Every finding on record at Oaks Nursing Home, Inc, The

Based on observations, staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two of 26 sampled residents (R) (R7 and R25) had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate assessment and care planning of the residents. Findings include: Review of the RAI Manual dated 10/01/2019 indicated, . information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. 1. Review of R25's admission Record located in the electronic medical record (EMR) tab titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, metabolic encephalopathy, major depressive disorder, and dementia. Review R25's Care Plan, dated 5/13/2025, located in the EMR Care Plans tab, revealed the resident was at risk for falls related to impaired mobility as well as psychotropic drug use. The intervention dated 10/25/2023 indicated the use of a clip alarm to alert the staff if the resident attempted to stand up. Review of R25's Significant Change MDS with an Assessment Reference Date (ARD) of 2/14/2025, located in the EMR MDS tab, revealed that Section P did not reflect the residents' use of the clip alarm. In an interview on 6/19/2025 at 11:12 am, the MDS Coordinator (MDSC) acknowledged that R25's Significant Change MDS, dated [DATE], did not reflect the resident's use of clip alarms. The MDSC stated the resident had been using the clip alarm since 2023. 2. R7 was observed in a reclining geriatric chair in the common area with a personal tabs alarm in place on 6/17/2025 at 9:08 am; on 6/18/2025 at 9:03 am and 11:29 am; and on 6/19/2025 at 8:35 am. Review of R7's Significant Change MDS with an ARD of 4/28/2025 and located under the MDS tab in the EMR revealed that the chair alarm section in Section P was coded with a 0 (zero) for the use of a chair alarm (indicating there was no chair alarm used). Review of R7's care plan under the care plan tab of the EMR revealed a fall care plan stating she was at risk for falls due to impaired mobility with a revision date of 3/31/2025. The clip alarm was added as an intervention on 3/31/2025. In an interview on 6/19/2025 at 9:52 am, the MDSC verified she had inaccurately coded R7's MDS assessment dated [DATE].

Based on observation, staff interview, and record review, the facility failed to revise the care plan of one of 26 sampled residents (R) (R16) for the use of a bed cradle. This failure had the potential to place R16 at risk of not receiving treatment to prevent skin breakdown. Findings include: Review of R16's admission Record, located in the electronic medical records (EMR) Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included Parkinsonism, diabetes mellitus type II, dementia, and contracture of other joints. Review of R16's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/10/2025, located in the EMR MDS tab, revealed the resident had impaired cognition. The resident was assessed to be dependent on staff for all activities of daily living (ADLs). The resident was assessed to be at risk for pressure ulcers. Review of R16's admission Assessment by the wound care nurse (WCN) on 3/16/2024 in the EMR Progress Notes tab revealed the resident was noted to have boggy heels with redness. Review of additional WCN notes dated 5/14/2024 revealed R16 had redness to the great toes. Treatment included skin prep and a bed cradle. Review of R16's Care Plans, with a revision date of 4/30/2025, located in the EMR Care Plans tab, revealed the resident was identified to be at risk for skin breakdown due to limited mobility. The care plan interventions did not reflect the use of the bed cradle to prevent pressure on the residents' feet. Observation on 6/16/2025 at 3:05 pm revealed R16 in bed position on her back with bilateral heel protective dressings and a bed cradle in place. In an interview on 6/18/2025 at 10:30 am, the WCN revealed the resident had boggy heels on admission to the facility, and then a few weeks later, the resident had redness to the big toe on both feet. The WCN stated the interventions included skin prep to the heels and great toes and use of a bed cradle to prevent pressure to the resident's toes. The WCN stated the interventions should be on the resident's care plan. The WCN stated that only the MDS Coordinator (MDSC) could revise the residents' care plans. In an interview on 6/19/2025 at 11:12 am, the MDSC revealed the WCN had asked her this morning about the bed cradle being added to the resident's care plan. The MDSC stated that she reviewed R16's care plan, and the intervention for the bed cradle had been omitted from the care plan. The MDSC confirmed that she was the only person allowed to revise the residents' care plans.

Based on observations, staff interviews, and a review of the facility documents titled, Infection Control for Dietary, and Leftovers, the facility failed to ensure that items in the dry storage area, freezers, and refrigerators were labeled and dated with a use by or expiration date. The facility also failed to ensure that cell phones were not left in clean storage areas of the kitchen. This deficient practice had the potential to affect 57 of 58 residents receiving an oral diet. Findings: A review of an undated facility document titled Infection Control for Dietary, revealed, It is our practice to follow the following procedures: 4. Cover, label, and date all leftover foods stored in refrigerators. A review of an undated document titled Leftovers, revealed: Immediately after serving, leftover foods should be refrigerated in a covered container that is labeled and dated. All leftovers are to be thrown away after 48 hours (2 days). Any unlabeled food found in the refrigerator will be thrown away. The initial kitchen tour began on [DATE] at 7:50 am with Dietary Supervisor DD. The Certified Dietary Manager (CDM) joined the tour while the surveyor was observing the dry food storage area. The following observations were confirmed at the time of observation via interview by either the Dietary Supervisor DD or the CDM: In the walk-in cooler, there were five large white containers containing tea with the dates ranging from [DATE] to [DATE]. Dietary Supervisor DD reported that tea was made daily, and the staff may have forgotten to change the dates on the tops of the containers. Observation in the dry food storage area revealed: a large container that was labeled as sugar, but it did not have an in-date or a use-by date, and a large container that was a quarter full which contained flour and did not have an in-date or a use-by date. Dietary Supervisor DD reported the containers were cleaned every weekend and cleaned as needed. Observation revealed that there was buildup in the handles of the sugar and flour containers. Further observation revealed a box with multiple bags of gelatin in it sitting on a shelf, but there was no way to identify when the gelatin arrived or when the gelatin expired. The CDM reported that the gelatin was removed from its original box and placed into the current box and confirmed that there was no expiration or use-by date on the gelatin. Observation revealed pie crusts on a shelf, not in a box and there was no in-date or expiration date. CDM confirmed that there was no way to determine when the pie crusts expired. Further observation revealed a cart with several loaves of bread and only two of the loaves had an expiration date. CDM reported that the bread is delivered to the facility frozen and the bread is then removed from the original box and stored in the freezer. Once they are ready to use the bread it is defrosted. However, CDM was unable to identify how long the bread should be kept once defrosted. Observations in the stand-up freezer in the dry food storage area revealed a bag of potato wedges, a bag of sweet potato fries, a bag of breaded okra, two bags of fried rice, two bags of imitation crab meat, and a bag of corn nuggets that did not have received or expiration dates. Further observation in the stand-up freezer revealed three individual personal-size pepperoni pizzas that were not in the original container and did not have a received date or an expiration date. Observation in the reach-in refrigerator located near the ice machine revealed a bowl of chicken noodle soup dated [DATE] without a use-by or expiration date, and a bowl of gravy dated [DATE] and [DATE] without a use-by or expiration date. In an interview at 8:36 am, the CDM reported that the second date was placed on the gravy probably because that is the date that it was warmed up and stated the items in the refrigerators should be used within three days of the storage date. Observations of the walk-in cooler during the kitchen tour on [DATE] at 11:14 am revealed one 10-pound box of cucumbers with no in-date or use-by date. The cucumbers had a white fuzzy substance on them; one box of tomatoes without a received date or a use-by date; one 50-pound box of potatoes with no received date or no use-by date. When the lid was removed from the box of potatoes, observation revealed one potato sitting near the top had a white fuzzy substance on it. The CDM confirmed the observations. The CDM reported that the vegetables were delivered on Tuesday of this week and the items in the cooler should be checked daily. The CDM further reported the box of cucumbers and the potato had not been identified prior to observation with the surveyor. A further tour of the kitchen on [DATE] at 3:20 pm with Dietary Supervisor DD of the dry food storage area revealed two loaves of bread on a cart, one plastic container labeled rice, and one plastic container labeled pasta, and all were without received or expiration dates. Observations in the stand-up freezer in the dry food storage area revealed three bags of sweet potato fries, two bags of fried rice, two bags of imitation crab meat, and three individual pepperoni pizzas that did not have received dates or expiration dates. Dietary Supervisor DD acknowledged that she had removed the bread from the freezer this morning and it will be used for breakfast tomorrow. Dietary Supervisor DD reported that the rice and pasta in the white containers will likely be used within a month. She confirmed that the items in the stand-up refrigerator in the dry storage area were not labeled with received dates or expiration dates. During an interview with the Administrator on [DATE] at 9:03 am she reported that the kitchen was discussed in the morning meetings and during Quality Assurance meetings but there were no current Performance Improvement Plans (PIP) for the kitchen/dietary. During an interview on [DATE] at 9:14 am, the Administrator provided blank documents of the morning QA sheet and Quality Assurance Meeting sheet. She again reported that there were no current (PIPs) for the kitchen. During an interview on [DATE] at 9:39 am the CDM reported that all dietary staff were responsible for labeling food items and this process was discussed during orientation. During an interview on [DATE] at 10:05 am with Dietary Aide BB in the dry storage area he reported that he was responsible for sweeping, mopping, stocking, and dishes. He reported that they clean daily but extra cleaning is done on Sundays. Dietary Aide BB reported that he had cleaned the large containers labeled flour and sugar, but the handles still had flour and other food buildup. Dietary Aide BB reported that he was not aware of having to put dates on items when putting them in the freezer or when stocking the shelves. During an observation and interview on [DATE] at 10:14 am with the CDM she confirmed the presence of rust and cobwebs on the shelves holding the canned items. CDM denied that she had spoken to anyone about replacing the rusty shelves. Dietary Supervisor DD reported that they have never had to put dates on food items before. Interview with Dietary Aide CC on [DATE] at 10:22 am revealed that leftovers can be stored in the refrigerator for three days and items should have an in-date and a use-by date. During an observation on [DATE] at 10:25 am in the kitchen near the dishwasher area, there was a cart that typically holds cleaned dishes that had a soiled towel on it, and a cell phone was lying on it. The CDM removed the phone and towel and acknowledged it did not belong there.

Based on observations, staff interviews, and record review, the facility failed to monitor and clean the respiratory equipment per medical doctor (MD) orders for one resident (R) (R26). The sample size was 24 residents. Findings include: On 1/20/2024 at 3:31 pm, the facility Director of Nursing (DON) informed the survey team that the facility did not have policies related to cleaning oxygen concentrators or following MD orders. Observations on 1/19/2024 at 9:28 am and 2:41 pm and on 1/20/2024 at 7:55 am of R26's oxygen concentrator revealed the slated exterior vent cover on the back of the concentrator had obvious dust covering the slats. The interior filter was noted to be visibly dirty, with an accumulation of dust on the interior vent slats. The filter was dirty. R26 was wearing her oxygen and receiving the oxygen via nasal cannula (NC). A review of the MD orders dated 11/2/2023 revealed that R26's oxygen concentrator filter was to be cleaned during every night shift. During an observation of R26's oxygen concentrator and interview with the Registered Nurse Supervisor (RNS) AA on 1/20/2024 at 8:22 am, RNS AA acknowledged that R26's oxygen concentrator covers, slats, and filter were dirty. During a follow-up with the RNS AA, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) on 1/20/2024 at 8:39 am, they revealed staff were supposed to monitor the concentrator daily to ensure the oxygen filter was clean. They stated that the oxygen concentrator and filter should have been cleaned as ordered. During an interview with the DON on 1/21/24 at 8:50 am, she acknowledged the oxygen concentrator had not been cleaned daily per MD orders.

Based on observations, staff interviews, and a review of the dietary menu cycle, the facility failed to ensure staff followed food recipes for preparing pureed foods for four of four residents who received a puree diet. This failure had the potential to compromise the nutritive value of tuna sandwiches for four of the four residents who received a puree diet. Findings include: During an interview on 1/20/2024 at 11:25 am, Dietary Supervisor EE was informed that recipes would be needed when observing the puree meal later in the day. The Dietary Supervisor EE reported that recipes were not used by the dietary staff. She went on to report that she had been cooking for over [AGE] years and she knew how to prepare items. On 1/20/2024 at 3:10 pm Dietary Aide II was observed performing a puree of tuna salad for the dinner meal. At the time of the surveyor's arrival, Dietary Aide II had already pureed the bread. Observation revealed there was tuna in a can and thickener on the table. Dietary Aide II reported that she was using a four-ounce (oz) scoop to portion out the amount needed for the meal. Five scoops of tuna were put in the blender and an unmeasured amount of liquid from another can of tuna was poured into the blender. Dietary Aide II stated there were only four residents who received a puree meal. Once the tuna was blended, one four-oz scoop of thickener was added to the blended tuna, and the mixture was blended again. The tuna mixture was then placed into a container, covered, and placed in the refrigerator. Dietary Aide II stated that one four-oz scoop was the equivalent of one portion size for each resident. Dietary Aide II was not observed to follow a recipe while preparing the pureed tuna sandwich for residents who received a pureed meal. A review of the menu cycle for week number 3 did not specify portion sizes or a breakdown of meals per dietary needs. The menu indicated Tuna Sandwich for the supper meal on Saturday (1/20/2024). During an interview with the Administrator on 1/21/2024 at 9:03 am, she reported that the kitchen was discussed in the morning meetings and during quality assurance meetings, but there were no current Performance Improvement Plans (PIP) related to the kitchen. During an interview on 1/21/2024 at 9:39 am with the Certified Dietary Manager he/she reported that dietary staff typically cooked items prior to the puree process. CDM was informed of the surveyor's observation of the puree process on 1/20/2024 related to the pureed tuna sandwich, which consisted of tuna, liquid from a separate can of tuna, and food thickener. CDM reported that the tuna sandwich should have been prepared the regular way prior to blending/pureeing it. CDM went on to report that mayonnaise should have been added to the tuna during the blending of the puree. A tour of the kitchen with the CDM began on 1/21/2024 at 10:05 am and ended at 10:25 am. The CDM provided a book with recipes and menus that had been signed by a Registered Dietitian (RD). However, she reported that this book was not for the current menu cycle nor did the current RD sign off on these menus. She went on to explain that the recipes were not current, but they were used as a guide in determining portion sizes for the residents. A recipe was found for Tuna Salad but CMD and Dietary Supervisor DD both reported that it could not be used because it was not for the current meal cycle. The Dietary Supervisor DD reported that she notified someone in the office yesterday that they did not have current menus signed by the RD and the RD was supposed to send the signed menus to the facility.

Based on observation, record review and staff interview, the facility failed to develop a diabetes care plan for one resident (R) #42. The sample size was 23 residents. Findings include: Review of R #42's clinical record revealed that she had [DIAGNOSES REDACTED]. Further review of the physician's orders [REDACTED]. Review of her Medication Administration Records (MAR) revealed that the FSBSs were scheduled before meals at 6:30 a.m., 11:30 a.m., and 4:30 p.m. Further review of the MARs revealed an order to check the blood sugar if the resident was symptomatic, such as diaphoresis (sweating), confusion, combativeness, or lethargy. Review of R #42's FSBS results from January to March of 2017 revealed that her blood sugars varied from a low of 61 on 3/15/17 at 6:30 a.m., to a high of 512 on 2/14/17 at 4:30 p.m. Review of a Hgb A1C (glycosylated hemoglobin, a blood test that reflects the mean glucose concentration over a period of approximately eight to twelve weeks) dated 2/10/17 revealed a result of 7.7 (normal less than 5.7). Review of R #42's Annual Minimum Data Set ((MDS) dated [DATE] and her Quarterly MDS dated [DATE] revealed that she received insulin all seven days of the assessment period. Review of R #42's care plans revealed that none of them addressed the management of her diabetes. On 3/14/17 at 5:08 p.m., Licensed Practical Nurse (LPN) AA was observed to perform R #42's FSBS, and obtained a result of 309. During medication administration observations on 3/14/17 at 5:18 p.m., LPN AA was observed to give 10 units of Humalog insulin subcutaneously to R #42. During interview with the MDS Coordinator on 3/16/17 at 9:35 a.m., she stated that she typically put information for a diabetic resident in their nutrition care plan. Review of R #42's potential for nutritional complications care plan at this time revealed the only information included that might indicate that R #42 was diabetic was that she was on a NCS (no concentrated sweets) diet. During further interview with the MDS Coordinator at this time, she stated that the nurses monitored R #42's blood sugars and that she received insulin, and verified that this was not included anywhere in the plan of care.

Based on observation, staff and resident interviews and facility physical plant safety checklist review, the facility failed to ensure that the water temperatures in resident rooms and common shower rooms on two (2) of four (4) hallways (B and D) were not greater than 120 degrees Fahrenheit (F). Findings include: 1. Observations during initial tour of the facility on 12/10/12 between 11:15 a.m.-12:10 p.m. revealed that water temperatures on the D-Hall measured greater than 120 degrees F. .Temperatures were taken with Maintenance/Housekeeping staff "AA", who used a gold colored digital thermometer. The following rooms and water temperatures were identified as a concern: Room D-1: 122.3 Room D-2: 122.7 Room D-3: 121.3 Room D-4: 121 Room D-5: 121.3 Room D-6: 122.3 Interview with maintenance staff "AA" on 12/10/12 at 11:15 a.m. revealed that the D-hall has it's own hot water tank. Continued interview revealed that there is one (1) person responsible for taking water temperatures every other week and maintain a log of the temperatures. Review of Physical Plant Safety Checklist dated 2/2012-11/2012 revealed that the checklist, completed on a monthly basis, revealed water temperatures ranging from 106-112 degrees F on the B and C halls. There was no evidence that water temperatures had been taken on the D hall. During interview with the Administrator on 12/10/12 at 2:55 p.m., he confirmed that the Physical Plant Safety Checklist only had temperatures recorded for the B and C halls. Interview with resident "Z" on 12/10/12 at 3:20 p.m., with the administrator in attendance, revealed that he/she showers five (5) times per week and that the water is always hot. Continued interview revealed that he/she has to be extremely carefully when using the shower in his/her bathroom. Interview with resident "A" on 12/11/12 at 10:15 a.m. revealed that he/she showers three (3) times a week with the help of staff and that the water is hot. Continued interview revealed that Monday he/she had to ask the Certified Nursing Assistant (CNA) to turn down the water because it was too hot. 2. Observations on 12/10/12 between 11:35 a.m and 12:05 p.m. with maintenance staff "AA" revealed water temperatures on the B hall were measured higher than 120 degrees F. Water temperatures were checked with the facility digital thermometer Bathrooms water temperatures on B hall above 120 degrees F were: Room B2-120.7 Room B4-120.2 Room B6-120.2 Room B9-121 Room B10-122 Room B11-122 Room B12-122 B hall shower 120

Based on record review, observation and staff interview, the facility failed to provide an accurate assessment for dental/oral care for two (2) residents (#43 & "A"), from a sample of twenty-six (26) residents. Findings include: 1. Record review for resident # 43 revealed that the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].. Observation on 07/25/11 at 11:51 a.m. revealed the resident's teeth were discolored brown, rotted, jagged, broken and multiple upper and lower teeth were missing. Review of the current quarterly Minimum Data Set (MDS) assessment 3.0 dated 06/06/11 and annual MDS dated [DATE] revealed no evidence that the resident's oral/dental status was assessed accurately. Review of the Nursing Admission assessment dated [DATE] revealed the resident had her own teeth and they were in poor condition. Interview with Care Plan Coordinator, Registered Nurse "EE" on 07/26/11 at 3:35 pm, revealed that after reviewing the current annual MDS 3.0, there was no information about the resident's teeth. Continued interview revealed that after reviewing the admission nursing assessment, the nurse verified that the resident was assessed as having teeth in poor condition. Observation on 07/26/11 at 3:40 p.m. with the Care Plan Coordinator, Registered Nurse (RN) "EE" revealed that, after looking at the resident's teeth, she confirmed that the resident's teeth were discolored, brown, jagged and some were missing. Observation on 07/27/11 at 9:12 am revealed resident #43 in her room sitting in her lounge chair watching TV. There was one (1) upper front rotted tooth hanging down below the upper lip. 2.Interview on 07/26/11 at 10:23 a.m. with a family member of resident "A" revealed that the resident was losing teeth, had only a few teeth left, and that the resident's breath was bad. Observation on 07/25/11 at 12:10 p.m.; 07/26/11 at 10:51 a.m.; and 07/27/11 at 11:25 a.m., revealed resident "A" with a strong, unpleasant odor to their breath. Observation on 07/27/11 at 10:00 a.m., revealed that the resident's teeth were yellowed, and several teeth in the front appeared uneven and/or broken. Observation on 07/27/11 at 10:00 a.m. of Certified Nursing Assistant (CNA) "BB" providing oral care for resident ''A" revealed that the resident's teeth were yellowed, and several teeth in the front were uneven and/or broken. Review of the resident's Annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS assessment dated [DATE] noted that there were no oral or dental abnormalities. Interview on 07/27/11 at 10:20 a.m. with the MDS/Care Plan Coordinator revealed that resident mouths were assessed on admission, and with the yearly MDS assessment. Continued interview revealed that she was responsible for doing the yearly oral/dental assessment, and because resident "A" was uncooperative she could not remember if she actually looked in the resident's mouth. The MDS/Care Plan Coordinator verified that she assessed the resident as having no dental problems on the January MDS. Review of the "Oral Assessment" section of the Admission Nursing assessment dated [DATE] noted that a complete oral cavity exam was done; the condition was poor; and that some of the resident's natural teeth were missing. Interview on 07/27/11 at 11:15 a.m. with the MDS/Care Plan Coordinator revealed that the admission MDS dated 02/19/09 had assessed the resident as having assessed the resident as having some/all of their natural teeth lost. Continued interview revealed that this information did not carry over when she changed to a different MDS software system. Interview on 07/27/11 at 12:45 p.m .with the Director of Nurses revealed that she was aware that the facility needed to do a better job with assessing residents' oral and dental status.

Based on record review and staff interview it was determined that the facility failed to follow the plan of care related to falls for one (1) resident (#21) from a sample of twenty-four (24) residents. Findings include Review of the clinical record for resident #21 and the facility accident log revealed that on 7/14/2011 the resident was being transferred by one (1) Certified Nursing Assistant (CNA) from her bed to the gerichair when she fell to the floor and sustained 2 skin tears. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required total assist with all transfer and required two (2) persons physical assist. Review of the resident care plan revealed that the resident was care planned as requiring two (2) staff members for transfer. Interview with Director of Nurses on 7/27/2011 at 10:20 a.m. revealed that during the investigation of this fall she discovered that only one (1) CNA attempted to transfer resident #21 alone when the fall occurred. During the investigation of the fall, it was determined the the CNA was aware that it required two (2) persons transfer this resident but thought she could do it alone. Interview with Staff Trainer conducted on 7/27/2011 at 11:00 a.m. revealed that CNA's are trained to always follow residents care plans, facility policy and procedures in transferring residents. The number of persons needed for transferring residents is posted above all resident's beds.

Based on record review and staff interview, the facility failed to provide adequate supervision to prevent falls for one (1) resident (#21) from a sample of twenty-four (24) residents. Findings include: Review of the clinical record for resident #21 and the facility accident log revealed that on 7/14/2011 the resident was being transferred by one (1) Certified Nursing Assistant (CNA) from her bed to the gerichair when she fell to the floor and sustained 2 skin tears. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had been assessed as total assist with all transfers, requiring two (2) persons to physically assist. Review of the residents care plan revealed that the resident was care planned as needing two (2) persons to assist with transfers. Interview with the Director of Nurses (DON) on 7/27/2011 at 10:20 a.m. revealed that during the investigation of this fall she discovered that only one (1) CNA had attempted to transfer resident #21 on 7/14/2011. Continued interview revealed that the CNA believed that she could transfer the resident alone even though the resident was assessed as requiring two (2) persons for transfer. Interview with the Staff Trainer on 7/27/2011 at 11:00 a.m. revealed that this CNA had been checked off as compliant with transfers, positioning and walking on 5/9/2011 and therefore was able to work independently with the residents. Continued interview revealed that the CNAs are was also trained to always follow residents care plans and the facility policy and procedures in transferring residents. The number of persons needed for transferring residents is posted above all resident's beds.

Based on observation, record review, staff and family interview, the facility failed to provide/offer routine dental services for one (1) resident ("A") with identified oral/dental problems since admission to the facility in 2009. The sample size was twenty-six (26) residents. Findings include: Interview on 07/26/11 at 10:23 a.m. with a family member of resident "A" revealed that the resident was losing teeth, had only a few teeth left, and that the resident's breath was bad. Observation on 07/25/11 at 12:10 p.m.; 07/26/11 at 10:51 a.m.; and 07/27/11 at 11:25 a.m., revealed resident "A" with a strong, unpleasant odor to their breath. Observation on 07/27/11 at 10:00 a.m., revealed that the resident's teeth were yellowed, and several teeth in the front appeared uneven and/or broken. Review of the Oral Assessment section on the Nursing Admission assessment dated [DATE] noted that a complete oral cavity exam was done, and the condition was poor; that the resident had their own teeth, and that some teeth were missing. Review of the Admission Minimum Data Set (MDS) dated 02/19/09 assessed the resident as having some/all of their natural teeth lost, and did not have or did not use dentures. Interview on 07/27/11 at 11:30 a.m., with the Social Services Director revealed that dental assessments were done on admission, and that if she observed a resident demonstrating any mouth or facial pain, she would tell the nurse. The nurse would then contact the physician for an order to send the resident to the local dentist. Interview on 7/27/11 at 2:50 p.m. with the Director of Nurses revealed that there was a Standing Order on all residents' physician's orders [REDACTED].

Based on record review, observation and staff interview, the facility failed to provide/offer dental services for one (1) resident (#43) from a sample of twenty-six (26) residents. Findings include: Observation on 07/25/11 at 11:51 am revealed resident #43 with discolored brown, rotted, jagged, broken teeth and multiple upper and lower teeth missing. Review of the current quarterly Minimum Data Set (MDS) assessment dated [DATE] and the annual MDS assessment dated [DATE] revealed no evidence that the dental status of the resident had been assessed. Review of the Nursing Admission assessment dated [DATE] revealed the resident had her own teeth and they were in poor condition. Observation on 07/26/11 at 3:40 pm, with Registered Nurse (RN) "EE", of resident #43 revealed that the nurse confirmed that the teeth were brown, jagged, broken and there was missing lower and upper teeth. Interview with RN "EE" on 07/26/11 at 3:35 pm, revealed, that after reviewing the current annual MDS 3.0, there was no evidence that the resident's teeth had been assessed. Interview on 07/27/11 at 12:00 pm with the Director of Nurses revealed resident #43 was identified on admission to have missing and jagged teeth but nothing was done regarding her oral status because she did not have any problems eating. Continued interview revealed that no dental referrals had been made for resident #43.