specified, Informed by therapist she noticed (Resident #1's name) pushing a female resident into his room. Went immediately to room. Door was open and noted (Resident #1's name) standing on the left side of female resident's wheel-chair leaning over her. Walked in and noted hand fondling her right breast. Asked (Resident #1) what he was doing. He jerked his hand away quickly and stepped back away from woman. Stated 'we were getting ready to go to Bingo.' (Resident #1's name) reached over picked banana up and gave to this nurse and stated 'here this is for you.' Instructed both residents they were not to be in the room and immediately afterward removed female resident from room. Reported to DON (Director of Nursing). Interview with Nurse #2 on 11/29/18 at 11:30 AM revealed on 11/28/18 Therapy staff #1 reported to her that Resident #1 had rolled Resident #3 into his room. Nurse #2 stated she immediately responded and when she entered Resident #1's room Resident #1 was standing to the side of Resident #3's wheel chair and was straightening a blanket that was on Resident #3's lap. Nurse #2 stated she then observed Resident #1 use his left hand to squeeze Resident #3's right breast twice. Nurse #3 stated she then asked Resident #1 what he was doing and he immediately stepped away from Resident #3 and he said they were getting ready for bingo. Nurse #2 stated Resident #1 then picked up a banana and gave it to her. Nurse #2 stated she informed the residents that they should not be in the room together and she removed Resident #3 from Resident #1's room and reported the incident to the DON. Review of the facility's investigation revealed a written statement from Therapy staff #1 which specified, on 11/28/18 at 9:15 am she was passing by room [ROOM NUMBER] which was occupied by Resident #3 and Resident #5 and Resident #1 was standing inside the room with both residents in the room. The statement specified therapy staff #1 reported to nursing on the hall to make aware of situation and later returned to the room and asked Resident #1 if he was there to take resident to BINGO. Resident #1 stated yes and the staff member remained in the room until Resident #1 pushed Resident #3 out of room toward the 100 hall. The statement specified; When I checked to see if that the resident (Resident #1's name) was headed in the right direction toward BINGO, resident was not, resident (Resident #1 name) pushed resident (Resident #3's name) into his room. I then reported to staff with staff removing resident (Resident #3's name) from residents (Resident #1's name) room. Interview with Therapy staff #1 on 11/29/18 at 11:55 AM revealed she did not see Resident #1 act inappropriately, but thought it was odd for a male resident to be in the room occupied by two female residents, so she reported it to the nursing staff. Therapy staff #1 stated she was unaware Resident #1 had a history of [REDACTED].#2) on 10/28/18. Therapy staff #1 stated she also was not aware Resident #1 should not be pushing other residents in their wheelchairs. An interview with the Nurse Practitioner (NP) on 11/29/18 at 2:10 PM revealed Resident #1 was alert and oriented and was aware of his actions. The NP stated following the 10/30/18 incident where Resident #1 and Resident #2 were observed having inappropriate contact Resident #1 he was placed on 1:1 staff to resident monitoring for a 24 hour period and following the initial 24 hour period he was then placed on 15 minute checks by staff to monitor his behaviors. The NP stated she was involved with the decision to place Resident #1 on 15 minute staff monitoring and was in agreement with this decision. The NP stated since Resident #1 had a second occurrence of having inappropriate contact with another female resident (Resident #3) on 11/28/18 he was placed back on 1:1 staff monitoring which would continue until he was discharged to an assisted living facility because Resident #1 no longer required skilled level care. Interview with the Director of Nursing (DON) on 11/28/18 at 4:35 PM revealed Resident #1 should not be allowed to push any resident in their wheelchairs. The DON stated Resident #1 had previously exhibited inappropriate touching of a female resident and he was aware of his actions. The DON stated if staff observed Resident #1 pushing another resident in their wheel chair the staff member should instruct him to stop pushing the resident and report the behavior to a nurse. Interview with the administrator on 11/29/18 at 8:40 AM revealed on 11/28/18 Resident #1 was placed back on 1:1 staff monitoring after he rolled Resident #3 in her wheel chair into his room and was observed by a nurse to touch the female resident's breast. During another interview with the administrator on 11/29/18 at 4:05 PM, the administrator stated Resident #1 should not be allowed to roll resident's in their wheel chairs and if he was observed doing this staff should stop him. She stated Resident #1's inappropriate behaviors had been shared with department managers at morning stand up meetings which are attended by department managers. The administrator stated her expectation was for the department managers to share any concerns, such as Resident #1's inappropriate behaviors of touching female residents and rolling other residents in their wheel chairs, with the employees in their department to protect the residents in the facility. The administrator stated Resident #1 would remain on 1 on 1 direct staff monitoring until he is discharged from the facility to an assisted living facility. On 11/30/18 at 8:32 AM the administrator was informed of the Immediate Jeopardy. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 11/30/18 at 8:40 PM. The facility's credible allegation of IJ removal indicated: Carolina Care Health and Rehabilitation Credible Allegation of Immediate Jeopardy removal: For the purpose of this allegation Carolina Care Health and Rehabilitation (CCHR) is not in substantial compliance with the regulation set forth, this plan of correction constitutes CCHR credible allegation of Immediate Jeopardy removal. On (MONTH) 28, (YEAR) Resident # 1 took resident # 2 to her room and resident # 2 performed oral sex on resident # 1. Nurse # 1 removed resident #1 from resident # 2's room. Nurse completed head to toe assessment to ensure no physical harm. Resident # 2 will be monitored by staff to be free from contact from resident # 1. Family for Resident # 2 notified of incident on (MONTH) 28, (YEAR). Police called and notified of incident on (MONTH) 28, 2019 in regards to resident # 2. Resident # 2 will be protected from abuse. On (MONTH) 28, (YEAR) resident # 1 was seen with resident # 3 touching her breast. Nurse #2 removed resident #3 from resident #1's room. Nurse completed head to toe assessment to ensure no physical harm. Resident # 3 will be monitored by staff to be free from contact from resident # 1. Family for Resident # 3 notified of incident on (MONTH) 28, (YEAR). Police called and notified of incident on (MONTH) 28, 2019 in regards to resident # 3. Resident # 3 will be protected from abuse. Facility identified other residents to be at risk as all female residents due to the nature of the allegation. Social worker/ appointed designee's interviewed all interviewable female residents throughout facility as of (MONTH) 29, 2019. All non interviewable residents will be monitored by nursing staff to ensure they are free from abuse. All non interviewable residents will be assessed head to toe by Director of Nursing or designee by (MONTH) 30, (YEAR). Family took resident #1 home for the night to avoid further incident. Upon return to the facility on 0otober 29, (YEAR) Administrator started resident on one to one supervision for 24 hours. Facility then started 15 minute checks ongoing on resident # 1 whereabouts. Social worker/designee in serviced all facility staff on (MONTH) 29, (YEAR) on action plan to monitor resident #1 in regards to being around female residents. Social Worker/ designee in serviced staff on (MONTH) 30, (YEAR) on facility abuse policy in regards to sexual abuse and resident right to be free from any abuse at all times. Administrator issued 30 day discharge notice to resident # 1 on (MONTH) 29, (YEAR) in regards to being a danger to himself and others as well as resident level of care no longer requires Skilled Nursing Care . Family appealed. Discharge notice appeal held on (MONTH) 8, (YEAR) with decision still pending. Social Worker will attempt to find safe location for transfer. Effective (MONTH) 28, (YEAR) Administrator amended plan to 1:1 supervision for resident # 1. Administrator will ensure that a staff member is assigned to resident # 1 at all times until other placement is secured. Nursing will monitor residents daily to ensure they are free from abuse. Rehab Director in serviced all rehab staff in regards to resident # 1 being around or pushing female residents in wheelchair. Administrator or designee will randomly question 4 female residents 5 times per week for any potential abuse and reporting to include if resident has ever experienced abuse at facility for 1 month then 3 days per week for 1 month then 1 time per week for 1 month and 2 times per month for 3 months. Administrator reviewed findings to QAPI committee on (MONTH) 30, (YEAR) for any further corrections. Social working will update Administrator and QAPI committee of any contacts for placement. CCHR will continue to review action plan and make any necessary adjustments until placement of accused resident is obtained. Administrator updated QAPI Committee to change of 1:1 supervision on (MONTH) 30, (YEAR). Facility will remove Immediate Jeopardy as of (MONTH) 30, (YEAR). The facility's credible allegation of IJ removal was verified on 11/30/18 at 9:05 PM. Observations revealed Resident #1 had 1 on 1 direct staff monitoring in place and no inappropriate resident or staff behaviors were observed in the facility, Interviews with residents revealed that they felt safe in the facility, interviews with facility staff revealed they had received inservice training on resident abuse and were aware they should immediately stop any form of resident abuse they observe, separate the residents involved to protect the residents and then report the abuse, review of facility documentation revealed resident skin audits were completed as specified on the credible allegation which revealed no suspicious bruising or injuries and review of resident interviews conducted by staff revealed residents felt safe at the facility and had not been mistreated. 2. Review of the facility's policy entitled; Abuse Investigation and Reporting policy, which was dated as revised (MONTH) (YEAR), revealed the following Policy Statement; All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility managemen