Every finding on record at John Edward Harter Nursing Center

Based on record review and interviews, the facility failed to submit the required staffing information based on payroll data in a uniform format by the required deadline. Specifically, the facility failed to submit data for quarter one (October 1, 2024 - December 31, 2024) of the federal fiscal year 2025. Findings include: A review of the facility's Payroll Based Journal (PBJ) report from Center of Medicare Services (CMS) revealed the facility failed to submit data within the required timeline for quarter one of 2025. Review of the facility's document titled CMS Data Submission Report for quarter one of 2025, revealed it did not contain all the components required by CMS, specifically the daily resident census was not included in the report. During an interview conducted with the Administrator on 05/08/25 at 2:28 PM, the Administrator confirmed the PBJ report submitted for quarter one of 2025 did not include the required information of the daily resident census.

Based on interview and review of facility policy, the facility failed to establish and implement a water management program which identified measures to minimize the risk of Legionella in the facility. Findings include: Review of the facility's policy titled Legionnaire's Disease Policy and Procedure, effective date 01/02/20 revealed, Legionnaires' disease is a serious pneumonia caused by the Legionella bacteria. It is not contagious and is typically contracted by inhaling contaminated water droplets, often from contaminated sources like cooling towers or water systems in buildings. Symptoms can include fever, cough, chills, muscle aches, and headaches, similar to the flu . To test for Legionella in a nursing home, start with a risk assessment to identify high-risk areas. Then, create a sampling plan, collect water samples from identified sites, and analyze them in a lab. Finally, implement a water management plan to control Legionella growth and spread, including regular testing and corrective actions . 1. Establish a WMP team (Infection control Team). 2. Describe the building water systems. 3. Identify areas where Legionella could grow and spread. 4. Decide where to apply and how to monitor control measures. 5. Establish interventions when control limits are not met. 6. Ensure the program runs as designed and is effective . During an interview on 05/08/25 at 2:45 PM the Director of Nursing (DON) presented water testing results for the facility's activities room, and empty resident room [ROOM NUMBER]. When asked if the facility had a process for evaluating all areas identified by the facility as potential sites for Legionella growth, the DON stated she only had testing results date 01/24/25 for the activities room and room [ROOM NUMBER]. When asked for a water management program that governed the facility's Legionella prevention program, the DON stated she would look for it. When asked who was responsible for the facility's water management and legionella program, the DON stated she was responsible for the program. During an interview on 05/08/25 at 4:29 PM, the DON admitted the facility did not have a Legionella prevention program. Per the facility's policy, the DON admitted she had not: 1. Established a WMP (water management program) team; 2. Described the building's water systems; 3. Identified areas where Legionella could grow and spread in the facility; 4. Decided where to apply and how to monitor control measures. 5. Established interventions when control limits are not met. 6. Ensured the program runs as designed and is effective.

Based on observation and limited record reviews, the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for the 1st, 2nd, and 4th quarters of Fiscal Year (FY) (YEAR), and the 1st quarter of FY (YEAR). Reports for 4 out of 5 quarters reviewed for FY (YEAR) and FY (YEAR). The findings included: Review of the Certification And Survey Provider Enhanced Report (CASPER) report 1702S Staffing Summary Reports for FY (YEAR) and the first quarter of FY (YEAR) generated 3/8/2018, on 3/13/18 at 5:30 PM revealed that report results for the following dates had no data returned for selected criteria for(NAME)Edward Harter Nursing Center: 10/01/2016 thru 12/31/2016-first quarter FY (YEAR) 01/01/2017 thru 03/31/2017-second quarter of FY (YEAR) 07/01/2017 thru 09/30/2017-third quarter of FY (YEAR) 10/01/2017 thru 12/31/2017-first quarter of FY (YEAR) Further review of the results of CASPER report 1702S Staffing Summary Report for the third quarter of FY (YEAR) (04/01/2017 thru 06/30/2017) revealed required information regarding staffing for this time frame that was submitted 07/18/2017, within the regulatory time frame of 45 days after the last day in the fiscal quarter. During interview with Director of Nursing (DON) and Minimum Data Set (MDS) nurse on 3/13/18 at 6:00 PM, they verified that there was no staffing data submitted for the first, second and third quarter of FY (YEAR) and the first quarter of FY (YEAR). DON reported that the Human Resources Manager (HRM) is responsible for submission of the information to the CMS database. Both DON and MDS nurse reported that they had verbalized concerns regarding submission of the staffing information when they had reviewed Quality Measures/5 Star Reporting information, but were assured that the information was being submitted as required by the HRM. During interview with HRM on 3/14/18 at 9:55 AM, when asked for a copy of the policy regarding submission of the Payroll Based Journal (PBJ) files regarding staffing to the CMS database, s/he replied that there was no policy. When asked to describe the process that s/he followed when submitting the PBJ files regarding staffing to the CMS database, s/he replied that the information was submitted via the CMS transmission website quarterly. S/he further reported that there had been a data entry error regarding the facility identification (ID) information provided during submission, stating that the SC was not entered as a part of the facility ID, and this was why the files were rejected. S/he reported that all of the information had been re-submitted the morning of 3/14/18 prior to the interview. HRM later returned at 10:39 AM and provided a policy,(NAME)Edward Harter Nursing Center Payroll Based Journal-Electronic Staffing Data Submission. When asked to clarify when asked if there was a policy earlier, surveyor was told that there was no policy, HRM did not reply. Review of documentation provided by HRM on 3/14/18 at 10:18 revealed a photocopy of the original submission report for submission ID 89, which was submitted to the CMS PBJ database on 7/17/17 at 12:22 PM. The information in this file reflected the staffing information for 01/01/17-03/31/17. The report was rejected due to a fatal error related to invalid facility ID. Additional information provided to reflect resubmission of information on 3/14/18 at 09:42 AM with submission ID 26 with pending final validation that file was accepted. Review of photocopy of PBJ Submitter Final Validation Report provided by HRM on 3/14/18 at 11:56 AM revealed that the information was accepted with a processing completion date/time of 03/14/2018 at 9:42 AM with a message 4009/WARNING: The record was submitted more than 45 days after the end of the Federal Fiscal Quarter. Review of documentation provided by HRM on 3/14/18 at 10:18 revealed a photocopy of the original submission report for submission ID 95, which was submitted to the CMS PBJ database on 7/18/17 at 09:38 AM. Review of photocopy of PBJ Submitter Final Validation Report provided by revealed that the information was accepted with a processing completion date/time of 7/18/17 at 9:39 AM. The information in this file reflected the staffing information for 04/01/17-06/30/17. This information was originally sent and accepted within the regulatory guideline timeframe of 45 days. Review of documentation provided by HRM on 3/14/18 at 10:18 revealed a photocopy of the original submission report for submission ID 921 which was submitted to the CMS PBJ database on 10/03/2017 at 3:02 PM. The information in this file reflected the staffing information for 07/01/17-09/30/17. The report was rejected due to a fatal error related to invalid facility ID. Additional information provided to reflect resubmission of information on 3/14/18 at 09:46 AM with submission ID 28 with pending final validation that file was accepted. Review of photocopy of PBJ Submitter Final Validation Report provided by HRM on 3/14/18 at 11:56 AM revealed that the information was accepted with a processing completion date/time of 03/14/2018 at 9:46 AM with a message 4009/WARNING: The record was submitted more than 45 days after the end of the Federal Fiscal Quarter. Review of documentation provided by HRM on 3/14/18 at 10:18 revealed a photocopy of the original submission report for submission ID 27, which was submitted to the CMS PBJ database on 02/15/2018 at 09:55 AM. The information in this file reflected the staffing information for 10/01/17-12/31/17. The report was rejected due to a fatal error related to invalid facility ID. Additional information provided to reflect resubmission of information on 3/14/18 at 09:46 AM with submission ID 28 with pending final validation that file was accepted. Review of photocopy of PBJ Submitter Final Validation Report provided by HRM on 3/14/18 at 1:27 PM revealed that the information was accepted with a processing completion date/time of 03/14/2018 at 1:16 PM with a message 4009/WARNING: The record was submitted more than 45 days after the end of the Federal Fiscal Quarter. Despite requests, no information was provided regarding the transmission information regarding the first quarter of FY (YEAR), which included the dates 10/1/2016-12/31/2016. Review of the(NAME)Edward Harter Nursing Center Payroll Based Journal-Electronic Staffing Data Submission policy and procedure information provided by the HRM on 3/14/18 at 10:39 AM revealed that the submission will be done on a quarterly basis and that when the report has been successfully submitted to CMS, the facility should receive a confirmation sheet with ID#, including a date and time stamp.

Based on observation and interviews, the facility failed to maintain the grease disposal system according to regulations. The findings included: During an observation on 01/05/17 at 12:42 pm along with the Dietary Manager (DM) the grease disposal container was observed to be sitting partially off of its concrete platform. It was also observed to have dark, caked grease spillage along the back end and covering a plastic trash can lid that was lying beside the container. In an interview on 01/05/17 at 12:51 pm, the DM stated that the fryers are cleaned weekly and the grease is placed in the container. The DM did not have any information on the vendor who maintains the container. In an interview on 01/05/17 at 1:04 pm the Administrator stated a maintenance company comes in and pumps out the grease quarterly but was not sure how the container was emptied.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from physical abuse. CNA #1 hit Resident #1 across the face while providing care. The incident was witnessed by two other employees. One of one resident reviewed for abuse. The findings included: The facility reported an allegation of physical abuse of Resident #1 by CNA (certified nurse aide) #1 on 3/3/16. The description indicated CNA #1 was observed by 2 co-workers slapping Resident #1 in the face while delivering ADL (activities of daily living) care to the resident. Review of the facility's Five-Day Follow-Up Report dated 3/7/16 indicated the facility found evidence of physical abuse. CNA #3's facility-obtained statement dated 3/3/16 indicated s/he was asked to get Resident #1 up for the day. S/he, CNA #1 and CNA #2 went to the resident's room around 10:00 AM. As they began to care for Resident #1 s/he became a little combative with CNA #1. Resident #1 settled down as they talked to him/her and they were able to finish getting him/her dressed and in the chair. Resident #1 suddenly reached up and smacked CNA #1 in the face. CNA #1 then smacked Resident #1 on the face with an open hand. CNA #3 told CNA #1 s/he couldn't do that and CNA #1 said (s/he) messing with the wrong one. CNA #2's facility-obtained statement dated 3/3/16 indicated at approximately 10:00 AM s/he witnessed an alarming situation. CNA #1 was providing care for Resident #1 along with him/her and CNA #3. Resident #1 seemed to be combative when CNA #1 slapped the resident across the face. Immediately after the slap CNA #1 then said to the resident you're messing with the wrong one. In a telephone interview with the surveyor on 7/7/16 at approximately 10:05 AM, CNA #2 stated that s/he was in the room with CNA #1 and Resident #1 on 3/3/16. They were trying to get the resident up and dressed. Resident #1 was combative and hit CNA #1 in the face. CNA #1 hit the resident back on the face. S/he also stated you messing with the wrong one.

Based on review of facility files and interview, the facility staff failed to implement policies to ensure each resident remained free from physical abuse. CNA #1 hit Resident #1 across the face while providing care. The incident was witnessed by two other employees. One of one resident reviewed for abuse. The findings included: The facility reported an allegation of physical abuse of Resident #1 by CNA (certified nurse aide) #1 on 3/3/16. The description indicated CNA #1 was observed by 2 co-workers slapping Resident #1 in the face while delivering ADL (activities of daily living) care to the resident. Review of the facility's Five-Day Follow-Up Report dated 3/7/16 indicated the facility found evidence of physical abuse. CNA #3's facility-obtained statement dated 3/3/16 indicated s/he was asked to get Resident #1 up for the day. S/he, CNA #1 and CNA #2 went to the resident's room around 10:00 AM. As they began to care for Resident #1 s/he became a little combative with CNA #1. Resident #1 settled down as they talked to him/her and they were able to finish getting him/her dressed and in the chair. Resident #1 suddenly reached up and smacked CNA #1 in the face. CNA #1 then smacked Resident #1 on the face with an open hand. CNA #3 told CNA #1 s/he couldn't do that and CNA #1 said (s/he) messing with the wrong one. CNA #2's facility-obtained statement dated 3/3/16 indicated at approximately 10:00 AM s/he witnessed an alarming situation. CNA #1 was providing care for Resident #1 along with him/her and CNA #3. Resident #1 seemed to be combative when CNA #1 slapped the resident across the face. Immediately after the slap CNA #1 then said to the resident you're messing with the wrong one. In a telephone interview with the surveyor on 7/7/16 at approximately 10:05 AM, CNA #2 stated that s/he was in the room with CNA #1 and Resident #1 on 3/3/16. They were trying to get the resident up and dressed. Resident #1 was combative and hit CNA #1 in the face. CNA #1 hit the resident back on the face. S/he also stated you messing with the wrong one. Review of the facility's Patient/Resident Abuse Policy revealed it is the policy of the facility to provide all residents with protection from any form of physical abuse.

Based on observations, record review, and interviews, the facility failed to identify the potential for pain and develop a plan of care to attempt to prevent or address pain for Resident #10, 1 of 3 sampled residents reviewed for pain management The findings included: The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Observations throughout the survey revealed the resident was nonverbal, had contractures of bilateral upper and lower extremities. While seated in the reclined gerichair on 1-25-16 at 12:40 PM, the resident had arms tightly crossed across her/his chest and held close to her/his body, knees bent and leaning to the left, against the chair arm. No positioning pillows were in evidence. The resident appeared to be grimacing as Certified Nursing Assistant (CNA) #2 fed her/him. Following the meal, the resident seemed to relax until CNA #2 repositioned the gerichair into the upright position, at which time the resident visibly stiffened, frowned, and appeared guarded. The CNA removed the resident from the table, got a washcloth, and began cleansing the resident's face from her/his left side and slightly behind the chair. The resident was enucleated on the left. Resident #10 grimaced and grabbed the surveyor's arm and squeezed tightly. At 2:47 PM and 4:25 PM, the resident was observed in a low bed, positioned appropriately on her/his side. S/he responded to her/his name by opening her/his eyes. No frowning/grimacing was in evidence. The resident appeared relaxed. On 1-26-16 at 8:45 AM and 1-27-16 at 8:41 AM, Resident #10 was observed in the activity room, seated in a reclined gerichair in front of the television. Both times, a staff member was observed walking away from the resident's side. The resident was frowning/grimacing as if in pain and appeared to be guarding her(him)self. The resident's knees were bent and against the arm of the gerichair. At 8:45 AM on 1-27-16, the resident began to moan. At 9:40 AM, the resident appeared relaxed and resting in bed. Certified Nursing Assistant (CNA) #1, assigned to Resident #10's care, stated that s/he got the resident up with a lift. When asked if and when range of motion (ROM) was provided, the CNA stated s/he would do the exercises prior to getting the resident up to the gerichair for lunch. CNA #1 stated the resident tolerated ROM well. S/he doesn't hardly grunt or anything. At 11:08 AM, upon entering the room, the surveyor observed the resident uncovered, gritting her teeth and frowning. CNAs #1 stated that s/he and CNA #3 were preparing to do ROM and then get Resident #10 out of bed with the lift. As the CNA's lifted and extended the resident's arms and legs during the exercises, the resident intermittently groaned and gritted her/his teeth. The resident tightly gripped both staff members' arms/hands as CNA #1 attempted' to extend the right leg and CNA #3 was flexing and extending the left arm. CNA #3 brought the resident's tight grip to the surveyor's attention. When the surveyor called attention to the resident's moaning, CNA #1 stated that s/he normally moans with ROM. The right leg hurts more than left. The left is more looser. The surveyor called attention to and CNA #1 affirmed the resident's frowning and moaning when CNA #3 left the room to obtain a gerichair and lift. The resident held her(his) body stiffly and began moaning and gritting her/his teeth again when positioned on the sling, elevated, and transferred to the gerichair. When left alone, after several minutes, the resident visibly relaxed in the chair and straightened her/his arms and legs out (left > right). Record review on 1-27-16 at 9 AM revealed physician's orders [REDACTED]. and [MEDICATION NAME] 325 mg (milligrams) tablet. Take 2 tablets by mouth every 4 hours as needed for pain. Review of the 8-20-15 and 11-19-15 Pain Assessments revealed the resident was unable to answer. No signs/symptoms of pain were noted. Review of the 11-15 through 1-16 Medication Administration Records (MAR) on 1-27-16 at 9:20 AM revealed that the resident had not received anything for pain in the 3 month period and the documented pain level was 0. During an interview on 1-27-16 at 12:56 PM, the attending physician stated s/he was familiar with the resident. When you go to touch or move her, she's (he's) always frowning. S/he stated the resident was unable to communicate due to End-Stage [MEDICAL CONDITION]. When told about the symptoms displayed during the survey and especially at the time of the observed transfer, s/he agreed these signs and symptoms were indicative of pain. The physician stated s/he was not aware of other symptoms and stated, Its our job to keep her (him) comfortable. Review of the Care Plan on 1-27-16 at 9:09 AM revealed no plan to address pain or the potential for pain, in consideration of [DIAGNOSES REDACTED]. During an interview at 1:20 PM, the Minimum Data Set (MDS)/Care Plan (CP) Coordinator reviewed the Care Plan and verified that the Care Plan did not address pain management or the potential for pain. The nurse stated s/he had not been aware until today that Resident #10 had been exhibiting signs and symptoms of pain but that the resident's needs would have to be anticipated because of her/his non-verbal status. With the resident's [DIAGNOSES REDACTED].

Based on record review and interview, the facility failed to review and revise the care plan with appropriate interventions after falls for Residents #6, 1 of 2 sampled residents reviewed for accidents. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 01/27/2016 at 8:27 AM, review of the incident report dated 1/18/16 revealed the resident was in her wheel chair, bending over, slipped to the floor and landed in the sitting position. An alarm was intact and sounded. On 01/27/2016 at 11:42 AM, review of the POF revealed orders for bed and chair alarms and for blue (fall) mats at bedside to ensure resident safety. 01/27/2016 11:51:26 AM review of the nurses notes revealed a note dated 1/18/16 of a witnessed fall when the resident slipped out of the wheel chair with no injuries noted. The RP (Responsible Party) and MD (Medical Doctor) were notified. The resident was noted to have a low bed. Record review also revealed a daily dressing change to a laceration of the forehead in October, 2015 which required sutures. On 01/27/2016 at 12:08 PM, review of the undated care plan revealed Potential for fall/accident/injury was identified as a problem. Interventions included side rails, incontinent care, reinforce use of call light, clutter free environment, assistive devices, bed in low position, sit with resident when leaning PRN, reminders not to lean, provide diversional activities, and sit with resident when anxious. The care plan was updated at the time of the fall to continue the current care plan. Review of the 1/13/16 care plan revealed no new interventions. On 01/27/2016 at 1:17 PM, review of a 10/2/15 incident report revealed the resident was found in the floor of the activity room on 10/2/15 with her face on the floor and bleeding from the forehead. The resident was sent to the ER (emergency room ) for evaluation. On 01/27/2016 at 1:40 PM, review of the Fall Assessments with the Director of Nursing (DON) revealed no new interventions were added to prevent falls from the wheel chair. During an interview on 01/27/2016 at 1:41 PM, the DON confirmed the resident fell from the wheel chair on both occasions. S/he stated that the staff has been instructed to keep an eye on the resident and to keep the resident in areas where s/he was visible and to put the resident back to bed if observed leaning and reaching for things to make the environment safer because the resident had fall mats beside the bed. The DON confirmed the care plan had not been updated to include those interventions. The DON further confirmed the fall preventions listed on the care plan were not appropriate for a resident falling from a wheel chair.

On the days of the Recertification Survey, based on observation, interview, and review of the facility's policy titled "Storage of Medications", the facility failed to ensure one medication container of expired medications was destroyed per policy. Additionally, 23 tablets of Mucinex were noted without an expiration date in one of one medication cart reviewed. The findings included: During a review of the medication cart contents on 4/30/13 at 9:59 AM, the following was observed: 1) One resident medication drawer contained a unit dose container of 15 expired Lasix pills, 2) Mucinex 600 mg Extended Release bi-layer tablets were located in two medication drawers without expiration dates noted on the package ( one resident medication drawer contained 11 tablets and the second resident medication drawer contained 12 tablets). During an interview with Licensed Practical Nurse #1 on 4/30/13 at approximately 10:10 AM, s/he verified the Lasix was expired and the Mucinex 600 mg Extended Release tablets did not have an expiration date noted on the packaging. During a review of the facility policy and procedure titled "Storage of Medications" on 5/2/13 at 9:00 AM, the policy stated, "No discontinued, outdated, or deteriorated drugs or medications shall be stored in this facility".

On the days of the Recertification Survey, based on observations, and interviews the facility failed to assure PDI Super Sani-Cloth Germicidal Disposable Wipes were being used within the expiration time frame. The findings included: During a review of the medication storage room on [DATE] at 10:40 AM, two single use packets of PDI Super Sani-Cloth Germicidal Disposable Wipes were located in the blood glucose caddy and three single use packets of PDI Super Sani-Cloth Germicidal Disposable Wipes were located on the treatment cart. The MFG (manufacturing) date of ,[DATE] without an expiration date was noted on all five single dose packets. During a interview with Licensed Practical Nurse (LPN) #1 on [DATE] at approximately 10:50 AM, s/he verified the manufacturing date of ,[DATE] located on the PDI Super Sani-Cloth Germicidal Disposable Wipes and stated :"This is what we use to clean the glucometer". During an interview with LPN #1 and the Unit Clerk on [DATE] at 10:51 AM, the Unit Clerk stated, "I will contact the company for information regarding an expiration date and get the Material Safety Data Sheet (MSDS)". The Unit Clerk provided a letter from the Manufacturing Company and the MSDS information on [DATE] at 11:30 AM. The Unit Clerk provided a letter faxed to the facility on [DATE] dated [DATE], which stated the "Super Sani-Cloth will continue to be stamped with the manufacture date (MFG) in which the shelf life is 2 years from the date of manufacture". The Director of Nursing (DON) at 1:45 PM on [DATE] stated "I want to thank you for notifying us of the expired Sani-Cloth packets which have all been removed from the unit". The DON also stated s/he checked with the purchaser at the hospital who orders the supplies for the nursing facility, and s/he was unaware that a letter had been mailed to all facilities and distributors on [DATE]. The purchaser was also unaware that the Sani-Cloth wipes had a 2 year shelf life.

On the days of the survey, based on record review and staff interviews, the facility failed to coordinate a plan of care for 1 of 1 residents (Resident #7) receiving Hospice services. The findings included: The facility admitted resident #7 on 11/02/2010 with [DIAGNOSES REDACTED]. Review of the medical record revealed the facility had completed a care plan on 11/18/2010. On 11/24/2010 the resident was admitted to Hospice services. A Hospice Care Plan was dated for 12/1/2010. The facility did not update their plan of care to include Hospice Services and the Hospice Care Plan did not address the services that would be performed by the facility. The Hospice Service reviewed and updated their Plan of Care on 12/6/2010, 12/14/2010, 12/28/2010, and on 1/5/11. There was no evidence of facility involvement in the Hospice care plan. RN (Registered Nurse) #1 was asked on 1/19/2011 at 10:50 AM, "What does the 2m, 3m, 8 prn mean on the Hospice Face Sheet"? RN #1 stated that she did not know but that the Hospice Nurse could be called". A call was placed to the Hospice nurse, who spoke to the Surveyor. The Hospice Nurse explained, "The 2m-3m means 2-3 visits a month and 8 visits as needed." The DON (Director of Nursing) was interviewed on 1/19/2010 at 11:40 AM. She agreed that there was no evidence of coordination of the resident's plan of care between the facility and the Hospice service. She stated that the facility had a care plan and Hospice had a care plan. LPN (Licensed Practical Nurse) #1 was interviewed on 1/19/2011 at 11:55 AM. She stated she was unaware if the Hospice Service was providing a CNA (Certified Nursing Assistant) or not. Although both the facility and the Hospice Service had a plan of care, there was no plan of care coordinated between the two entities. There was nothing to identify what care the facility would be responsible for or what the Hospice would be responsible for. The facility had one problem noted on their plan of care dated 11/16/2010 of Death/Dying issues that included an approach to refer pain to Hospice care plans. However, Hospice did not admit the resident to their services until 11/24/2010.

On the days of the survey, based on record review and staff interviews, the facility failed to perform a significant change assessment for 1 of 1 residents (Resident #7) receiving Hospice services. The facility did not conduct a Significant Change Assessment for Resident #7 who was admitted to Hospice Services for a terminal illness. The findings included: The facility admitted resident #7 on 11/02/2010 with [DIAGNOSES REDACTED]. Review of the medical record revealed the facility had completed a care plan on 11/18/2010. On 11/24/2010 the resident was admitted to Hospice services. During record review on 1/19/2011, there was no Significant Change Assessment on the medical record following admission of the resident to Hospice services. The DON (Director of Nursing) was interviewed on 1/19/2010 at 11:40 AM. The DON stated that she was not aware that a Significant Change Assessment had to be completed when a resident was admitted to Hospice services. LPN (Licensed Practical Nurse) #1 was interviewed on 1/19/2011 at 11:55 AM. LPN #1 was responsible for completing the Comprehensive Assessments. She stated that she had not been aware that a Significant Change Assessment was required when a resident was admitted to Hospice Services.