Every finding on record at King Health and Rehabilitation Center

Based on observations, record review and staff interviews, the facility failed to implement their policies and procedures for hand hygiene when NA #1 failed to perform hand hygiene after handling dirty linens and NA #2 failed to perform hand hygiene while handling residents water cups and passing fresh ice and water. This was for 2 of 5 staff members observed for infection control practices (NA #1 and NA #2).Findings included:A review of the facility policy titled Hand Washing Requirements with effective date of 2/6/20 stated in part: Hand hygiene should be performed after handling soiled equipment or utensils, after removing gloves or aprons, and after any contact with potentially contaminated objects. There was no mention of how to handle soiled linens in the policy.a. A continuous observation was completed on 6/21/26 from 11:33AM to 11:40AM. NA #1 came out of a resident's room and removed her gloves and threw them in the trash bin in the hallway. She did not perform hand hygiene, and a wall mounted hand sanitizer dispenser was observed nearby on the wall in the hallway. NA #1 entered another resident's room and donned a pair of gloves. She gathered up a pile of dirty linens from the resident's room and carried them into the hallway and placed them into a dirty linen bin. NA #1 then removed her gloves and threw them in the trash but did not perform hand hygiene. NA #1 then proceeded to remove a clean washcloth from 1 the linen cart in the hall at which time she was asked if she had completed hand hygiene. NA #1 stated she had not and that she was just nervous and she should have completed hand hygiene. b. A continuous observation was completed on 6/21/26 from 11:45AM to 11:48AM. NA #2 entered a resident's room, and with her bare hands removed the lid from the resident's water cup and placed it on the bedside table. NA #2 exited the room out into the hallway and filled the cup with ice from an ice cooler in the hallway. NA #2 then took the cup back into the room and filled it with water from the bathroom sink and placed the cup back onto the resident's bedside table. NA #2 left the resident's room and did not complete hand hygiene. NA #2 then walked across the hallway to another resident's room and removed the lid from the resident's water cup and placed it on the bedside table. NA #2 exited the room out into the hallway and filled the cup with ice from an ice cooler in the hallway. She then went into the bathroom and filled the cup with water and then placed it back on that resident's bedside table. NA #2 left that resident's room and did not complete hand hygiene before entering the next resident's room. The Surveyor then intervened and asked NA #2 to come out into the hallway. NA #2 was asked if she had been completing hand hygiene while passing ice and water. NA #2 stated she did not complete hand hygiene but should have because she could have brought germs from one resident to the next because she did not clean her hands between handling their dirty cups. An interview with the Director of Nursing (DON) was completed on 6/24/26 at 11:30AM. She stated that all staff were trained on hand hygiene during their new hire orientation as well as annually and as needed. She stated NA #1 had told her she had been observed by a state surveyor not completing hand hygiene and the DON reeducated on hand hygiene immediately. The DON stated both NA #1 and NA #2 should have completed hand hygiene and the entire staff would be reeducated on proper hand hygiene. She also stated the facility had very recently hired an Infection Preventionist, but she had just begun her employment and had not completed her training yet. In an interview with the Administrator on 6/24/26 at 3:00PM, he stated he expected the staff to follow proper hand hygiene.

Based on observations, policy review and staff interviews, the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean under the shelf of 1 of 1 steam tables observed. This practice had the potential to affect residents. The findings included: A review of the Live Well Healthcare Solutions Food Service Closing Checklist read as: All plate warmers, pellet warmers, tray racks and steam tables cleaned and turned off. During the kitchen observation on 04/15/25 at 3:09 PM the steam table was observed. The 5-foot steamtable shelf was observed with dark brown dried food debris. On 4/16/25 at 10:18 AM the 5-foot steamtable shelf was observed with dark brown dried food debris and was sticky to touch. In an interview on 4/16/25 at 10:20 AM the Corporate Dietary Supervisor stated staff should clean the steamtable shelf. In an interview on 4/16/25 at 12:10 PM the Administrator stated the kitchen staff would scrub the steamtable shelf clean. He reported they would add the shelf to the daily sanitation checklist and inspection.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan from 12/27/24 through 3/13/25 for 1 of 1 resident reviewed for urinary catheter (Resident #37). The facility also failed to update the care plan to reflect the change in the dialysis schedule for 1 of 2 residents reviewed for dialysis (Resident #48) and failed to update the care plan to reflect the change in dietary status for 1 of 2 residents reviewed for tube feeding (Resident #79). The findings included: Resident #37 was readmitted to the facility on [DATE] with diagnoses which included obstructive and reflux uropathy. She was hospitalized from 11/21/24 through12/4/24 and 3/11/25 through 3/13/25. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #37 was cognitively intact and was coded as frequently incontinent of bladder. The Admission/Readmission Nursing Collection Tool dated 12/4/24 and completed by Nurse #1 revealed that Resident #37 returned to the facility with an indwelling urinary catheter. A care plan for Resident #37's indwelling urinary catheter was originally created on 12/4/24 and resolved on 12/27/24 by MDS Coordinator #1. Interventions included: maintain catheter anchor, maintain catheter privacy bag, observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify md as indicated, and provide catheter care each shift. The Provider Progress note dated 12/18/24 and completed by the Nurse Practitioner revealed that Resident #37 had an indwelling urinary catheter when genitourinary details were reviewed. The infection note dated 1/23/25 at 11:19 PM and completed by Nurse #3 revealed that Resident #37's indwelling urinary catheter was documented as patent and draining. In an interview with the Minimum Data Set (MDS) Coordinator #1 on 4/16/25 at 9:42 AM, they revealed that if a resident was readmitted with an indwelling urinary catheter, then the care plan should be updated within 14 days to include that focus. She stated she was normally notified in the morning clinical meeting of any changes in a resident's clinical status. Resident #37's care plan was updated on 12/4/24 to include the new indwelling urinary catheter from the hospital, but it was resolved on 12/27/24 because MDS Coordinator #1 did not see any orders in Resident #37's electronic medical record (EMR) or the hospital discharge summary on 12/4/24. MDS Coordinator #1 stated she could not provide a reason why she did not assess the resident visually and reconcile with the electronic medical record. She indicated that she saw so many residents, it was hard to keep track. The indwelling urinary catheter section in the care plan was readded on 3/13/24 when Resident #37 returned from another hospitalization . The care plan for Resident #37 updated on 3/13/25 revealed that the resident requires a urinary catheter related to: obstructive uropathy. Interventions included: change per physician order, empty as needed and record output, maintain catheter anchor, maintain catheter privacy bag, observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify md as indicated, and provide catheter care each shift. A joint interview with the Director of Nursing (DON) and Assistant DON on 4/16/25 at 10:13 AM revealed that on 12/4/24, the admitting nurse should have entered urinary indwelling catheter orders. When entering documentation in the admission collection tool, the chosen answers automatically updated the care plan. They stated that the MDS nurses should have visually assessed Resident #37 and provided accurate support with record review. The Administrator was interviewed on 4/16/25 at 3:58 PM. He stated that MDS Coordinator #1, who resolved the catheter care plan on 12/27/24, should have completed a reassessment to see if the indwelling urinary catheter was still present or removed from Resident #37. 41772 2. Resident #48 was admitted to the facility on [DATE] with diagnoses that included kidney transplant failure, end stage renal disease (ESRD) and dependence on renal dialysis. The quarterly minimum data set (MDS) assessment dated [DATE] indicated Resident #48 had severe cognitive impairment. Resident #48 was coded as receiving dialysis. The comprehensive care plan for Resident #48 was initiated 10/23/24 and last reviewed 2/10/25. The care plan included in part the focus area of Resident #48 was at increased risk for complications secondary to requiring hemodialysis secondary to ESRD. The interventions included Resident goes to dialysis Tuesday, Thursday, and Saturday with an 11:00 AM chair time at the Dialysis Center. Review of a physician's order dated 2/19/25 revealed Resident #48's dialysis days were Monday, Wednesday, Friday with an 11:00 AM chair time at the Dialysis Center. An interview was conducted with MDS Coordinator #1 on 4/16/25 at 1:13 PM. She indicated changes to residents' care was communicated each morning during the clinical meeting. MDS Coordinator #1 stated the care plans were usually updated in the clinical meeting. She further stated the care plan was not updated because the information probably did not get communicated. An interview was conducted with the Director of Nursing (DON) on 4/15/25 at 3:11 PM. The DON stated information was pulled from the 24-hour report and reviewed each morning during the clinical meeting. She stated the nurse who entered the dialysis order was responsible for making sure changes to Resident #57's dialysis schedule was communicated in the 24-hour report. The DON stated the MDS nurse should have updated the care plan to reflect the change in resident's dialysis scheduled days. 3. Resident # 79 was admitted to the facility on [DATE] with diagnoses that included oropharyngeal phase dysphagia and adult failure to thrive. The quarterly minimum data set (MDS) assessment dated [DATE] indicated Resident #79 had severe cognitive impairment with disorganized thinking and inattention. Resident #79 was coded for feeding tube and received more than 51% of her calories from feeding. The comprehensive care plan for Resident #79 was initiated 12/23/24 and last updated 3/18/25. The care plan included in part a focus area of Resident #79 was at risk for complications related to the need for an enteral tube feeding and for possible malnutrition with tube feeding. The interventions included Resident # 79 received a meal tray. Review of a physician's order dated 3/19/25 revealed Resident #79 had a diet order for nothing by mouth (NPO), NPO texture, NPO consistency. An interview was conducted with MDS Coordinator #1 on 4/16/25 at 1:13 PM. She indicated changes to residents' care was communicated each morning during the clinical meeting. MDS Coordinator #1 stated Resident #79 had two different care plans for tube feeding. She indicated the care plan should have been updated to reflect Resident #79's updated diet status of NPO. An interview was conducted with the Director of Nursing (DON) on 4/15/25 at 3:11 PM. The DON stated information was pulled from the 24-hour report and reviewed each morning during the clinical meeting. She stated the nurse who entered the NPO order was responsible for making sure changes to Resident #79's diet was communicated in the 24-hour report. The DON stated the MDS nurse should have updated the care plan to reflect the change in resident's diet to NPO.

Based on observations, record review, and staff interviews, the facility failed to label a new tube feeding formula bottle when it was hung for 1 of 2 residents with a feeding tube (Resident #245). The findings included: Resident #245 was admitted to the facility on [DATE] with diagnoses which included failure to thrive, dysphagia, and gastrostomy status (surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage). Gastrostomy, feeding tube, and enteral tube feeding are interchangeable descriptions. Review of Resident #245's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was dependent on staff with most activities of daily living (ADL). Resident #245 received all nutrition and hydration through the feeding tube. Review of Resident #245's care plan dated 4/3/25 revealed she was at risk for complications related to the need for a feeding tube. Interventions included: administer tube feedings and flushes per order, head of bed elevated during feedings per order, pause feedings during personal care as indicated, residual checks per order, and tube insertion site care per order. Review of a physician order dated 4/11/25 revealed an order for Resident #245 to receive Glucerna 1.5 at 65 milliliters (ml) per hour (hr) administered continuously over 12 hours (6:00 PM - 6:00 AM) with all shifts required to document in the medication administration record (MAR). Check tube placement prior to administration. Review of the April 2025 MAR revealed that Nurse #2 signed off Resident #245's enteral tube feeding of Glucerna 1.5 at 65 ml/hr was started at 6:00 PM on 4/12/25. An observation of Resident #245's tube feeding formula bottle was conducted on 4/13/25 at 11:52 AM. There were no date, time, or flow rate on the tube feeding bottle. An observation and interview with the Assistant Director of Nursing (ADON) was conducted on 4/13/25 at 11:53 AM. She stated that when nurses hang a new tube feeding formula bottle, they needed to label it with the resident's name, date, time, and flow rate per hour. The ADON stated that Resident #245's tube feeding was started at 6:00 PM on 4/12/25 and completed at 6:00 AM this morning. Nurse #2 was interviewed via telephone on 4/14/25 at 2:25 PM. She revealed that when hanging a new tube feeding bottle, she was supposed to label it with the resident's name, date and time of administration, and the flow rate per hour. Nurse #2 was not sure why she had not labeled Resident #245's tube feeding formula bottle at 6:00 PM on 4/12/25. During an interview with the Director of Nursing (DON) on 4/15/25 at 12:01 PM, she revealed that when a new tube feeding bottle was hung, the nurses should label the bottle with their name, the resident's name, the date and time of administration, and the rate of the tube feeding formula administration. The DON stated that the tube feeding bottle in Resident #245's room should have been properly labeled when hung at 6:00 PM on 4/12/25 by Nurse #2. The Administrator was interviewed on 4/16/25 at 3:59 PM. He stated that Resident #245's tube feeding bottle hung on 4/12/25 by Nurse #2 should have been properly labeled.

Based on observation, record review, staff interview, and the facility policy, the facility failed to ensure a staff member followed facility policy to sign off a controlled medication immediately after administering on the controlled medication count sheet. This occurred for 1 of 4 staff observed during medication administration (Nurse #1). The findings included: Review of the facility policy entitled: Pharmacy Preparation and General Guidelines: IIA6 -Controlled Substances Policy read in part: When a controlled substance is administered, the licensed nurse immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration 2) Amount administered 3) Remaining quantity 4) Initials of the nurse administering the dose, completed after the medication is actually administered. During an observation of medication pass on 4/15/25 at 8:40 AM, Nurse #1 was observed administering one controlled medication to Resident #57: Oxycodone 10mg - Give 1 tablet by mouth every 12 hours as needed for pain. Nurse #1 removed the Oxycodone medication from the bubble pack and administered it to Resident #57. Nurse #1 did not document (sign out) the medication on the controlled medication count sheet. An interview was conducted with Nurse #1 with the Assistant Director of Nursing present on 04/15/25 at 10:22 AM. Nurse #1 confirmed she had not completed the narcotic medication count sheet immediately for the controlled medication she administered to Resident #57. Nurse #1 acknowledged she should have pulled the narcotic medication, administered, and signed out the medication as soon as she administered it. An interview was conducted with the DON on 4/15/25 at 3:30 PM. The DON stated Nurse #1 should have pulled the narcotic medication, administered, and immediately signed the medication out on the controlled medication count sheet.

Based on observation, record review, and staff interviews, the facility failed to obtain physician orders for the management of an indwelling urinary catheter for 1 of 1 resident reviewed for urinary catheter (Resident #37). The findings included: Resident #37 was readmitted to the facility on [DATE] with diagnoses which included obstructive and reflux uropathy. She was hospitalized from 11/21/24 through 12/4/24 and 3/11/25 through 3/13/25. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #37 was cognitively intact and was coded as frequently incontinent of bladder. The care plan for Resident #37 was created on 12/4/24 and resolved on 12/27/24 revealed that the resident requires a urinary catheter. Interventions included: maintain catheter anchor, maintain catheter privacy bag, observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify md as indicated, and provide catheter care each shift. The Admission/Readmission Nursing Collection Tool dated 12/4/24 and completed by Nurse #1 revealed that Resident #37 returned to the facility with an indwelling urinary catheter. The Provider Progress note dated 12/18/24 and completed by the Nurse Practitioner revealed that Resident #37 had an indwelling urinary catheter when genitourinary details were reviewed. Review of Resident #37's electronic medical record from 12/4/24 until 3/11/25 revealed no physician orders regarding the care of her indwelling urinary catheter. The skilled note dated 1/14/25 at 3:50 PM and completed by Nurse #2 revealed that urine was obtained from Resident #37 for diagnostic testing. The infection note dated 1/23/25 at 11:19 PM and completed by Nurse #3 revealed that Resident #37's indwelling urinary catheter was documented as patent and draining. The care plan for Resident #37 created on 3/13/25 revealed that the resident requires a urinary catheter related to: obstructive uropathy. Interventions included: change per physician order, empty as needed and record output, maintain catheter anchor, maintain catheter privacy bag, observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify md as indicated, and provide catheter care each shift. Resident #37 had the following physician orders related to an indwelling catheter dated 3/14/25: - Check indwelling urinary catheter anchor placement each shift - Check indwelling urinary catheter anchor each week and as needed every day shift every 7 days for catheter care - Indwelling urinary catheter care each shift - Change indwelling urinary catheter as needed for clinical indications such as infection, obstruction, or when the closed system is compromised Multiple telephone attempts were made to contact Nurse #1, but she did not return the call. A telephone interview was conducted with Nurse #3 on 4/14/25 at 1:52 PM. She revealed if a resident had an indwelling urinary catheter, then catheter care must be provided each shift or if they are incontinent, whenever they had a bowel movement. Also, it was important to make sure the bag was anchored and positioned correctly, and output was monitored. All catheter instructions should be included in the medication administration record (MAR), or treatment administration record (TAR). Nurse #3 stated that Resident #37 had a catheter when she was readmitted to her assigned hall on 12/4/24. She could not remember if the orders were entered at that time or not. Nurse #3 indicated that she knew how to care for an indwelling urinary catheter, even if there were no orders. During a telephone interview with Nurse #2 on 4/14/25 at 2:16 PM, she revealed that indwelling urinary catheters were monitored to make sure it was draining or had discoloration or sediment present. If the indwelling urinary catheter needed to be changed, then she would do so if it became clogged, not draining, or leakage/comes out. Indwelling urinary catheter care was mainly performed by the nurse aides. If she was helping with incontinence care, then she would assist with catheter care at the end. Nurse #2 stated that Resident #37 was readmitted from the hospital (12/4/24) with the indwelling urinary catheter. Catheter instructions/care were sometimes included on the TAR or on the MAR. Nurse #2 stated that there should always be an order for catheter care and when changing the indwelling urinary catheter. She indicated she had been a nurse for [AGE] years and if there were not any orders for an indwelling urinary catheter, then she would do what she normally does with catheters. She did not realize there was a lack of indwelling urinary catheter orders for Resident #37, but if she did, she should have notified her supervisor. An interview was conducted with the Director of Nursing (DON) on 4/15/25 at 8:06 AM. She revealed that she could not find any catheter care/changing orders for Resident #37 prior to 3/14/25, and she could not say the exact date when the indwelling urinary catheter was inserted for Resident #37. The DON stated that when the facility received Resident #37 on 12/4/24 with a newly inserted indwelling urinary catheter, orders for catheter care and changing of the catheter should have been entered immediately by the admitting nurse (Nurse #1). The DON indicated that the orders were not put in for Resident #37's catheter perhaps because nursing staff just assumed that catheter care/changing would be completed, even if the orders were not entered. The Administrator was interviewed on 4/16/25 at 3:56 PM. He stated that none of the nursing staff followed up on Resident #37's hospital discharge summary dated 12/4/24 missing indwelling urinary catheter care orders. Regardless, Nurse #1 should have contacted the Medical Director for clarification orders.

Based on record review and staff interviews, the facility failed to refer a resident with a newly identified serious mental illness for a Level II Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for PASRR (Resident #55). Findings included: Resident #55 was admitted to the facility on [DATE]. A Level I PASRR determination notification letter dated 3/9/20 indicated No further PASRR screening is required unless a significant change occurs with the individual's status which suggest a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions. A review of Resident #55's medical record indicated on 6/25/24 the diagnosis of bipolar disorder was added and on 12/24/24 the diagnosis of major depressive and generalized anxiety disorders was added. There was no evidence indicating a Level II PASRR referral had been completed for Resident #55 after the new diagnoses of serious mental illnesses had been identified. An interview with the Social Worker (SW) on 4/14/25 at 11:25 a.m. revealed she was not aware Resident #55 had new serious mental illness diagnoses. She further stated it was her responsibility to complete a Level II PASRR screening for the residents. She revealed she would be notified by the Minimum Data Set (MDS) nurse or Director of Nursing (DON) of new identified mental health diagnosis. In an interview with the DON on 4/15/25 at 11:23 a.m. she revealed the medical record system was configured to alert the SW of new identified mental health diagnoses and was not sure why the SW did not receive an alert in the instance of Resident #55. During an interview with the Administrator on 4/16/25 at 9:09 a.m. he revealed he was not aware Resident #55's Level II PASRR referral had not been completed and explained this was a problem. He revealed the SW will be retrained and complete an audit of all residents who may require a PASRR referral.

Based on observations and staff interviews, the facility failed to discard expired medications 2 of 3 medication carts (D Hall Medication Cart and E Hall Medication Cart) reviewed for medication storage. The findings included: a. An observation of the D Hall medication cart with Medication Aide #1 on 04/16/25 3:55 PM revealed an opened box of Bisacodyl Suppositories (medication used to cause a bowel movement) with an expiration date of 3/31/25. An interview with Medication Aide #1 on 4/16/25 at 4:01 PM revealed she thought the nurses were responsible for checking the medication carts for expired medications. b. An observation of the E Hall medication cart with Nurse #2 on 4/16/25 at 4:06 PM revealed: an opened bottle of CoQ10 (a dietary supplement used in some people with certain conditions)100 with an expiration date of 2/2025 and an opened bottle of Antacid Antigas liquid (medication used to help sooth or relieve heartburn, acid indigestion and sour stomach) with an expiration date of 2/2025. An interview with Nurse #2 on 4/16/25 at 4:09 PM revealed the nurse assigned to the medication cart was responsible for checking the cart for expired medication. Nurse #2 stated she had missed the medications during her cart check. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/16/24 at 4:13PM. The ADON stated the nurses assigned to the medication cart were responsible for checking the cart. The ADON further stated nurses on the management team check the medication carts as well as the pharmacist comes in monthly and does a thorough check of the medication carts.

Based on record reviews and staff interviews, the facility failed to protect the rights of 1 of 2 residents (Resident #2) to be free from misappropriation of a narcotic medication (Oxycodone) prescribed to treat pain. Findings included: Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses which included: surgical aftercare following surgery on the nervous system, spinal stenosis, osteoarthritis, chronic pain, and post-traumatic stress syndrome (PTSD). Review of the quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #2 was cognitively intact and received opioid medication. Review of Resident #2's physician cumulative orders included an order dated 2/2/24 for Oxycodone hydrochloride, immediate release 5 milligrams (mg), one tablet every four hours as needed for pain for seven days (stop date 2/9/24). On 2/29/24 the Administrator was away from the facility and unavailable for interview. During an interview with the Director of Nursing (DON) on 2/29/24 at 3:00 p.m. and review of the initial allegation report submitted to the state agency on 2/4/24 revealed that the hall nurse made the weekend supervisor and the DON aware that approximately 16 Oxycodone IR 5mg were missing. The contracted agency nurse who worked the night before had documented that a narcotic bubble card was removed from the medication cart, but the bubble card and the narcotic sheet were not turned in. Initial efforts made to contact the nurse were unsuccessful by the facility and the contracted agency at that time. Full audits were completed of all the medication carts to ensure no other narcotics were missing. The medication room was also searched for missing narcotics. Staff were educated about misappropriation of medication. The police were notified. During the survey on 2/29/24 at 3:58 p.m., attempts made to contact the accused contracted agency nurse via telephone were unsuccessful. The facility's investigation report submitted to the state agency on 2/9/24 included the return telephone call from the contracted agency nurse insisting she was not sure what happened to the missing bubble card of Oxycodone and the narcotic sheet. The contracting agency also notified the facility that the contracting agency nurse was immediately suspended, pending investigation, and the nurse submitted to a drug test the next morning of which the results were negative. The police were notified, and statements were gathered from other staff members. Summary of the facility's investigation documented Resident #2 received her medications and had an adequate supply until the missing medication was replaced by the pharmacy. The contracted agency was notified and the contracted agency nurse responsible for the incorrect count was suspended by the contracting agency pending investigation. The contracted agency nurse was designated do not return by the facility. The medication (Oxycodone) was not located. Law enforcement, Drug Enforcement Agency (DEA), Department of Social Services (DSS), and the North Board of Nursing were notified. A Quality Assurance and Performance Improvement (QAPI) Action Plan of the identified misappropriation of the 16 Oxycodone IR 5mg tablets was reviewed and signed by the Administrator, DON, and the Medical Director on 2/5/24. The facility's corrective actions following the incident included: nurses, medication aides, including contract associates were educated on misappropriation of resident property/narcotic medications. The contracted agency was notified to take disciplinary action. The pharmacy was notified. The DON conducted a 100% review of all the facility's medication carts' narcotic drawers (carts on Hall A, 2 on Hall B, Hall C, Hall D, and Hall E) paired with the residents' individual narcotic count sheets, medication containers, and the change of shift-controlled substance count sheets. All medication carts and medication rooms were audited by the DON to ensure all medication counts were accurate. No further discrepancies were identified. The DON would report all findings of audits to the QAPI Committee monthly for 3 months for any needed improvement to prevent a reoccurrence. The date of completion was 2/6/24. The action plan was validated by reviewing the education provided to the staff, reviewing the interviews with staff and residents, and reviewing the daily Controlled Substance Count Sheet/Card Audits. Staff were interviewed and confirmed receiving education on misappropriation of residents' property/medications. Resident #2 was discharged from the facility on 2/20/24.

Based on observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on 9/2/22. This was for 1 deficiency that was cited in the area of Label and Medication Storage (F761) and recited on the current recertification and complaint survey of 1/24/24. The QAA committee additionally failed to maintain implemented procedures and monitor interventions the committee put in place following the onsite revisit following the recertification on 10/19/22. This was evident for 1 deficiency in the area of Label and Medication Storage (F761) originally cited on the recertification and complaint survey on 9/2/22 and recited on the current recertification and complaint survey of 1/24/24. The continued failure of the facility during two 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: F761: During the facility's recertification survey on 1/24/24, the facility failed to secure medications for 1 of 1 resident (Resident #44) observed with medications at bedside. During the facility's recertification survey of 9/2/22, the facility failed to discard expired medications from 1 of 1 medication storage room reviewed for medication storage. During the facility's onsite follow-up survey on 10/19/22, the facility failed to date an opened tubersol (vial of injectable medication to test for tuberculosis) multi-dose vial in the medication storage refrigerator for 1 of 1 refrigerator observed. During an interview on 1/24/24 at 3:15 PM with the facility's administrator. He stated that the QA members were made up of Administrator, the Director of Nursing, Dietary Manager, Business office manager, Maintenance Director, Social Worker, Activities Director, and Housekeeping Director. The Nurse Practitioner and the Medical Director were always invited to attend. He stated that both he and the director of nursing have been made aware of the concerns regarding this survey and the repeat of several citations. He stated that all of the issues will be looked into, and a thorough plan of correction will be drawn up and implemented to ensure these citations would not be repeated again in the future.

Based on observations, resident and staff interviews and record review, the facility failed to secure medications for 1 of 1 resident (Resident #44) observed with medications at bedside. Findings Included: Resident #44 was admitted to the facility on [DATE]. Her diagnoses included, in part, dementia, psychotic disturbance, mood disturbance, anxiety and major depressive disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had mild cognitive impairment. A review of the medical record revealed there was no order for Resident #44 to self-administer medication. An observation and interview with Resident #44 were conducted on 01/21/24 at 12:13 PM. The Resident was alert and sitting up in bed. A medication cup that contained eight pills was clearly visible on the overbed table next to the Resident's bed. There were four white pills. two blue pills, and two pink pills in the cup. She revealed the nurse often leaves her pills for her to take when she is ready. She further revealed she took two of the pills earlier but did not have enough orange juice to take the rest. She said she yelled out and asked the nurse for more juice to take the pills with, but the nurse did not bring her anything else to drink. She stated she was not sure what the names of the pills in the were or for what they were prescribed. An interview was conducted with Nurse #1 on 01/21/24 12:33 PM. She explained when she gave medications to a resident, she watched the resident swallow the medication before she left the room. She added there were no residents on Hall B who had an order to self-administer. She verified she was Resident #44's nurse and shared when she brought the medications to Resident #44 earlier, the resident asked for more orange to finish taking her medications. Nurse #1 stated she left the medications in the cup on the Resident's overbed table and went to get more juice. She added when she went to get the juice, she got called away to help with a resident trying to get out of bed and then called to another resident who was verbally aggressive with another staff member. She said she due to being called away, she forgot to return to Resident #44 with the orange juice. She stated the Resident could have taken her medications with the water in her cup, but she preferred the orange juice. She further stated she should not have left the medications on the Resident's overbed table unattended. In an interview with the Director of Nursing (DON) on 01/21/24 at 1:17 PM, she stated if a resident self-administered medications there had to be a physician order and an assessment that indicated a resident was able to self-administer medication. If a resident was not able to self-administer medication, the nurse watched a resident swallow the medications before they left the room. The DON verified Resident #44 was not able to safely self-administer medications and did not have an order to self-administer. She said Nurse #1 was educated not to leave medications in a resident's room. She added, if Resident #44 did not take all her medications while the nurse was administering them, Nurse #1 should have removed the medications from her room and returned with them when she had the orange juice. The DON stated a nurse should never leave medications unattended with a resident who did not have an order to self-administer their medications.

Based on staff interviews, interview with the Resident Representative and record reviews, the facility failed to provide the Resident Representative a written notification for the reason for transfer to the hospital for 2 of 2 residents (Resident #4 and Resident #1) reviewed for hospitalization . Findings included: 1. Resident #4 was admitted to the facility on [DATE]. She discharged to the hospital on 2/15/23 and was readmitted to the facility on [DATE]. The medical record revealed Resident #4's contact person was a family member. The medical record demonstrated the resident was transferred to the hospital on 2/15/23 due to a change in condition. Resident #4 returned to the facility on [DATE]. No written notice of transfer was documented to have been provided to the Resident Representative. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 had moderately impaired cognition. An attempt to interview Nurse #1, the nurse on duty when Resident #4 was transferred to the hospital, was unsuccessful. During an interview with the Social Worker (SW) on 6/13/23 at 2:31 PM, she explained when a resident transferred to the hospital, a copy of the transfer/discharge notice was sent with the resident. She stated the business office then sent a copy of the notice to the resident's representative. The Business Office Manager was interviewed on 6/13/23 at 2:19 PM. She said when a resident transferred to the hospital, a copy of the transfer/discharge notice was sent with the resident. She thought a copy of the notice was also sent to the Resident Representative, but it was not anyone in the business office who typically sent the written notification. On 6/13/23 at 11:55 AM an interview was completed with the Director of Nursing (DON). She shared when a resident was transferred to the hospital, the facility sent the following paperwork with the resident: medication administration record, face sheet, a transfer summary that included clinical information, bed hold policy and transfer/discharge notice. The DON added she didn't think written notification was provided to the Resident Representative, but that the business office called and verbally notified the Resident Representative. Resident #4's Representative was interviewed by telephone on 6/14/23 at 10:27 AM. She recalled the facility notified her by telephone when Resident #4 was sent to the hospital. She said after the resident went to the hospital, the facility had not sent a written notice of transfer/discharge to her. On 6/14/23 at 11:15 AM an interview was completed with the Administrator. He shared nursing staff sent a transfer/discharge notice with the resident when the resident was transferred to the hospital. The facility had not sent a written notification for transfer/discharge to a Resident Representative when a resident went to the hospital and was expected to return to the facility. He was unable to demonstrate that a notice was sent to Resident #4's Representative and said he didn't think nursing staff made a copy of the notice when they sent a resident to the hospital. 2. Resident #1 was admitted to the facility on [DATE]. He discharged to the hospital on 4/3/23 and had not returned to the facility. The admission MDS assessment dated [DATE] indicated Resident #1 had severely impaired cognition. The medical record revealed Resident #1's family member was listed as a contact person. The medical record demonstrated the resident was transferred to the hospital on 4/3/23 due to a change in condition. No written notice of transfer was documented to have been provided to the Resident Representative. On 6/13/23 at 11:00 AM, an interview was conducted with Nurse #2. She stated she was the nurse on duty when Resident #1 was transferred to the hospital. She revealed Resident #1 demonstrated a change of condition and the nurse practitioner gave an order for him to be sent to the hospital. Nurse #2 said when she sent a resident to the hospital, she typically sent a copy of the medication administration record, face sheet, advance directives information, transfer/discharge notice and bed hold policy. She recalled Resident #1 had a family member whom she spoke to regarding his care. She was unable to recall if she contacted Resident #1's family member when he transferred to the hospital but added she normally would call a representative when a resident was sent to the hospital. During an interview with the Social Worker (SW) on 6/13/23 at 2:31 PM, she explained when a resident transferred to the hospital, a copy of the transfer/discharge notice was sent with the resident. She stated the business office then sent a copy of the notice to the resident's representative. The Business Office Manager was interviewed on 6/13/23 at 2:19 PM. She said when a resident transferred to the hospital, a copy of the transfer/discharge notice was sent with the resident. She thought a copy of the notice was also sent to the Resident Representative, but it was not anyone in the business office who typically sent the written notification. On 6/13/23 at 11:55 AM an interview was completed with the Director of Nursing (DON). She shared when a resident was transferred to the hospital, the facility sent the following paperwork with the resident: medication administration record, face sheet, a transfer summary that included clinical information, bed hold policy and transfer/discharge notice. The DON added she didn't think a written notification was provided to the Resident Representative, but that the business office called and verbally notified the Resident Representative. Attempts to interview Resident #1's Representative by telephone were unsuccessful. On 6/13/23 at 2:41 PM and 6/14/23 at 11:15 AM interviews were completed with the Administrator. He shared nursing staff sent a transfer/discharge notice with the resident when the resident was transferred to the hospital. He added, if there was a responsible party, the facility made a copy of the notice and sent it to the family member. He recalled Resident #1's family member was called after he transferred to the hospital and informed of the discharge notice but wasn't sure the family member was provided with a written notification of the transfer/discharge.

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

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

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

Based on observation, record review, and resident and staff interviews the facility failed to provide a communication board to maintain communication during activity of daily living care in 1 of 1 resident (Resident #51) reviewed for communication. The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #51 had no speech, was limited to making concrete request only but understood speech with clear comprehension. The Resident required extensive assistance of two staff members with bed mobility and total assistance of one staff member with dressing, eating, toilet use, personal hygiene, and bathing. A review of the care plan dated 7/11/2022 identified focused areas that read Resident #51 had difficulty expressing his needs related to being nonverbal and required assistance with activity of daily living (ADL) needs related to limited mobility due to a recent cardiovascular accident with left [CONDITION(S)], the use of a gastrostomy tube and a [CONDITION(S)] with speech impairment. The interventions included a communication board. An interview was conducted with Resident #51 on 8/15/2022 at 10:27 a.m. and the Resident used gestures and nodded for communication and required lip reading to understand. When asked if he had a communication board, he shook his head no. An observation of Resident #51's room on 8/15/2022 at 10:28 a.m. was conducted and a communication board was not present in the closet, bedside table, end table or on the walls. An interview was conducted with Nurse #2 on 8/16/2022 at 9:42 a.m. and she revealed communication for Resident #51 takes time and causes frustration and anxiety for the Resident. She denied ever seeing a communication board or device to be used with the Resident while providing daily care. An interview was conducted on 8/16/2022 at 1:52 p.m. with Nursing Assistant #1, assigned to Resident #51. She revealed she had been assigned to the Resident many times and had not seen a communication board for the Resident and had not utilized one during his daily care. An observation of Resident #51's room on 8/16/2022 at 1:57 p.m. was conducted and a communication board was not present. An interview was conducted on 8/16/2022 at 2:02 p.m. with Speech Therapist #1 and she revealed she had worked with Resident #51 intermittently since his admission. She stated a communication board was recommended, and provided at the bedside, for communication on 5/12/2021, again on 10/1/2021 and in July 2022. She revealed the Resident had moments of anxiety when the communication board was not used. She added all recommendations were provided to the nursing team and to the interdisciplinary team. She stated the communication board should have been added to the care plan when first recommended. She conducted a room observation at 2:23 p.m. and revealed she did not see the communication board that she had provided. An interview was conducted with the Administrator on 8/16/2022 at 4:02 p.m. and he revealed his expectation was for all residents and staff to be provided with the necessary tools for communication.

Based on observation and staff interviews the facility failed to discard expired medications from 1 of 1 medication storage room reviewed for medication storage. The findings included: On 8/17/2022 at 3:24 p.m. a review of the medication storage room was conducted with the Nurse Supervisor #1. An observation of the cabinets revealed a store grocery bag that contained four home medications prescribed to a discharged resident. Two of the four medications were expired. Medication #1 was [MEDICATION(S)] 5 mg with 30 tablets inside the bottle with an expiration date printed on the prescription label of 5/5/2022. Medication #2 was [MEDICATION(S)] with an expiration date printed on the prescription label to discard after 5/5/2022. An interview was conducted with Nurse Supervisor #1 on 8/17/2022 at 3:26 p.m. and she revealed the medications were from a discharged Resident. She stated it was the facility practice to request a family member take home medications with them or to lock them up for the Resident until discharge if they did not have family to take the medications home. She added the narcotics should not have been in the cabinet but locked in an area designated for controlled medications. She stated it was her expectation that all expired medications be discarded according to the current recommended practice. An interview was conducted with the Administrator on 8/17/2022 at 4:02 p.m. and he revealed it was his expectation for medications to be stored per the facility protocols and for expired medications to not be stored in the medication room.

Based on observations, record review and resident and staff interviews, the facility failed to apply a bunny boot as ordered by the physician for 1 of 4 residents reviewed for pressure ulcers (Resident #70). The findings included: Resident #70 was admitted to the facility on [DATE]. Review of a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MAR for August 2022 revealed the order for bunny boot to right foot to use in bed to keep toes from pushing against bed was signed off as completed for 8/1/22 to 8/14/22 and 8/17/22. An observation 8/14/22 10:45 AM revealed Resident #70 lying in bed. Resident #70 ' s feet were observed lying flat on the mattress and there was not a bunny boot on Resident #70 ' s right foot. An observation on 8/17/22 at 8:30 AM revealed Resident #70 lying in bed. He did not have a bunny boot in place to his right foot. During an interview with Resident #70, he stated he did not have a bunny boot for the right foot and the staff never offered to put it on. On 8/17/22 at 8:42 AM, an interview was conducted with Nurse #1. She stated she worked Sunday 8/14/22 and signed off on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she signed on the MAR for 8/17/22 that she applied the bunny boot to Resident #70 ' s right foot because she just got in a hurry and signed it off, but she had not applied it. On 8/17/22 at 8:28 AM, an interview was conducted with the Director of Nursing. She stated when a nurse signs or checks off the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review, and staff interviews the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 of 1 resident (Resident #51) reviewed for dental care. The findings included: Resident #51 was admitted to the facility on [DATE]. A review of the facility dental visits for the past 12 months revealed Resident #51 had a comprehensive dental visit on 10/28/2021. The Dental progress note documented the Resident was missing 16 teeth and had only root tips present on tooth 6, 7, 14, 23, 24 and 26 with heavy plaque and heavy inflammation. A review of the annual Minimum Data Set (MDS), dated [DATE], revealed the dental assessment documented Resident #51 had no cavities or broken natural teeth, An interview was conducted on 8/16/2022 at 3:20 p.m. with the MDS Director. The MDS Director reviewed the Resident's dental exam notes from the 10/28/2021 visit, that documented the Resident had multiple missing teeth, 7 teeth that were root tips, and two non-restorable teeth. The surveyor and the MDS Director walked to Resident #51's bedside for an observation of his oral cavity. The MDS Director requested the Resident open his mouth for an observation and then she stated she observed he had inflamed gums to the top right side with multiple tooth fragments and obvious black areas on his teeth. She added, the dental exam visit from 10/28/2021, that stated he had multiple missing teeth and broken teeth matched the oral assessment conducted on 8/16/2022 and she would create a correction to the 4/6/2022 MDS. An interview was conducted on 8/25/2022 at 3:03 p.m. with the Responsible Party (RP) for Resident #51 and she revealed the resident had issues with his teeth prior to the facility admission on 5/11/2021, that included several broken teeth.

Based on observations, resident and staff interviews, the facility failed to maintain 1. furniture in good repair (Room 108A and B) and 2. failed to maintain a clean floor in a resident room for 2 of 8 resident rooms (Room 120A Room 108) and reviewed for environment. The findings included: 1. On 8/14/22 at 12:11 PM, an observation of Room 120A revealed the floor in the resident ' s room and bathroom appeared dirty and dull. The area around the toilet in the bathroom had a large, blackened area. The floor of the residents room appeared dirty and the corners were observed to have a buildup of dirt and debris. On 8/14/22 at 12:11 PM, the resident in Room 120A was interviewed. She stated the housekeeper came in and drug the broom and the mop around the room. She stated there was no pressure applied and the dirt would not come up anything because it was ground in. On 8/17/22, the Housekeeping Director was interviewed. She stated Room 120 is on the B hall and that is the worst in the facility. She stated the facility doesn ' t have anyone on staff to do the floors right now; their last employee quit. She stated they are in the process of hiring someone. On 8/17/22 at approximately 4:00 PM, the Administrator was interviewed. He stated the facility was having a hard time hiring staff but he did expect the resident rooms to be clean, including the floors. 2. An observation was made of room #108, Resident #23's room, on 11/15/2022 at 10:37 AM. The resident was observed lying in her bed alert and looking at a magazine. It was observed the bedside nightstand had a broken handle on the top drawer. An interview was conducted with Resident #23 at that time. She explained she couldn't open the drawer because the handle was broken and because of her tremor and muscle weakness she could not pull the drawer out from the sides. She stated she was scared to use the drawer for fear of cutting herself on the broken metal. The Resident further stated she was unable to recall to whom she had reported the broken handle. She said it would be nice to be able to use the top drawer without fear of being injured. On 08/17/2022 at 2:26 PM the Maintenance Director was interviewed. He stated he had been in position of Maintenance Director for two months. He further stated he had hired a new helper two weeks ago. He explained he did daily environmental rounds to assess for needed repairs but must have missed the broken drawer handles. He further explained when Corporate visited, they assessed the need to replace bedside nightstands and they had ordered eighty new ones. He revealed he did not know when the tables would be delivered. On 08/17/2022 at 2:35 PM during an observation of Resident #23's with the Maintenance Director he agreed the drawer handle needed to be repaired. He also observed missing drawer handles to bed A's bedside table and a malfunctioning fluorescent light. He stated he was going to repair the issues immediately. On 08/17/2022 at 2:49 PM Executive Director was interviewed. He stated he was made aware of the environmental concerns in Resident #23's room. He explained it was his expectation that the facility policies and procedures were sufficient to overcome human error. He stated the issues would be repaired immediately.

Based on record reviews and staff interviews, the facility failed to ensure two staff members provided care for 2 of 3 residents reviewed for accidents (Resident #4 on 7/7/20 and Resident #2 on 8/2/20) reviewed for falls. Resident #4 sustained a fall from her bed that resulted in fractures to her left wrist and to the 8th and 9th ribs on her right-side. Resident #2 sustained a fall from her bed that caused a hematoma to the back of her head, an acute [MEDICAL CONDITION] femur with medial displacement, and an acute femoral neck fracture in her left leg. Resident #2 passed away at the hospital. Findings included: 1. Resident #2 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 was alert and oriented; required extensive assistance with two persons for bed mobility, hygiene, and transfers and was noted as totally incontinent of both bowel and bladder. Resident #2 had limitation in range of motion on her right and left lower extremities and her left upper extremity. Resident #2's care plan dated for 10/18/2019 revealed that she was at risk for injury from falls due to her [MEDICAL CONDITION] and limited mobility. Items were to be placed within reach and her bed was to be in the low position. She was to have two-person assist with bed mobility and transfers. Resident #2's 10/20/18 care guide revealed she required a two-person assist for all bed mobility and transfers. A note written by Nurse #1 dated for 8/3/2020 at 12:15 AM indicated that she was called to Resident #2's room around 8:45 p.m. on 8/2/2020. The note detailed Nurse #1 finding Resident #2 on the floor beside her bed with a small bump on the back of her head and complaining of pain on both sides of her groin. She and NA #1 used the lift to help her back in bed. Resident #2's vital signs were within normal range for her. The on-call physician was contacted, and orders were received for pain medication to be given and x-rays to be performed when the mobile x-ray group was available in the morning. Per facility standing orders, they began neurological checks (checks testing her mental alertness and pupil reactivity) due to a bump on the back of her head. Neuro checks were documented in chart and were all within the resident's normal limits. It also revealed that Nurse #1 entered Resident #2's room around 4:00 a.m. to find Resident #2 cool, clammy to touch and only grunting responses when asked questions. Nurse #1 stated she immediately took her vital signs and they were within her normal range except her oxygen level was 85%. Nurse #1 applied oxygen via nasal cannula and that level rose to 95%. Nurse #1 called the doctor with abnormal findings and obtained an order to send out. Emergency medical services (EMS) was called and an ambulance transported Resident #2 to the hospital for evaluation. Neuro checks were observed documented in the chart. Hospital records from 8/2/20 indicated that Resident #2 was found to have an acute [MEDICAL CONDITION] femur with medial displacement, and an acute femoral neck fracture in her left leg. Death Certificate received on 8/26/20 revealed Resident #2's cause of death was complications from [MEDICAL CONDITION]. The manner of death was accidental and the cause of death was listed as a fall from an unknown height. The incident report from 8/3/2020 stated that Resident #2 rolled off bed during incontinent care. It also indicated that neurological checks and vital sign assessment were immediately taken. X-rays were to be done and an order for [REDACTED]. On 8/10/2020 at 1:14 p.m. an interview with Nurse Aide #1 (NA #1) via phone revealed that on 8/2/2020 at approximately 8:30 p.m. she entered Resident #2's room and discovered she required incontinent care. She stated that she raised her bed, rolled Resident #2 on her left side, cleaned her, and then turned to get a new brief off the nearby chair. She turned back to see Resident #2 roll forward and off the side of the bed onto a floor mat landing on her back. NA #1 stated that she immediately assessed Resident #2 by asking her how many fingers she was holding up which Resident #2 was able to do. She then explained she told Resident #2 she was going to leave the room and find help and would be right back. NA #1 stated that Resident #2 was not complaining of any pain prior to the incident and had been able to roll onto her left side with her assistance. NA #1 further explained that she had known where the care guide was and should have had a second staff member assisting her with incontinent care. The NA explained she had been the only NA on the hall at that time and did not see anyone in the hall to assist her at that time and chose not to leave Resident #2 soiled. She did not think to use the call bell to find another staff member. NA #1 stated Resident #2 had been alert and oriented the entire time. On 8/11/2020 at 6:43 a.m. an interview with Nurse #1 revealed that she was on the adjoining hall when NA #1 came to get her to assist with Resident #2 on 8/2/20 around 9:00 p.m. She stated when she arrived at the room, she found Resident #2 lying on her back on the floor mat beside her bed. She stated that Resident #2 was alert, oriented and had a small bump on the back of her head. She also complained about both left and right groin pain and reported her pain was 7/10 on the pain scale (0 being no pain and 10 being severe pain). Nurse #1 stated that her vital signs were normal and she and NA #1, used the total body lift to help her back into bed. Nurse #1 then contacted the on-call provider MD and an order was received for a hip and pelvis x-ray. She stated that Resident #2 wanted to wait for the mobile x-rays first thing in the morning before going to the hospital. She then stated that neuro checks were performed every 15 minutes for the first hour, then every 30 minutes for the next 3 hours and then hourly after that. She stated that she entered Resident #2's room around 4:00 a.m. to perform another neurological check and found Resident #2 cool, clammy to touch and only grunting responses when asked questions. She stated that her oxygen level had dropped to 85% so she applied oxygen via nasal cannula and that level rose to 95%. She contacted the on-call provider again and obtained an order to send her out to the emergency department. She then called 911 at and an ambulance arrived to transport Resident #2 to the hospital for evaluation. Nurse #1 stated that she was available and would have helped NA #1 if she had asked for assistance. Nurse #1 added that the mobile x-rays were never performed. They were on their way to the facility, but the resident was sent out prior to their arrival. On 8/10/2020 at 2:13 p.m. an interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that they were aware of the events that occurred on 8/2/2020 with Resident #2. Both the DON, ADON, and the administrator had a conference call with the agency NA #1. They both stated that NA #1 stated she had not waited for help in assisting Resident #2 with incontinent care and had chosen to do it alone. The DON also stated that NA #1 admitted to her that she was aware that Resident #2 required two staff members for bed mobility and she still made the decision to provide incontinent care without assistance from another staff member. The DON stated that they told NA #1 that her services were no longer needed at that time. The facility Plan of Correction dated for 8/2/2020 with a completion date of 8/5/2020. These steps will be followed for all residents: 1) Ensure correct number of staff members needed to provide care 2) Address and ensure bed surface is sufficient for turning and repositioning 3) Whether or not the resident has a physical impairment or behaviors that need to be considered. 4) Identify any resident that cannot assist with turning or repositioning. 5) All Nurse Assistants will be re-educated on the locations of the resident Kardex and where the find the information needed to ensure appropriate care is provided. 6) All Nurse Assistants will be re-educated in proper techniques for turning and repositioning. In addition to the above, the facility Quality Assurance (QA) process will include a Resident Questionnaire Tool to ensure all NAs were reviewing the Kardex and a question and answer quiz to test their knowledge on the where to locate specific items on the Kardex. The QA process will also include a completed Nurse Aide Competency checklist that includes procedures that are to be used when moving residents up in bed and turning residents from side to side. The DON or ADON will interview at least 3 NAs per day for 8 weeks and then weekly for 4 weeks on all shifts, as well as, random audits to ensure staff members are following the Kardex as written. 2. Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated she had severe cognitive impairment, required extensive assistance with two persons for bed mobility, hygiene and transfers and was noted as always incontinent of bowel and bladder. A care plan dated 4/22/2020 revealed that Resident #4 was at risk for injury from falls due to limited mobility and right lower leg amputation. She was to have mats on floor around her bed. Resident #4 was also care planed for two-person assist with all activities of daily living. Resident #4's care guide (a guide indicating resident needs and care to be provided) noted that she was to have two-person assist with bed mobility and transfers. A note written by Nurse #2 revealed on 7/7/2020 at 2:39 a.m. the NA had rolled Resident #4 on her right side to perform incontinent care and while she was trying to adjust her bed sheets, Resident #4 rolled off her bed and onto the floor. Resident #4 suffered a large skin tear to her left forearm and top of left hand. She also complained of her left rib cage area hurting. Mobile x-rays were ordered and completed at the facility and revealed she had left wrist and rib fractures. Resident #4 was sent to hospital for evaluation on 7/7/2020 at 6:41 am. On 8/11/2020 at 2:25 p.m. an interview with NA #2 revealed that she was an agency NA who had worked in the building once prior to 7/7/2020. She stated she was oriented to the building on her first day and then given her assignment. She stated that she wasn't aware where the care guide was located and did not ask. She came in for her shift and proceeded to provide care for the residents. On 7/7/2020 at approximately 2:30 a.m., she entered Resident #4's room to provide incontinent care and rolled her onto her right side. While she was adjusting her bed sheets, Resident #4 rolled forward, off the side of the bed and onto the floor. NA #2 stated that she thought she probably should have had another staff member assist her, but she wanted to go ahead and get the Resident #4 cleaned up. On 8/12/2020 at 8:35 a.m. an interview with Nurse #2 revealed that NA #2 came out of the room yelling for help. She went into Resident #4's room and found her lying beside her bed on the floor mat. Resident #4 had a large hematoma on her left wrist and a large skin tear on her left forearm. Nurse #2 stated that her vital signs were stable, but she was unable to determine her pain level due to her dementia. She stated that she and NA #2 used the lift to help her back into bed. She added there had been the usual number of staff for the third shift that day. On 8/10/2020 at 2:13 p.m. an interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that they were aware of the events that occurred on 7/7/2020 with Resident #4. Both the DON and the ADON, spoke with agency NA #2 on 7/7/2020. They both stated that NA #2 stated she had not waited for help in assisting Resident #4 with incontinent care and had chosen to do it alone. The DON stated that all agency staff are oriented to the building and are made aware of the location of resident care guide prior to their first day there by letting them shadow one of the other nurse aides currently on the floor. The DON stated that the facility put a plan of correction (POC) in place on 7/7/2020 after this incident with a completion date of 7/9/2020 that included NA education on locations of the resident care guides for all staff, including agency staff. This re-education included competency forms for each NA and documentation that no NA would be allowed to work until they had completed a demonstration of competency. This was monitored by the DON and ADON to ensure ongoing completion. This POC was reviewed and no issues were noted. The facility Plan of Correction dated for 8/2/2020 with a completion date of 8/5/2020. These steps will be followed for all residents: 1) Ensure correct number of staff members needed to provide care 2) Address and ensure bed surface is sufficient for turning and repositioning 3) Whether or not the resident has a physical impairment or behaviors that need to be considered. 4) Identify any resident that cannot assist with turning or repositioning. 5) All Nurse Assistants will be re-educated on the locations of the resident Kardex and where the find the information needed to ensure appropriate care is provided. 6) All Nurse Assistants will be re-educated in proper techniques for turning and repositioning. In addition to the above, the facility Quality Assurance (QA) process will include a Resident Questionnaire Tool to ensure all NAs were reviewing the Kardex and a question and answer quiz to test their knowledge on the where to locate specific items on the Kardex. The QA process will also include the DON or ADON interviewing at least 3 NAs per day for 8 weeks and then weekly for 4 weeks on all shifts, as well as, random audits to ensure staff members are following the Kardex as written. The Corrective Action Plan was verified on 8/12/20 through audit review and staff interviews. Record reviews revealed staff has completed their individual competency demonstrations and signed and dated prior to their next shift. Log sheets reveal staff names with their upcoming random audit dates to be completed by the DON. Interviews with various staff members (nurses and nurse aides) revealed they were knowledgeable. Each staff member interviewed was able to verbalize the location of resident care guides and the importance of moving residents correctly in bed and while turning.

Based on staff interviews, record review, and Physician interview the facility failed to notify the resident's physician of a meal refusal prior to administering insulin that was ordered by the physician to be given with meals for 1 of 4 (Resident #192) residents reviewed for insulin administration. The failure of the facility to notify the physician of the resident's refusal to eat and administering the insulin without a meal as ordered resulted in the resident becoming unresponsive and sent to the Emergency Department. She required a central line and intubation on admission to the Emergency Department. Her final [DIAGNOSES REDACTED]. The facility also failed to notify the physician of an unattended weight loss for 1 of 4 (Resident #65) sampled residents reviewed for nutrition. Immediate jeopardy began on 1/25/19 when the facility staff failed to ensure Resident #192's physician was notified the resident, who was diagnosed with [REDACTED]. The immediate jeopardy was removed on 2/8/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of level D (no actual harm with the potential for minimal than harm that is not immediate Jeopardy) for example #2. Findings included: 1. Resident #192 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. There was also an order [REDACTED]. According to the manufacturer, [MEDICATION NAME] 70/30 is a mixture of a man-made fast-acting insulin to help control mealtime spikes in blood sugar and long-acting insulin that works up to 24 hours to help control blood sugar between meals. The manufacturer guidelines stated that people with type 2 diabetes should have the injection within 15 minutes before or after starting their meal. Resident #192's (MONTH) 2019 Medication Administration Record [REDACTED]. The [MEDICATION NAME] 70/30 58 units of insulin scheduled for 9:00 AM was documented as administered on 1/25/19 at 10:24 AM by Nurse #2. According to the meal percentage sheet, Resident #192 did not eat anything for breakfast or lunch on 1/25/19. During an interview with Nurse Aide (NA) #6 on 2/6/19 at 4:46 PM about Resident #192's condition and meal intake on 1/25/19, she stated that the resident was on the bedpan several times that morning, and that she had refused breakfast. When asked if she notified the nurse of the resident's refusal to eat breakfast, she stated Nurse#2 was made aware. During an interview with Nurse #2 on 2/7/19 at 1:17 PM she stated that at approximately 10:00 AM she went into Resident #192's room to administer medications and she was at baseline with no altered mental status. Nurse #2 stated she knew she did not eat her breakfast and had tried to get her to eat something at that time, but the resident refused any food. When asked if she gave her the full dose of [MEDICATION NAME] 70/30 insulin when she knew the resident had not eaten breakfast, she stated that she did. She stated she had gone into Resident #192's room at approximately 12:00 PM to check her blood sugar and found her unresponsive. Nurse #2 stated she couldn't wake Resident #192 up and checked her blood sugar with a result of 189 mg/dl. She stated she applied oxygen, checked vital signs, notified the DON, and EMS was called to transfer the resident to the hospital. She stated that she checked the resident's pupils and they were fixed and dilated. A progress note dated 1/25/19 at 6:43 PM written by Nurse #2 stated she entered Resident #192's room at 12:15 PM and found Resident #192 unresponsive. The resident's SpO2 (blood oxygen saturation level) was 98%, blood pressure (BP) was 98/68 mmHg, Pulse 54 beats per minute (bpm), and FSBS was 189. Review of the (MONTH) 2019 MAR indicated [REDACTED]. During an interview with the Director of Nursing (DON) on 2/6/19 at 5:02 PM she stated she was in Resident #192's room after she was notified of her being unresponsive. She stated the resident's blood sugar was 189 mg/dl and that there was no indication to be concerned about the insulin being administered or blood sugar level. Review of Resident #192's EMS report from 1/25/19 revealed the resident was found at the facility to be unresponsive. The chief complaint documented that the resident was found unresponsive by staff and it was reported to EMS that the resident was last seen normal at 11:00 AM, her vital signs were all normal, and her blood glucose was 129 mg/dL. The first blood glucose level documented by EMS at 1:05 PM was 23 mg/dL. At 1:09 PM [MEDICATION NAME] 50% (D50 - a hypertonic solution of [MEDICATION NAME], simple sugar chemically identical to glucose) 25 grams was administered. At 1:13 PM the resident's blood glucose was 273 mg/dL. At 1:30 PM her blood glucose was 110 mg/dL. At 1:30 PM her blood glucose was 110 mg/dL. Resident #192 was received by the hospital ED staff at 1:45 PM. Review of the ED Report from 1/25/19 documented the resident was found unresponsive at the facility by EMS and EMS obtained a blood glucose of 23 mg/dL. Triage Lab results from ED admission on 1/25/19 at 2:48 PM were Glucose 26 mg/dL. The resident required a central line (a catheter placed into a large vein to give medications or draw lab work) and intubation at 2:52 PM for acute [MEDICAL CONDITION], she received D50 for [DIAGNOSES REDACTED], intravenous fluids (IVF) for [MEDICAL CONDITION], and admission to Intensive Care Unit (ICU). Her final [DIAGNOSES REDACTED]. Review of hospital records from 1/27/19 at 9:22 AM revealed a Critical Care Progress Note by Physician Assistant (PA) #1 and Hospital Physician #1 that stated problems addressed for Resident #192 involving her insulin dependent diabetes mellitus (IDDM) were likely related to insulin dose and not eating. During an interview on 2/7/19 at 3:35 PM the Staff Development Coordinator stated NAs are educated on notifying the nurse when a resident does not eat on orientation and as needed. Nurses are educated to look at each resident receiving insulin individually during each medication administration and were educated to withhold insulin if meals were not consumed. She further stated, if the resident does not eat a meal it was expected that the nurse call the provider for further orders before insulin is administered. During an interview with the facility Pharmacist on 2/7/19 at 5:11 PM she stated she would have expected the nurse to hold all short acting insulin if a meal wasn't consumed. She stated if the resident's blood sugar was 109 at 6:27 AM, and she didn't eat or have [MEDICATION NAME] administered, the blood sugar going up to 189 mg/dl at approximately 12:15 PM seemed inconsistent. She stated [MEDICATION NAME] 70/30 is used to regulate and lower blood sugar levels for residents with diabetes, it has an onset of action within 10-20 minutes for the short acting and the medication peaks within 1-4 hours of administration. During an interview with the Medical Director on 2/7/19 at 3:55 PM she stated she was not aware of the particular incident with Resident #192's low blood sugar and transfer to the ED and her associate was most likely contacted for transfer orders. When asked if she expected the nurse to hold insulin if a resident did not eat, she stated most residents in the nursing home don't eat all the time. When asked if she expected the nurse to check another blood sugar prior to administering insulin after a 4-hour time period and no food was consumed, she stated yes but she did not fault the nurse for administering the insulin without food. She stated most likely the resident had been receiving this ordered insulin dose for a long period of time and for whatever reason on that particular day she had an adverse reaction to the insulin, but she had probably had the insulin administered at that dose without food in the past without the same effect. On 2/7/18 at 6:37 PM, the administrator was informed of the immediate jeopardy. The facility provided a credible allegation of Immediate Jeopardy removal on 2/8/19. The allegation of Immediate Jeopardy removal indicated: Credible Allegation of Immediate Jeopardy removal: Date: 2/08/2019 Corrective action accomplished for those residents found to have been affected by the deficient practice. Resident #192 was admitted on [DATE] for short term rehabilitation services. Resident #192 received skilled nursing and rehabilitation services from 1/23/2019 up to 1/25/2019. Review of facility most recent minimum data set, with Assessment reference date 1/25/2018 section I (active diagnosis) indicated resident #192 had a [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. On 1/25/2019 resident #192 received [MEDICATION NAME] 70-30 at 10:24am. Interview with nurse aide #1 who was caring for resident #192, on 1/25/2019 morning shift, indicated resident #192 refused her breakfast in the morning of 1/25/2019. Interview with nurse assistant #2 conducted by the facilitys Director of Nursing indicates resident #192 ate snacks during the night of 1/24/2019 to the morning of 1/25/2019. On 1/25/2018, at 12:15pm less than two hours after resident #192 received the [MEDICATION NAME] 70-30, 58 units; licensed nurse #1 indicated; she went to resident #192 room and observed resident #192 been unresponsive. She immediately obtained vital signs as well as blood glucose. Blood glucose result was noted to be 189 (adult normal limits 70-110). Licensed nurse #1 contacted emergency medical services who then transferred resident #192 to the hospital. On 2/08/19; State agency surveyors indicated that the root cause of this alleged noncompliance is the action by licensed nurse #1 to administer [MEDICATION NAME] 70-30 at 10:24am while resident #192 refused her breakfast meal without notifying physician before that action. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. Audits of 100% of resident - medication orders were completed by the Director of Nursing, Assistant director of Nursing and/or Unit Manager on 2/7/2019, and 2/8/19 to identify any other resident with any insulin order that need to be given with meals. The audit concluded there were eight other residents identified with orders for insulin medication to be given with meals. Audit of Insulin administration records for the last 7 days indicated all other eight identified residents received their insulin as ordered with meals. 100% audit of all current residents clinical documentation within the last 7 days completed by the Director of Nursing, Assistant Director of Nursing, Staff development Coordinator and/or Nurse Manager to determine any identified need for notification of changes that was completed in a timely manner. The audit revealed no other missing/delayed notification of changes to both physician and/or responsible party. This audit was completed on 2/08/19. Findings of this audit are documented on clinical records audit toollocated in the facility compliance binder. On 2/8/2019, 100% audit was completed by the Director of Nursing, Assistant Director of Nursing, Staff development Coordinator and/or Nurse Manager of all incidents reports completed within the last 7 days to ensure notifications were done in a timely manner. The audit revealed no other missing/delayed notification of changes to both physician and/or responsible party. This audit was completed on 2/08/19. Findings of this audit are documented on incident reports audit toollocated in the facility compliance binder. Measures will be put into place or what systematic changes will be made to ensure that the deficient practice will not occur. Effective 2/8/2019 and moving forward, the facility Licensed nurse and will not administer insulin for any resident with an order to be given with meals/food when a resident refused his/her meal/food. Facility Licensed nurse on Duty will notify physician when a resident with ordered insulin refuse their meal/food and document physician decision in each residents medical records before the insulin is administered. Licensed nurses will add any new recommendation from Physician in a 24 hour report form as well effective 2/8/2019 Effective 2/8/2019 and moving forward the facilitys clinical team, which includes Director of nursing, Assistant Director of Nursing, and/or Nurse supervisors initiated a process for reviewing clinical documentation create for the last 24 hours for all residents, 24 hour report sheets, incident reports for the last 24 hours and Physician orders [REDACTED]. This systemic process will take place daily (Monday through Friday). Any identified issues will be addressed promptly and appropriate actions will be implemented by the DON, ADON, SDC and/or Registered Nurse supervisor. This process will be incorporated in a daily clinical meeting any negative findings will be documented on the daily clinical report formand maintained in the daily clinical meeting binder. Effective 2/08/2019, week end Registered Nurse supervisor and/or designated licensed nurse will review clinical documentation created for the last 24 hours for all residents, 24 hour report sheets, incident reports for the last 24 hours and Physician orders [REDACTED]. This systemic process will take place every Saturday & Sunday. Any identified issues will be addressed promptly and appropriate actions will be implemented by the DON, ADON, SDC and/or Registered Nurse supervisor. The result of this systemic process will be documented on the weekend supervisor report form maintained in the Daily Stand up meeting binder. Findings from this systemic changes will be discussed in the daily stand up meetingMonday through Friday effective 2/8/2019. Week end supervisor #1 will be educated on this requirement before their next scheduled day to work by the facility Director of Nursing. The Facility Director of Nursing (DON), Assistant Director of Nursing and/or staff development coordinator will complete 100% education for all licensed nurses to include full time, part time and as needed staff. The emphasis of this education was on the importance of notifying Physician and the responsible party in a timely manner for any incident/accidents, residents change of condition, change of treatment/intervention an injury of unknown source and/or Medication error if any. The education also emphasized the responsibility of the licensed nurse on Duty to notify physician when a resident with ordered insulin refuse their meal/food and document physician decision in each residents medical records before the insulin is administered. Licensed nurses were also educated to document any new physician recommendation on the 24 hour report sheets effective 2/8/19. This education will be completed by 2/8/2019. Any Licensed Nurse not educated by 2/8/2019 will not be allowed to work until educated. This education will also be added on new hires orientation process for all new licensed nurses and will also be provided annually effective 2/8/2019. The facility plans to monitor its performance to make sure that solutions are sustained. Effective 2/8/2019, Assistant Director of Nursing, and/or Staff Development Coordinator, will monitor compliance with notification of changes to Physician and/or responsible party to include notification to physician for any resident with insulin order who refuse their meal. This monitoring process will be accomplished by reviewing the daily clinical meeting reports to ensure completion and proper follow through. Any issues identified during this monitoring process will be addressed promptly. Findings from this monitoring process will be documented on a daily clinical report form and filed in clinical meeting binder after proper follow-ups are completed. This monitoring process will take place daily for 2 weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Director of Nursing will review the completion of daily clinical report, and proper follow through and ensure notification of changes is rendered as appropriate. Director of nursing document findings from this monitoring process daily clinical checklist form and filed in clinical meeting binder after proper follow-ups are completed. This monitoring process will take place daily Monday through Friday for 2 weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Facility Quality Assurance & Performance Improvement Committee was notified of this plan of action on 2/8/2019. Effective 2/08/19, Facility Director of Nursing and/or Assistant Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly for three months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. The title of the person responsible for implementing the acceptable plan of correction Effective 2/8/2019 the facility Administrator and the Director of Nursing will be ultimately responsible for the implementation of this plan of correction to ensure the facility attains and maintains substantial compliance. Date of immediate jeopardy removal 2/8/19 The credible allegation of Immediate Jeopardy removal was verified 2/8/19 at 8:02 PM as evidenced by: Review of facility's records revealed in-services were completed with all active facility staff on 2/7/19 through 2/8/19. The DON, ADON, SDC, and nursing supervisors were trained to provide all education regarding abuse/neglect policy, insulin administration and documentation, and physician notification/orders to every employee before they were able to work at the facility either by phone or in-person. Review of facility audits from 2/7/19 to 2/8/19 revealed that they were completed and that orders were changed to reflect the new insulin order verbiage for all resident's receiving insulin or other types of diabetic medications. Clinical records audit tool, Incident reports audit tool, 24-hour report, and the clinical meeting binder were reviewed for completion. During an interview with NA #3 on 2/8/19 at 7:41 PM revealed that she was educated on the facility Abuse and Neglect Policy and stated that she would report any concerns or suspicions to the DON. She also received education that stated if a resident did not eat she would offer alternates and/or report the refusal to the nurse and document the meal intake percentage in her charting. An interview with NA #4 on 2/8/19 at 7:41 PM revealed that education was provided on the facility Abuse and Neglect Policy. She stated that all concerns or suspicions would be reported to the DON or administrator. She stated she also received education that stated if a resident refuses their meal, offer alternatives to ensure they don't want anything, always document their meal percentage, and notify the nurse. During an interview with NA #1 on 2/8/19 at 7:49 PM she stated that if she suspected any type of abuse she was to report her suspicions to the DON and/or the administrator. She also received education that stated if a resident did not eat she was supposed to offer alternates or offer several more times, but that the resident had the right to refuse. If the resident still refused to eat she would notify the nurse and document the meal percentage. During an interview with Nurse #1 on 2/8/19 at 7:55 PM she stated that she was educated to ensure a snack or food was consumed before giving insulin. If the resident refused to eat, notify the provider and follow orders given for insulin administration, then document changes on the 24-hour report. Education on the facility Abuse and Neglect Policy stated that any and all suspicions of abuse should be reported to the DON and/or administrator. During an interview with Nurse #3 on 2/8/19 at 8:00 PM she stated that she was educated to ensure a snack or food was consumed before giving insulin. If the resident refused to eat anything she was supposed to notify the provider, and follow orders given for insulin administration. She would then document changes on the 24-hour report for the on-coming nurses. 2. Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was admitted from hospital. She was not in facility prior. Review of Resident #65's physician orders [REDACTED]. review of the resident's medical record revealed [REDACTED].#65 weighed 157 pounds. Record review revealed a Nutritional Screening and assessment dated [DATE] which indicated Resident #65 had a fair appetite, consuming 50-75% of most meals. Weight stable over last 6 months per family member's report, usual body weight prior to illness 158 pounds, and ideal body weight 130 pounds. A nutritional care plan note dated 1/10/19 written by the dietician revealed Resident #65's weight was 157 pounds. The registered dietician recommend adding a protein supplement twice a day with medication pass. The note specified the resident was at risk for weight changes related to use of therapeutic diet, dementia, and weight above average body weight. Will proceed to care plan. A care plan for nutrition dated 1/10/19 revealed Resident #65 was at risk for weight changes related to use of therapeutic diet, [DIAGNOSES REDACTED]. A handwritten addition of significant weight loss was added with no date entry. The care plan goal included resident will eat at least 75% of all meals through next review with an additional handwritten goal of no significant weight changes through next review handwritten. Interventions included: maintain current listing of likes and dislikes, administer vitamins as ordered, obtain weight monthly and as needed, encourage dining room for all meals, dietary recommendation add 30 milliliters of a protein supplement max twice a daily with medication pass for nutritional support. A review of an Admission/5 day Minimum Data Set assessment dated [DATE] revealed Resident #65 had severely impaired cognition. She was assessed as being independent with meals after set-up, having no swallowing disorder, was on a therapeutic diet, weighed 157 pounds and was 66 inches tall. An observation on 2/7/19 at 12:47 PM of Resident #65 revealed she was sitting at a table in the main dining room with lunch tray in front of her. Resident #65 had only consumed bites of her beans. A follow-up observation on 2/7/19 at approximately 1:00 PM revealed the activity assistant assisting Resident #65 to eat. Resident #65 had consumed approximately 75 percent of her meal. On 2/7/19 at 1:13 PM, an interview with NA #2 revealed Resident #65 was able to feed herself, but did need assistance at times. She stated she had good days and bad days. The family or family friend would visit frequently and assist the resident to eat. She stated she encouraged the resident to eat in the dining room if no one came in to visit, but sometimes she refused to go. Review of Resident #65's weight record revealed on 1/12/19 a weekly weight of 146.8 pounds was documented which was a 10.2 pounds or 6.5 percent significant weight loss since the resident's previous weight of 157 pounds obtained on 1/6/19. Lab results of a Liver Function Panel collected on 1/7/19 revealed an [MEDICATION NAME] of 2.5 and a total protein of 4.8. Normal lab values are 3.5-5.2 and 6.0-8.7, respectively. Review of Resident #65's medical record revealed there were no nutritional interventions or physician orders [REDACTED]. Additionally, review of the resident's medical record revealed [REDACTED]. On 2/7/19 at 9:32 AM, an interview with the dietary manager (DM) revealed she was unaware of the weight that was obtained for Resident #65 on 1/12/19 which reflected a significant weight loss from 1/6/19. She stated she tried to keep up with the weekly weights. She stated she pulled the report weekly and if there was a concerning weight, she requested nursing to reweigh the resident. If there was still a concern, she would notify the dietician by phone and get a recommendation for the physician to stop the resident's weight loss. The DM confirmed no interventions were implemented to address Resident #65's weight loss experienced from 1/6/19 to 1/12/19. On 2/6/19 at 11:20 AM the Assistant Director of Nursing (ADON) was interviewed. She stated weights were done on admission. In (MONTH) 2019, the facility initiated weekly weights x 4 after admission. Nursing assistants were to obtain the residents' weights and give the result to the nurse on the hall to enter into the computer. She stated if there was a 3 pound variance, a reweight was obtained. If the weight was still concerning, the physician was notified as well as dietary so that interventions could be put into place. Review of Resident #65's weight record revealed on 1/19/19 a weekly weight was not documented. On 2/6/19 at 12:40 PM, Nurse #1 was interviewed. Nurse #1 stated she was assigned to the E/F halls on 1/19/19, where Resident #65 resided. She stated nursing assistants obtained the resident weights and gave them to either her or the supervisor to enter into the computer system. The 14 day MDS dated [DATE] had a weight of 157 pounds. Review of Resident #65's weight record revealed on 1/26/19 a documented weekly weight of 139.8 which equates into a 17.2 pound or 10.96 percent weight loss since 1/6/19. A review of meal percentages from 1/6/19 to 1/26/19 for Resident #65 revealed she consumed between 50-75% of her meals. On 2/7/19 at 9:14 AM, the dietician was interviewed. She stated she didn't recall Resident #65 and that she wasn't sure if the resident was on weekly weights. She stated she would get the report when she rounded monthly and the Dietary Manager would notify her of any significant changes related to weekly weights. She stated she would ask the facility's risk committee why she didn't get the information regarding Resident #65 's weight loss identified on 1/12/19 and why no weekly weight was obtained for Resident #65 on 1/19/19. The RD confirmed no approaches were implemented to address the resident's weight loss which began on 1/12/19 until 1/30/19 when a house shake supplement was ordered. On 2/7/19 at 9:32 AM, an interview with the DM revealed on 1/29/19 she rounded with the dietician and saw Resident #65. She stated she spoke with the resident's family member who had several things listed that she did not want Resident #65 to eat due to her bowel trouble. The DM updated the resident's tray card. The DM also confirmed no interventions were implemented to address Resident #65's weight loss which began on 1/12/19 until 1/30/19 when a house shake was ordered. On 2/7/19 at 3:48 PM, an interview was conducted with the resident's physician. She stated she didn't have Resident #65's chart in front of her but wasn't aware she had experienced weight loss. She stated she expected to be notified of a weight loss.