**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 1 resident (#24) of 24 residents reviewed for dignity. The findings include: Review of the facility's policy titled, PATIENTS RIGHTS, revised on 6/2006, showed .The resident has a right to a dignified existence .A facility must protect and promote the rights of each resident, including .Privacy and confidentiality .A center must promote the exercise of rights for each patient . Review of an undated document provided by the facility titled, Confidentiality Statement, showed .The care of a patient is always personal in nature, and therefore any protected health information about his/her condition, treatment or personal data is absolutely confidential .The information in a patient's medical record is confidential and cannot be disclosed without the patient's knowledge and consent .The confidentiality of patient protected health information .MUST be maintained . Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Fracture of the Left Femur, Urinary Tract Infection, Communication Deficit, Dementia, and Anxiety. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #24 had moderate cognitive impairment. During an observation on 8/21/2023 at 11:05 AM, there was sign a posted on the wall above the head of Resident #24's bed that read, .MIDLINE [a type of intravenous access used for medication delivery] .NOT A PICC [Peripherally inserted central catheter] .Please ask regarding medication appropriate for infusion .8/15 [8/15/2023] .left Basilic [a vein in the upper arm] . The sign was visible to anyone who entered the room. During an observation on 8/22/2023 at 7:39 AM, there was sign a posted on the wall above the head of Resident #24's bed that read, .MIDLINE .NOT A PICC .Please ask regarding medication appropriate for infusion .8/15 .left Basilic . The sign was visible to anyone who entered the room. During an observation and interview with the Director of Nursing (DON) and the Administrator on 8/22/2023 at 11:38 AM, in Resident #24's room there was a sign posted on the wall above the head of Resident #24's bed that read, .MIDLINE .NOT A PICC .Please ask regarding medication appropriate for infusion .8/15 .left Basilic . The DON stated the sign .must have been . posted by the company that placed the Midline. The DON and Administrator confirmed the sign was visible to anyone who entered the room. The DON confirmed resident health information was not to be posted in resident rooms. During an interview on 8/23/2023 at 12:51 PM, the DON confirmed there was no documentation in the medical record that indicated the sign had been requested by Resident #24 or Resident #24's responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident #54's PASARR Level I Form dated 9/7/2022, showed .No mental health diagnosis is known or suspected .Level I Outcome: No Level II Condition- Level I Negative . Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hemiplegia and Hemiparesis following cerebral infarction affecting left dominant side, Dysphagia following cerebral infarction, Hypertension, Hyperlipidemia, Seasonal allergic rhinitis, GERD, Constipation, and Osteoarthritis. Review of the medical record showed Resident #54 received a diagnosis of Depression on 9/13/2022. Review of the medical record showed Resident #54 received a diagnosis of Adjustment disorder with mixed anxiety and depressed mood on 3/9/2023. Review of the medical record showed Resident #54 received a diagnosis of Generalized Anxiety Disorder on 6/21/2023. Review of the medical record showed Resident #54 received a diagnosis of Post Traumatic Stress Disorder (PTSD) on 7/12/2023. Review of Resident #54's annual Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact with active diagnoses that included Anxiety Disorder, Depression, and PTSD. Resident #54 received antianxiety and antidepressant medications on all 7 days of the look back period. Review of Resident #54's Notice of PASARR Level I Screen Outcome dated 8/22/2023, showed .Your Level I screen was submitted for a potential status change. Your screen shows more PASRR screening is not needed .DIAGNOSIS .Anxiety Disorder (Current Diagnosis) .Trauma/Stress Related Disorder (Current Diagnosis) .Depression- mild or situational (Current Diagnosis) .Other mental health diagnosis .adjustment disorder mixed with anxiety and depressed mood-suspected, nightmares .Rationale: Documentation reviewed and reports adjustment disorder mixed with anxiety and depressed mood and nightmares and added to this review as suspected .This review is submitted to update the diagnoses and medications .A Level II evaluation is not required and this Level I is approved with a Level I No Status Change . During an interview on 8/23/2023 at 9:43 AM, the MDS Coordinator stated a Level I was submitted from the hospital on 9/7/2022 prior to Resident #54's admission and had no mental health diagnoses noted. A Diagnosis of Depression was added on 9/13/2022, General Anxiety Disorder was added on 6/21/2023, Adjustment Disorder with Mixed Anxiety and Depressed Mood was added on 3/9/2023, and PTSD was added on 7/12/2023. The new diagnoses required a new PASRR to be submitted. The MDS Coordinator confirmed a new PASARR was not submitted until 8/22/2023 to reflect the new mental health diagnoses. The MDS Coordinator stated .we realized yesterday when we were asked for the PASARR that we didn't do it and went ahead and done it . The MDS Coordinator confirmed the PASARR was not resubmitted timely after the addition of new mental health diagnoses. Based on medical record review and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis for 2 residents (Residents #1 and #54) of 5 residents reviewed for PASRR. The findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder and Anxiety Disorder. Record review of the most recent PASARR Level 1 assessment dated [DATE], revealed Resident #1 had mental health diagnoses of Major Depression, Anxiety Disorder and Mood Disorder. Record review revealed Resident #1 received new diagnoses of Post-traumatic Stress Disorder (PTSD) on 1/4/2023 and Delusion Disorders on 1/24/2023. Record review revealed no new Level II PASARR had been submitted to include the new diagnoses of PTSD and Delusion Disorders with anti-psychotic medication use initiated on 2/21/2023. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had active diagnoses of .Anxiety .Depression .Delusions .PTSD . and received antipsychotic, antianxiety, and antidepressant medications during the last 7 days. During an interview on 8/22/2023 at 5:00 PM, the Director of Nursing stated, when a resident in the facility receives a new mental health diagnosis, a PASARR was to be resubmitted for the resident and confirmed a request for a PASARR II review had not been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to revise the Comprehensive Care Plan to include hospice services for 1 resident (#18) of 3 residents reviewed for hospice. The findings include: Review of the facility's policy titled, PATIENT ASSESSMENT AND CARE PLANNING, revised on 11/1/2013, showed .The Federally mandated Minimum Data Set .is the basis for the assessment component of the Comprehensive Patient Care System .The assessment information is used to develop the patient's care plan . Resident #18 was admitted to the facility on [DATE] with diagnoses including Hypertensive heart and chronic kidney disease with heart failure, Adult Failure to Thrive, Anorexia, Paroxysmal Atrial Fibrillation, Dysarthria following cerebral infarction, and Dysphagia. Review of the facility's policy titled, PATIENT CARE POLICIES, dated 2023, showed .Patients are assessed initially and at regular intervals using a Federal/State specified, standardized, comprehensive resident assessment instrument to identify functional capacity and health status .serve as the basis for planning individualized patient care .The center will include the attending physician in the development of the patient's plan of care by incorporating the physician's plan of care (orders) into the care plan. Decision making/planning is based on identified needs/problems and builds on patient strengths while taking into account the patient's preferences. The care plan serves as a guide for care decisions and is made available for use by all patient care personnel . Review of the medical record showed Resident #18 was admitted to hospice services on 7/29/2023. Review of Resident #18's significant change Minimum Data Set (MDS) assessment dated [DATE], showed Resident #18 had moderate cognitive impairment and had started receiving hospice care in the last 14 days. Review of Resident #18's Comprehensive Care Plan showed, Resident #18's code status was Do Not Resuscitate. The Comprehensive Care Plan did not reflect that Resident #18 received hospice services. During an interview on 8/23/2023 at 8:22 AM, the Director of Nursing (DON) confirmed Resident #18's care plan did not include hospice services. The DON stated it was her expectation that care plans were revised to include hospice services for residents admitted to hospice. During an interview on 8/24/2023 at 11:19 AM, the MDS Coordinator stated she was responsible for care plans. Resident #18 had a significant change MDS assessment on 8/4/2023 because she was admitted to hospice on 7/29/2023. The MDS Coordinator confirmed Resident #18's care plan should have been updated to include hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 resident (#18) of 3 residents reviewed for hospice. The findings include: Review of the facility's hospice contract with Resident #18's hospice provider dated 7/24/2008, showed .Plan of Care .the Skilled Nursing Facility shall provide services in accordance with the Hospice plan of care . Resident #18 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Adult Failure to Thrive, Anorexia, Paroxysmal Atrial Fibrillation, Dysarthria following cerebral infarction, and Dysphagia. Review of the facility's policy titled, PATIENT CARE POLICIES, dated 2023, showed .HOSPICE SERVICES .Physicians may request consultation for hospice care services .When a patient elects hospice services, the hospice will guide the plan of care in collaboration with the center . Review of the medical record showed Resident #18 was admitted to hospice services on 7/29/2023. There was no hospice plan of care in Resident #18's medical record. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], showed Resident #18 had moderate cognitive impairment and had started receiving hospice care within the last 14 days. During an interview on 8/23/2023 at 8:02 AM, Licensed Practical Nurse (LPN) #1 stated she was the designated person appointed from the facility to communicate with Resident #18's hospice provider. LPN #1 stated the hospice provider's plan of care was to be available for facility staff to review either in the computerized chart under resident documents or in the hospice binder located at the nurses' station. LPN #1 confirmed Resident #18's hospice plan of care was not available in the resident's computerized chart or in the hospice binder. During an interview on 8/23/2023 at 8:22 AM, the Director of Nursing (DON) stated it was her expectation that the hospice provider's plan of care was available in the resident's medical record either in the computerized chart or in the hospice binder at the nurses' station so that facility staff could provide coordinated care with the hospice company.

Based on facility documentation review and interview the facility failed to ensure that all required members attended the quality assessment and assurance committee (QAA) meetings on a quarterly basis. The findings include: Review of the facility policy titled, QAPI [quality assessment and performance improvement] PLAN undated, showed, .will strive to meet the following goals based on our purpose, guiding principles and scope for QAPI .will strive to meet or exceed the clinical outcome goals. Priority will be set for those goals that are considered high-risk, high-volume or problem-prone areas .Governance and Leadership .Accountability for QAPI .Ultimately the Administrator (ADM) and Director of Nursing (DON) are accountable for the success or failure of the program .The DON .will be the QAPI champion. This champion will be accountable for all nursing QAPI activities .Department Managers will be educated on the QAPI Plan and expectations . Review of QAPI meeting sign-in sheets from 7/27/2022 -7/26/2023, showed the DON was absent from 5 of the 13 meetings. Of the 5 QAPI meeting absences, the DON was not present for the first 3 consecutive meetings of the beginning quarter of 2023, dated 1/25/2023, 2/22/2023, and 3/22/2023. During an interview on 8/24/2023 at 8:48 AM, the ADM confirmed the DON did not attend the 1/25/2023 meeting because she was on vacation. The ADM confirmed the DON did not attend the 2/22/2023 meeting because she was at the Regional DON meeting. The ADM confirmed the DON did not attend the 3/22/2023 meeting and stated the DON was present in the facility earlier that day and was unsure why she did not attend.

Based on facility policy review, observation, and interview the facility failed to ensure appropriate personal protective equipment (PPE) was worn while providing care for a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) positive resident. The findings include: Review of the facility policy titled, Infection Control Manual Volume 1 dated 6/2023 showed, .Core Principles of COVID-19 Infection Prevention .Centers should provide guidance (e.g., posted signs at entrances about recommended actions .Hand hygiene .Face covering or mask .in accordance with CDC [Center for Disease Control] guidance .Post visual alerts in strategic places .alerts should include instructions about current .recommendations . when to use source control .Appropriate staff use of Personal Protective Equipment .Droplet Precautions .In addition to Standard precautions, use Droplet precautions for a patient known or suspected to be infected with microorganisms transmitted by droplets .PPE .Facemasks should be used upon entry into the patient room .Based upon pathogen or clinical syndrome, there is a risk of exposure .spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield in place of goggles) should be worn . During an observation on 8/21/2023 at 11:28 AM, outside of the COVID unit was a table which contained 5 packs of blue plastic gowns, 5 boxes of exam gloves of various size, 1 box of medical face masks, and 5 individual packaged N-95 masks. Signage for Contact Precautions was posted outside of the COVID unit on the left door, just below the glass. The highly visible sign read as follows: STOP .CONTACT PRECAUTIONS EVERYONE MUST .Clean their hands .PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit .Put on gown before room entry .Discard gown before room exit .Do not wear the same gown and gloves for the care of more than one person .Use dedicated or disposable equipment .Clean and disinfect reusable equipment before use on another person . The COVID unit was visualized through the glass of the 2 closed doors. Small clear plastic cabinets with multiple drawers were outside of each residents room in the COVID unit, these cabinets contained PPE for staff to obtain before caring for the residents. During an observation on 8/21/2023 at 11:30 AM, Certified Nursing Assistant (CNA) #1 entered a resident room in the COVID unit, CNA #1 was noted to wear a surgical face mask and a face shield on top of the head, not in the appropriate position to cover the face. CNA #1 entered a room which displayed a highly visible Droplet Precautions sign present on the front of the door to the room. The Droplet precaution sign posted in a fully visible area where each component of PPE is explained, and which type of PPE is to be worn by staff while providing care or coming in contact with a COVID positive resident. Staff were to wear gown, gloves, mask and face shield as stated on the Standard precaution sign and add the PPE component of a N-95 mask. CNA #1 confirmed a room was entered in the COVID unit without donning appropriate PPE while a lunch tray was delivered to a COVID positive resident. CNA #1 stated I should have put on PPE .I made a mistake . CNA #1 was in the immediate presence of 2 other resident care staff members who wore a gown, gloves, N-95 mask, and face shield in the proper position during the observation. During an interview on 8/21/2023 at 11:59 AM, the Administrator confirmed the expectation was resident care staff would wear full PPE (gloves, gown, N-95 face mask [a mask that filters from the air small particles to include droplets], and a face shield/goggles) when entering a room with a COVID positive resident. During an interview on 8/22/2023 at 2:55 PM, the Infection Preventionist (IP) stated the expectation was for resident care staff to wear full PPE when entering a room or coming in contact with COVID positive residents. The expectation is also for resident care staff to wear a face shield to fully cover the face while in in the room and providing care for COVID positive residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of the facility investigation, and interview the facility failed to maintain resident privacy for one Resident (Resident #2) of 4 residents surveyed for resident rights. The facility violated Resident #2's right to personal privacy when a staff member used a cellular phone to photograph Resident #2, without her knowledge or consent, then transmitted the photo to another staff member by cellular phone. The findings included: Review of the facility policy, Use of Personal Cellular Phones/Camera Equipped Mobile Devices, revised 5/1/2012, showed .while a partner is performing job duties .personal cellular phone or .electronic device must be kept in their bag or locker, not on his/her person and must be turned off .Partners may not take digital or still photographs or record audio or video footage with personal .devices for personal use while on company premises .camera equipped or audio equipped recording devices are strictly prohibited from use anywhere on company property .partners .found to be in violation of any aspect of this policy will be subject to disciplinary action, up to and including termination from employment . Medical record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses including Acute upon Chronic Respiratory Failure, Functional Paraplegia, Morbid Obesity, Type 2 Diabetes, Hypertension, Atherosclerotic Heart Disease, COVID 19 Pneumonia, Major Depression and Generalized Anxiety Disorder. On admission Resident #2 refused cognitive testing but was noted to be cognitively impaired, had severe depressive symptoms, and signs of generalized anxiety with verbal and physical behaviors directed at others. Resident #2 was dependent upon one person for all activities of daily living. Review of the facility investigation and witness statements showed on Saturday 4/22/2023 sometime before lunch (exact time unknown) a facility staff member (Certified Nurse Assistant) CNA #1, text messaged her peer, Dietary Worker (DW) #3 a photograph of Resident #2 lying in her bed, fully clothed with a blanket over her lower torso. Resident #2 was lying with her head near the footboard, and it appeared she was reading mail, with shredded papers in the bed atop the covers. The photo appeared to have been taken from a vantage point in the room behind the resident and the resident appeared unaware she was photographed. DW #3 who was on break at the time with a coworker DW #2, briefly showed the text to DW #2. Afterwards, DW #3 also showed the cook on duty at the time, (who was the assistant Dietary Manager) (DW#1) the text, informed DW #1 she had no idea why the text was sent to her, then deleted the text from her phone. Continued review of the facility investigation and witness statements revealed when the Administrator began the facility investigation and questioned CNA #1, she had already deleted the phone and text message from her phone as well. However, CNA #1 in a written statement, did admit she had taken to the photo, texted it to her peer in the dietary department, and stated she had done so with no ill intentions. CNA #1 reported in her statement she was concerned for the Resident due to several bouts of aggressive and confused behaviors that morning and had sent the photo to her peer in efforts to explain difficulties she had encountered redirecting Resident #2 that morning after breakfast. CNA #1 issued a written apology for her actions and acknowledged she was aware her actions violated facility policy. Interview with the Administrator on 7/17/2023 at 12:30 PM in the conference room confirmed the facility investigation determined CNA #1 had violated the facility mobile device use policy and violated Resident #2's right to privacy. Facility Corrective Actions included: 1. Resident #2 passed away on 4/24/2023 which was unrelated to the incident. 2. Ad Hoc QA (Quality Assurance) meeting of the incident by the Administrator, Director of Nursing (DON), Regional [NAME] President, Social Services Director, Regional Nurse and Corporate Compliance Officers was held on 4/26/2023 by teleconference. 3. CNA #1 was initially placed on administrative leave on 4/24/2023 pending investigation then formally terminated by Human Resources on 4/28/2023 at the conclusion of the investigation. 4. The partner who received the text (DW#3) was in-serviced on the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and the Mobile Device Policy on 4/27/2023. 5. The facility investigation revealed no other residents impacted by the incident. 6. The facility conducted interviews with all alert and oriented residents and family representatives of non-interviewable residents to assess for any additional noncompliance. No concerns were identified. This was completed by 4/27/2023. 7. To help ensure the deficient practice does not recur, all facility staff employed as of 4/26/2023 were in-serviced on the NHC Patient Protection and Response Policy for Allegations of Abuse, Neglect, Misappropriation of Property and Exploitation, and the Use of Mobile Device Policies. (All employees are trained on the policies during new hire orientation and are required to review them annually as a component of the facility corporate compliance program which was already in place prior to the incident). 8. The training was conducted by the DON, Nurse Manager, Social Work Director, Nurse Staffing Coordinator, Dietary Manager, Payroll Manager and/or Administrator. Any staff who were unavailable on 4/26/2023, were required to complete the training before their next shift and sign attestations the training was completed. 9. The facility validated all staff training was completed per the corrective action plan on 5/1/2023. 10. Beginning on 5/1/23 the Administrator, DON, Resident Care Coordinator, Nurse Staffing Coordinator, Social Worker or Designee performed a monthly audit of compliance with the above policies reviewed in staff retraining by interviewing 10 employees for 3 months (May to July) to ensure employees are aware of facility policy that the taking of pictures, recordings or texting resident information is inappropriate and are questioned if they are aware of any such actions ongoing to ensure resident privacy and dignity are maintained. 11. Results of the ongoing monitoring will be reported to the full QA committee during the July 2023 meeting. The QA committee consists of the Administrator, Director of Nursing, Medical Director, QA Physicians, Dietician, Social Services Director, Infection Preventionist, Director of Plant Operations and Health Information Director. The QA committee meets monthly. Additional staff training and/or monitoring will be determined as necessary by the Quality Assurance Committee. The first full review by the QA committee was held on 5/1/2023 and monitoring was ongoing. Review and validation of the facility corrective actions put in place in response to the incident was conducted during the onsite survey 7/12/23 to 7/17/23. Staff interviews were conducted with 14 employees from various departments across both shifts, included clinical and non-clinical employees. All had completed the required retraining as outlined in the corrective action documents and all could recite verbatim the facility polices related to resident rights, privacy, the facility prohibition on the possession or use of personal mobile devices outside authorized break areas as outlined in the policy. No employees were observed with personal devices on their persons or in use in the clinical or common areas throughout the survey. All staff interviewed could state why the facility corrective actions had been implemented and were aware of the facility expectations in relation to resident privacy as well as the consequences of noncompliance outlined in the facility policies. Interviews with 4 alert and oriented residents and 4 family representatives of cognitively impaired persons showed no concerns with resident rights, privacy or dignity concerns, abuse or neglect, or unresolved grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure 1 resident (#11) received routine dental services of 18 residents sampled. The findings include: Review of the facility's policy Dental Services, undated, revealed .To ensure patients are receiving the care and services necessary for proper denture and dental health .Build accountability into each process to ensure effectiveness .Establish process for communication of dental needs .of patients .Ensure all partners are aware of process for communication of dental needs . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Muscle Weakness, Anxiety Disorder, and Anemia. Medical record review of the Quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of the care plan dated 9/3/19 revealed .risk of altered nutrition status .Dental consult as warranted . Medical record review of a Food and Nutrition Services progress note dated 9/10/19 revealed .Staff contacted RD [Registered Dietician] to notify of [Resident #11's name] reporting she is having trouble with her dentures and needs new ones. She reports that she is getting choked on her food because she can't chew it. Diet change to Low Sodium, Mechanical with ground meats for ease of chewing. Reassess diet texture change as needed/when new dentures are obtained . Medical record review of a Physician's Order dated 9/10/19 revealed a diet of low sodium with mechanical ground meat. Interview with Resident #11 on 11/18/19 at 2:47 PM, in the resident's room, revealed her dentures no longer fit and she wanted new dentures. Further interview revealed she had reported the issue to the facility but had not been seen by the dentist. Interview with the Social Services Assistant on 11/19/19 at 12:34 PM, in the social services office, revealed the nursing staff maintained the list of residents to be seen by the dentist. Interview with the Resident Care Coordinator (RCC) on 11/19/19 at 12:46 PM, in the RCC's office, revealed the nursing staff did not maintain the list of residents to be seen by the dentist and the RCC was not aware of which residents were on the list. Interview with the Administrator on 11/19/19 at 12:49 PM, in the Administrator's office, revealed he maintained the list of residents to be seen by the dentist. Continued interview confirmed he had not been made aware of the resident's need to be seen by the dentist and Resident #11 had not been added to the dental list. Further interview confirmed it was his expectation to be notified immediately of dental concerns so the resident can be added to the dental list to be seen at the next visit or sooner if needed. Interview with the Director of Nursing (DON) on 11/19/19 at 12:53 PM, in the Administrator's office, confirmed she was unaware Resident #11 had a need to see the dentist. Continued interview confirmed it was her expectation for the RD or the staff member who informed the RD of Resident #11's need to be seen by the dentist to have notified the Administrator or DON.