Harlan Health And Rehabilitation Center

F-F692.)

Although the care plan, date initiated 07/16/2023, called for ST/OT to evaluate as indicated, an order for Speech Therapy was not obtained until 03/19/2025, after surveyor intervention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 19 185166 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 During an interview with the Speech-Language Pathologist (SLP) 1 on 03/19/2025 at 2:24 PM, she stated Resident R99 had not been assessed by speech therapy until 03/19/2025. SLP1 stated that upon assessment, Resident R99's Level of Harm - Actual harm teeth were bad, they're terrible, and that could be the reason Resident R99 had lost weight.

Residents Affected - Few An interview was conducted with Resident R99 on 03/20/2025 at 8:46 AM. The resident was observed to have communication deficits, and as a result, the State Survey Agency (SSA) team asked Resident R99 single questions at

a time, to which he would respond by answering 'yes' or 'no' and moving his head. During the interview, Resident R99 indicated his teeth hurt all the time, and had been hurting for about one year, nodding his head up-and-down and stating, yep to both of these questions (which were asked separately). Resident R99 also indicated that teeth pain made it difficult to eat at times, again nodding his head up-and-down and stating, yep. Resident R99 also indicated that there were times that he was hungry due to inability to eat because of the tooth pain, as he nodded his head up-and-down stating, yep.

Observation on 03/21/2025 at 2:04 PM revealed Registered Nurse (RN)6 assessed Resident R99, who was in bed, for pain. RN6 asked Resident R99 if he could sit up and the resident followed the instruction, sitting on the side of the bed. RN6 asked Resident R99 if he was having any pain and Resident R99 nodded his head up-and-down stating yep, teeth. RN6 then asked Resident R99 Your teeth are hurting right now? Resident R99 nodded his head up-and-down, stating yep. RN6 asked Resident R99 Scale of 1-10, how bad? Resident R99 replied yep, and proceeded to hold his hand up. When RN6 asked Resident R99 if his pain was a '5', Resident R99 motioned his left thumb up. RN6 then asked Is it a 10? to which Resident R99 stated yep. Observation at this time revealed RN6 examined Resident R99's mouth which revealed that the resident was missing multiple teeth in both the front and the back of the mouth, as well as, on both the top and bottom. In addition, the resident had multiple discolored teeth, with some that were partially black in appearance.

Interview with Certified Nursing Assistant (CNA) 8, on 03/20/2025 at 9:34 AM, revealed that during Resident R99's oral care, the resident would wince in pain, like someone touching a nerve. CNA8 added that he thought that was why Resident R99 had a hard time eating. CNA8 added that he had previously informed nursing staff about the resident's dental pain, but was informed the facility was waiting on a dentist. Further interview revealed CNA8 could not remember the specifics of when or who he told about Resident R99's dental pain.

During an interview with Licensed Practical Nurse (LPN)8 on 03/20/2025 at 3:05 PM, LPN 8 stated Resident R99's teeth looked bad, noting that some teeth were missing. LPN8 stated there was no assigned staff responsible for dealing with referrals and making appointments, saying, No one handles the appointments specifically;

we do our best to make sure they're followed up on. Further interview with LPN8 revealed when a resident complains of tooth/oral pain, nursing staff were required to notify the physician and document in the Health Status Note/Progress Note.

Review of Resident R99's chart for 2025 revealed no documentation regarding teeth/oral pain or notification to the physician about such an issue.

On 03/19/2025 at approximately 9:00 AM, a Regional Corporate representative brought in a typed Word Document, which she stated was a list of the times that the facility had attempted to contact the oral surgeon to whom Resident R99 was referred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 185166 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Review of this compiled document revealed it listed attempts on 07/09/2024, 08/06/2024, 09/02/2024 (Labor Day), 10/07/2024, 11/11/2024, 12/09/2024, 12/10/20/24, 12/16/2024, 01/06/2024 [sic], and 02/03/02025. For Level of Harm - Actual harm each of these 10 attempts, there was a note that the facility had called and left a message and was awaiting

a call back. There were no further attempts to contact the dental provider after 02/03/2025 until 03/19/2025, Residents Affected - Few after initiation of the Recertification survey.

Review of the Word document revealed that during the 03/19/2025 call (which was made after surveyor intervention regarding Resident R99's dental needs}, the facility was able to make actual contact with the provider and speak with them for the first time since the referral was made nine months earlier. Further review of the Word Document provided by the Regional Corporate representative revealed that on 11/11/2024 and 11/12/2024,

the facility contacted three additional dental office (two dentists and one oral surgeon). However, the dentist declined because they were not an oral surgeon, and the oral surgeon declined to see Resident R99, as they preferred not to take Nursing Home or residents with the resident's payor source. Review of this Word Document revealed no further attempts after 11/12/2024 to locate an any other available oral surgeons to remove Resident R99's teeth as needed.

Interview with Unit Manager (UM)1 on 03/20/2025 at 11:15 AM, revealed she took charge of the dental referral for Resident R99. Further interview with UM1 on 03/21/2025 at 11:58 AM, confirmed that there was nothing in Resident R99's medical record about the follow up for needed dental care. Instead, UM1 stated, she kept a spiral notebook with the calls made to the dental office at her desk because It was easier to work on in a notebook. UM1 stated she had made calls to the oral surgeon's office; however, they were not returned. She added that she had also tried outside providers, but they declined to take the resident because of his nursing home and/or payor source.

Interview with Resident R99's physician, on 03/20/2025 at 3:22 PM, revealed he had not been notified of Resident R99 having any dental pain. The physician stated the facility had told him that they had been trying to contact a dentist but were awaiting a call back.

During a joint interview with the Director of Nursing (DON) and Administrator on 03/21/2025 at 11:23 AM, the Administrator stated Resident R99 should have been in the facility's 360 Dental Program, and that was an oversight

on their part. The Administrator stated it was her expectation that staff document dental pain or oral care in

the progress notes or on the Medication Administration Record (MAR) to ensure it was on the 24-hour change in condition report. The DON also stated she expected to see pain documented in the progress notes or on the Medication Administration Review (MAR). Both the Administrator and DON indicated that the resident should have been seen for the broken teeth, saying that the facility had tried, but it was difficult to find someone who would take Nursing Home residents

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 47852 potential for actual harm Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure Residents Affected - Few each resident received food and drinks which were palatable, attractive, and at a safe and appetizing temperature for five of 35 sampled residents reviewed for food temperatures (Residents (R)19, Resident R67, Resident R86, Resident R98, and Resident R111). During resident council, residents expressed concerns of their food being served cold when

the aides passed their trays.

Observation of the breakfast meal, on 03/19/2025, revealed the sausage, eggs, biscuits, oatmeal, milk, and cranberry juice were not at an appetizing and acceptable temperature. Observation of the breakfast meal, on 03/20/2025, revealed the sausage, eggs, oatmeal, and grape juice were not at an appetizing and acceptable temperature.

The findings include:

Review of the facility's policy titled, Dietary Infection Control, undated, revealed temperatures must be maintained at 41 degrees (41 ) Fahrenheit (F) or below for cold or refrigerated food. Further review revealed temperatures must be maintained at the following Fahrenheit settings: all potentially hazardous food must be kept below 41 F and above 140 F during transportation. Continued review revealed temperatures must be maintained at 150 degrees F for pork (sausage).

Observation of a test tray on 03/19/2025 at 8:55 AM, with Dietary Manager (DM) 1 and DM2 the following food temperatures were recorded: sausage: 114.0 F, scrambled eggs: 116.5 F, biscuit: 84.3 F, oatmeal, 136 F, milk: 43.0 F, and cranberry juice: 44.0 F.

Observation of a second test tray on 03/20/2025 at 8:20 AM, with DM 2 and DM 3, revealed the following temperatures: sausage: 111.0 F; scrambled eggs: 111.0 F; oatmeal:138 F; and grape juice: 46 F.

During the Resident Group meeting, held on 03/18/2025 at 2:00 PM, with 13 residents in attendance, three residents complained about cold food. Resident R98 stated food often sat in the hallway and the kitchen sends it out

on the carts and it sometimes sits there 20 minutes before the aides serve the food. Resident R86 and Resident R111 agreed

the food was often cold.

During an interview, on 03/17/2025 at 3:20 PM, Resident R67 stated food was only warm about one-half the time and

the food was no good.

During an interview, on 03/17/2025 at 3:50 PM, Resident R19 stated meals were not warm several times a week.

During an interview, on 03/17/2025 at 6:00 PM, Resident R98 stated food was often not warm and the food was not always pleasant tasting.

During interview, on 03/19/2025 at 9:05 AM, DM1 stated the tray line was on schedule and that food service did not exceed expected preparation or delivery timeframes. DM1 stated that food temperature compliance was critical both for resident safety and palatability. DM1 stated that staff were expected to monitor food temperatures regularly during service.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During an interview, on 03/19/2025 at 11:40 AM, Resident R67 stated the food was so salty you can't eat it. Resident R67 further stated the facility would not give any eggs that were not scrambled and the texture of the eggs was Level of Harm - Minimal harm or rubbery. potential for actual harm

During an interview, on 03/19/2025 at 2:45 PM, the Administrator stated the plate warmer was not working Residents Affected - Few correctly and was not warming the middle row of plates. Additionally, the Administrator stated that serving foods within the safe handling zone was important to prevent foodborne illnesses.

During interview on 03/20/2025 at 8:27 AM, DM2 stated the trays had been delivered without delay and that

the service was consistent with internal protocols. DM 2 emphasized that delivering food at safe temperatures was essential not only for infection control but also for maintaining resident satisfaction and ensuring meals were served in a palatable state.

51157

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 185166 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 51157

Residents Affected - Few Based on observation, interview, and review of the facility's policy, the facility failed to serve food in accordance with professional standards for food service safety. The census was 132.

The findings include:

Review of the facility's policy titled, Tray Line and Meal Delivery Service, undated, revealed staff were to not touch the food surface areas of plates, bowls, cups, or saucers. Staff were to pick the items up by the outer rim only. Continued review revealed staff were to use tongs, spoons, scoops, etc. to serve all food including bread. Additionally, staff should wash their hands and change gloves between each task.

Review of the facility's policy titled, Hand Washing, undated, revealed staff were to wash their hands after handling soiled equipment or utensils and during food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks.

Observation on 03/17/2025 at 4:15 PM revealed Cook1 touched the surface area of plates as she removed them from the plate warmer. Further observation revealed she rested her gloved hands on the surface of the plates once they were sat on the tray line. Observation revealed Cook1 used her gloved hand to move the pot roast on the plate to make it look better. Cook1 then the proceeded to use the same gloved hand to place

a roll on the plate.

Continued observation of the tray line revealed Dietary Aide (DA)1 answered the telephone and did not wash her hands or change gloves. DA1 continued to work the tray line touching the bowl (inside) of the spoons and the fork prongs.

During an interview, on 03/17/2025 at 6:35 PM, Cook1 stated that touching the surface area of plates could lead to the contamination of food and make the residents sick.

During an interview, on 03/17/2025 at 6:45 PM, DA1 stated that touching the bowl of a spoon or the prongs of a fork could pass germs to the residents, and they could get sick. DA1 stated that she was unsure of the last time training on proper hand hygiene was conducted.

During an interview, on 03/17/2025 at 6:52 PM, the Corporate Registered Dietician stated that touching the surface area of plates and silverware was not good practice and food safety was the utmost concern. Continued interview with the Corporate Registered Dietician revealed that not following proper hand hygiene could lead to cross contamination of foods and make residents sick. The Corporate Registered Dietician stated that it was her expectation that all staff follow proper hand hygiene policies.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an interview, on 03/17/2025 at 7:08 PM, the Dietary Manager (DM) stated that the [NAME] should not have touched the pot roast, roll, or the surface area of plates. She stated the DA should not have touched Level of Harm - Minimal harm or the surface area of silverware and not changed their gloves after answering the telephone. Continued potential for actual harm interview with the DM revealed that touching the surface area of the plates and silverware, and not following proper hand hygiene could cause residents to get sick. Additionally, the DM stated that it was her Residents Affected - Few expectation for all staff to follow all policies and procedures to prevent illness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 185166 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0922 Have enough backup water supply for essential areas of the nursing home.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51157 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure it had safe drinking water Residents Affected - Many available when there was a loss of normal water supply for all residents. This had the ability to affect all 132 residents.

The findings include:

In an interview with the Administrator, on [DATE REDACTED] at 11:10 AM, she stated the facility did not have a policy to address the availability of water when there was a loss of normal water supply. Further, she stated it was her expectation that the facility would have drinkable water available each day for a period of three days, for the residents consumption.

Review of the facility's Water Utility Agreement, dated [DATE REDACTED], revealed the city's Municipal Water Works assisted the facility with emergency water access.

Review of the facility's Emergency Preparedness Plan document, dated [DATE REDACTED], from the Food Service Vendor, revealed the industry standard was to have 1.5 gallons of water per person, per day, available in the event of an emergency.

Observation on [DATE REDACTED] at 2:15 PM revealed the facility had a total of 1,368 gallons of water stored in a temperature-controlled building. Further observation revealed 1,248 gallons of the water had expired with expiration dates ranging from ,d+[DATE REDACTED]. This left a total of 120 gallons of drinkable water reserved for the residents in the event of an emergency.

Review of the facility's Emergency Preparedness Plan, however, revealed the industry standard was to have 1.5 gallons of water, per person, per day, which left the facility short of available water to support the residents for three days should the facility have a loss of normal water supply.

In an interview with the Maintenance Director, on [DATE REDACTED] at 2:27 PM, he stated he did not check the expiration dates on the potable (drinkable) water. Per interview, the Maintenance Director stated he thought

it was the responsibility of the Dietary Manager to check the expiration dates of the water. Further, he stated

it never occurred to him to check the dates of the water.

In an interview the Dietary Manager, on [DATE REDACTED] at 3:42 PM, she stated that she did not check the expiration dates and thought it was the responsibility of the Maintenance Director. The Dietary Manager stated that she was responsible for ordering the potable water but the Maintenance Director was responsible for storing the water and should have checked the dates.

In an interview with the Corporate Registered Dietician, on [DATE REDACTED] at 11:06 AM, she stated that the Registered Dietician (RD) had advised the Dietary Manager to check the potable water every August. The Corporate Registered Dietician stated that she had monthly phone meetings with the Dietary Managers and reminded them all to check their expiration dates. She stated that it was her expectation that the facility had enough potable water to provide to the residents, in the event of an emergency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 185166 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0922 In an interview with the Administrator, on [DATE REDACTED] at 11:10 AM, she stated the facility did not have a policy for potable water but stated her expectation was to have one gallon of water a day for three days for each Level of Harm - Minimal harm or resident, to ensure the facility could safely care for the residents, if there was a shortage of water. potential for actual harm Additionally, the Administrator stated that it was the responsibility of the Dietary Manager to check the dates of the potable water supply. Residents Affected - Many

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F-F790)

During an interview with CNA8 on 03/20/2025 at 9:34 AM, CNA8 stated that during Resident R99's oral care, Resident R99 would wince in pain, like someone touching a nerve. CNA8 stated he thought that was why Resident R99 had a hard time eating. CNA8 stated that he had previously informed nursing staff about the resident's dental pain but could not remember the specifics of when or who he told.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 19 185166 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Interview with CNA7 on 03/20/2025 at 9:20 AM, revealed she was one of the staff who did routine weights for

the residents on the hall where Resident R99 resided. CNA7 stated that the aides were not aware of weight loss as Level of Harm - Actual harm they did not see the previous weight when they recorded the current weight in the CNA book to give to the Care Coordinator. Residents Affected - Few Although the care plan called for ST/OT (Speech Therapy/Occupational Therapy) to evaluate as indicated,

an order for Speech Therapy was not obtained until 03/19/2025, after surveyor intervention. During an

interview with the Speech-Language Pathologist 1 (SLP1) on 03/19/2025 at 2:24 PM, SLP1 stated until 03/19/2025, Resident R99 had not been assessed by speech therapy. SLP1 stated that upon assessment, Resident R99's teeth were bad, they're terrible, and that could be the reason Resident R99 had lost weight. SLP1 stated that after assessing Resident R99 on 03/19/2025, she changed Resident R99's diet from regular with large portions, to mechanical soft meats and feeding assistance. Further interview with SLP1 on 03/20/2025 at 3:02 PM, revealed that once

the resident's diet consistency was changed, Resident R99 consumed 90 percent of his meal.

Interview with Registered Dietician (RD) 1 on 03/20/2025 at 3:04 PM, revealed that she was a corporate regional dietitian and was answering questions for the facility's RD, who was out of the country and unavailable for interview. She stated that assessments were completed annually, on change in condition, or upon request. RD1 stated Resident R99's last RD Assessment was in 06/2024, and at that time, Resident R99 weighed 171.6 pounds. Per RD1, the facility's RD documented that at that time, the resident's usual weight was 165, with a Body Mass Index (BMI) of 30.4 (mild obesity.) Continued interview with RD1 revealed that as of 03/10/2025, Resident R99 now weighed 128.4 pounds, adding, Wow, what happened? RD1 verified that the resident's average intake had declined. Although RD1 indicated that the facility's RD had made interventions such as an appetite supplement, a dietary supplement, and large servings. However, no information was provided to indicate that Resident R99's ongoing issues with multiple missing/painful teeth and a regular diet, had either been considered as a possible cause of the resident's continued weight loss nor addressed the issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 19 185166 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During a joint interview with the Administrator and Director of Nursing (DON) on 03/21/2025 at 11:23 AM, the DON stated that the supervisor recorded the weights that the direct care staff obtained into the system, Level of Harm - Actual harm which then triggers it in the 24-hour report. Per the DON, this report was then reviewed in morning meeting. However, no evidence was provided by the DON prior to the exit from the survey to verify that this occurred Residents Affected - Few each time Resident R99's weight loss was identified. The DON stated that the RD came to the facility weekly, and the Quality Assurance and Performance Improvement Committee (QAPI) met quarterly to discuss the findings of

the 24-hour reports, and sometimes more frequently. During the interview with the Administrator, she stated that Resident R99's teeth were in the same condition as upon admission and she did not believe that this was the cause of the resident's weight loss. She stated that the resident should have been in the facility's 360 Dental Program (which provides routine dental care), and that was an oversight on their part. The Administrator stated Resident R99 used to attend activities quite frequently with 75% of the activities involving food, and he would eat like a horse; however, he's not been going to activities much. The Administrator and DON expressed the opinion that Resident R99's weight loss was due to the resident's diagnosis of Huntington's disease, with the Administrator describing it as end-stage. However, there was no documented evidence of this in the Resident R99's clinical record. The Administrator stated Resident R99 had stayed within a 10-pound range since 12/02/2024, adding that, I consider that stable. However, Resident R99 had a 12-pound (7.9%) pound weight loss between the 12/10/2024 MDS and 03/10/2025 assessments, which occurred while the resident was not on a physician-ordered weight loss program. This weight loss constituted a severe (more extreme than significant) weight loss. In addition, the weight loss of 20% (32 pounds) in the six months between 09/17/2024 and 03/10/2025, and weight loss of 42 pounds (24.4%) between 06/21/024 and 03/20/2025 also both constituted a severe weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 19 185166 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Provide routine and 24-hour emergency dental care for each resident.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51174

Residents Affected - Few Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide/obtain needed dental care for one of 49 sampled residents (Resident (R) 99) who was reviewed for dental services. The facility failed to obtain needed dental services over a nine-month period for the resident who had multiple broken teeth which needed extraction. During this time, the resident sustained pain, as well as, a severe weight loss over a six and nine-month period.

The findings include:

Review of the facility's policy titled, Protocol for Oral Status Assessment, revision date 08/2017, revealed An assessment of the oral cavity of each resident will be completed annually by a nurse. This assessment will be documented on the Comprehensive MDS [Minimum Data Set] in Section L, as well as in the CAAs [Care Area Assessments]. Each resident will have an Oral Status Care Plan which will be reviewed and updated quarterly with each MDS and prn [as needed]. The documentation of the assessment in the CAA should address the resident's gums, edentulous/dentures (upper/lower), partial, broken or carious teeth, pain, difficulty chewing, etc. The CAA should also address any consults or referrals that have occurred since last comprehensive assessment and if the resident/family decline consult or further referral. The Oral Status Care Plan will be updated annually and prn with any changes in condition. The resident will have consult with Dentist on annual basis as indicated, unless the resident or resident representative declines dental consults.

It will be documented in the medical record if the consult is not obtained.

The undated Protocol for Oral Hygiene policy revealed that, Staff will notify nurse of any changes noted in oral cavity during oral care, residents' ability to chew, teeth, etc.

Review of Resident R99's record revealed the facility admitted Resident R99 on 07/05/2023, with diagnoses which included Huntington's Disease and cognitive communication deficit. Further review of the resident's record revealed that the resident was not currently on hospice and had not been given an end-stage diagnosis. The Admission MDS, with an Assessment Reference Date (ARD) of 07/14/2023, revealed the resident had obvious cavities or broken natural teeth. Per the MDS, the resident weighed 153 pounds and was 63 inches tall (5 feet, 3 inches), was not on a physician-prescribed weight loss plan, and had no nutritional approaches (such as mechanically altered diet). In response, the Dental Needs were triggered for CAA review, based on

the MDS data.

Review of the Comprehensive Care Plan (CCP), initiated on 07/16/2023 for Resident R99 and still current as of 03/17/2025 (the date the Recertification survey was initiated), revealed the resident was care planned for alteration in nutrition/hydration status, in part due to poor dental status. Approaches included obtaining speech therapy/occupational therapy (OT/ST) as indicated. Further review of the care plan revealed that Resident R99's teeth were discolored, missing, and broken, and interventions included that Resident R99 would have consults with the dentist as needed.

a. Review of the clinical record revealed Resident R99 had a tooth extracted in 08/2023. The resident then went back to the external dental office on 05/29/2024, to have three more teeth extracted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 19 185166 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185166 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harlan Health and Rehabilitation Center 200 Medical Center Drive Harlan, KY 40831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Record review of Resident R99's dental note dated 05/29/2024, revealed Patient [Resident] was very difficult to work on. He had trouble keeping his mouth open and he shakes. He tried really hard, but he was very Level of Harm - Actual harm uncomfortable, and he was very difficult to work on. He kept biting me. Will need to talk to his nurse at the nursing home and refer to an oral surgeon for extraction of all of his remaining teeth. Residents Affected - Few

Review of a Progress Note, dated 06/11/2024, revealed the facility received a phone call from the dental office regarding their referral to another provider for the extraction of the remaining teeth. The referring primary dental office informed the facility that Resident R99's information was sent over and if the facility had not received a call back by 06/14/2024, they were to call the dental office.

Further review of Resident R99's clinical record revealed no evidence that the facility contacted either the dentist/oral surgeon to whom the referral was made or with the primary referring dentist between the 06/11/2024 note and the initiation of the Recertification survey on 03/17/2025. Further review of Resident R99's medical record revealed no evidence that any other dentist saw Resident R99 for the needed extractions.

Review of the annual MDS, with an ARD of 06/21/2024, revealed the resident continued to have obvious broken teeth or cavities. Per the MDS, the resident was moderately cognitively impaired, based on a Brief

Interview for Mental Status (BIMS) score of 12/15, and had unclear speech, with slurred or mumbled words, and no refusal of care. Review of the next two MDS, a quarterly assessment with an ARD of 09/17/2024 and

a quarterly MDS with an ARD of 12/10/2024 revealed the section of the assessment regarding the resident's dental status was not completed.

b. Record review revealed that, in addition to the outside dentist that Resident R99 saw on 05/29/2024, the facility had

an agreement with a dental provider who came to the facility for routine care. Review of the facility's agreement with 360 Care (the mobile dental provider), effective 11/01/2018, revealed 360 Care offered dental services to the facility that included dental examination and oral cancer screening, diagnostic x-ray examination, prophylaxis and denture cleaning, tooth surface restorations, simple extractions, and removable prosthetic fabrication, relines and repairs.

Record review of 360 Care's visits to the facility revealed 360 Care had been to the facility on [DATE REDACTED], 05/09/2024, 07/02/2024, 08/13/2024, 09/11/2024, 10/03/2024, 10/22/2024, and 01/02/2025.

Review of Resident R99's medical record revealed no evidence that Resident R99 was seen or treated by this dental service

during any of these visits.

Review of facility records and observation revealed that, during the time that Resident R99 failed to receive needed dental care, the resident (who was not on a physician-ordered weight loss plan) sustained unplanned weight loss. Review of MDS assessments dated 06/21/2024, 09/17/2024, and 12/10/2024, a weight record dated 03/10/2025, and observation on 03/20/2025 at 5:47 PM, revealed Resident R99 sustained a weight loss of 20% (32 pounds) in the six months between 09/17/2024 - 03/10/2025, and weight loss of 42 pounds (24.4%) between 06/21/2024 - 03/20/2025, both of which constituted a severe (more extreme than significant) weight loss. (Refer to