**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete and submit a Discharge Minimum Data Set assessment for 1 Resident (#19) from a total sample of 13 residents. Findings include: Review of Resident #19's Discharge Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was discharged from the facility on this date. The Discharge MDS indicated Section GG (functional goals) was not completed. The Discharge MDS also indicated it was not submitted to the Center for Medicare Services (CMS). During an interview with the MDS Coordinator on 9/7/23 at 10:20 A.M., she said Resident #19's Discharge MDS (dated 4/28/23) section GG was not completed. The MDS Coordinator said the Discharge MDS was not submitted to CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document in the medical record regarding the administration of medication for 1 Resident (#20) out of a total sample of 13 residents. Findings include: Resident #20 was admitted in June 2023 with diagnoses including femur fracture, osteoarthritis, and depression. Review of Resident #20's most recent Minimum Data Set (MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated the Resident had moderately impaired cognition. Review of Medication Administration Record for Resident #20 on 9/2/23, indicated the following medications were not documented as given: -Mirtazapine 7.5 milligrams (mg) at bedtime -Simvastatin 20 mg at bedtime -Raloxifene 60 mg at bedtime -Diclofenac 1% topical gel at 9:00 P.M. -Tylenol 500 mg, 2 tablets (1000 mg) at 10:00 P.M. During an interview on 9/7/2023, the Unit Manager said he contacted the nurse who said she administered the medications to Resident #20 on 9/2/23, but forgot to document them as given.

Based on record review and interview the facility failed to implement weekly skin checks for one Resident (#23) out of a total sample of 12 residents. Findings include: Review of the facility's policy, with a revision date of 6/1/22 indicated the following under Practice Standards: Perform skin inspection on admission/readmission and weekly. Document on Treatment Administration Record (TAR). Resident #23 was admitted in August of 2022 with diagnoses that include chronic kidney disease, repeated falls, muscle weakness and cognitive communication deficit. Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 8/15/22 indicated Resident #23 scored a 13 out of 15, on the brief interview of mental status indicating he/she is cognitively intact. Further review of the MDS indicated Resident #23 required extensive assistance with daily tasks including bed mobility, dressing, hygiene and was at risk for developing pressure ulcers and was admitted with skin injuries. On 8/30/22 at 8:19 A.M., Resident #23 was observed sitting up in a chair in his/her room eating his/her breakfast. Resident #23's arm was uncovered, and a dressing was on his/her left forearm, initialed and dated 8/26/22. Resident #23 said he/she had a fall at home and had bruises and injuries. Review of Resident #23's medical record indicated a skin evaluation dated 8/11//22. No further weekly skin evaluations were present in the medical record, indicating two weekly skin checks were not implemented by nursing staff. During an interview on 8/30/22 at 3:33 P.M., Nurse #1 said all residents have orders for weekly skin checks on the electronic treatment record (E-TAR). Nurse #1 and the surveyor observed the E-TAR for Resident #23 which only had one weekly skin check dated 8/11/22. Nurse #1 acknowledged there were no further weekly skin checks completed for Resident #23 and said there was no order in place, (for weekly skin checks.) During an interview on 8/30/22 at 4:05 P.M., the Director of Nursing said skin checks on residents are to be done weekly per facility policy and physician's orders.

Based on observation, record review and interview the facility failed to ensure professional standards of care for one Resident (#23) out of a total sample of 12 residents, when a daily wound dressing was not removed for four days. Findings include: Review of the facility's policy, with a revision date of 6/1/22 indicated the following under Practice Standards: The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed, 3.4 perform daily monitoring of wounds or dressing for presence of complications or decline and document. Resident #23 was admitted in August of 2022 with diagnoses that include chronic kidney disease, repeated falls, muscle weakness and cognitive communication deficit. Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 8/15/22 indicated Resident #23 scored a 13 out of 15, on the brief interview of mental status indicating he/she is cognitively intact. The MDS also indicated Resident #23 required extensive assistance with daily tasks including bed mobility, dressing, and hygiene. On 8/30/22 at 8:19 A.M., Resident #23 was observed sitting up in a chair in his/her room eating his/her breakfast. Resident #23's arm was uncovered, and a dressing was on his/her left forearm, initialed and dated 8/26/22. Resident #23 said he/she had a fall at home and had bruises and injuries. Resident #23 said the nurse changed the bandage every day. Resident #23 then acknowledged that today's date was 8/30/22, which was four days since the last dressing change. Review of Resident #23's medical record indicated the following physician's order dated 8/11/22, left forearm skin tear, wash with normal saline, pat dry, cover with xerofoam and change daily until healed. On 8/30/22 at 8:19 A.M., Resident #23 was observed to be fully dressed. He/she pulled up his/her sleeve and the dressing to the forearm was in place initialed and dated 8/26/22. Review of the nursing progress notes indicated the following: * 8/26/22 at 15:02 (3:02 P.M.) indicated skin tear to left forearm dry, OTA (open to air.) * 8/28/22 at 23:07 (11:07 P.M.) skin tear to left forearm dry, OTA. During an interview on 8/30/22 at 3:33 P.M., Nurse #1 said Resident #23 had a skin tear on his/her left arm that was dry and did not need a dressing. Review of the electronic treatment administration record (E-TAR) with Nurse #1, indicated the daily dressing had stopped on 8/27/22. Nurse #1 and the surveyor went to Resident #23's room and observed the left forearm dressing dated 8/26/22. Nurse #1 removed the dressing and said the area was a healed skin tear approximately four inches in length, with approximately one inch of scabbing in the middle. Nurse #1 said the dressing should have been removed. During an interview on 8/31/22 8:27 A.M. the Director of Nursing said the Resident #23's dressing on the forearm was discontinued on 8/27/22.

Based on observation, record review and interview the facility failed to ensure an accurate medical record for one Resident (#23) out of a total sample of 12 residents. Findings include: Resident #23 was admitted in August of 2022 with diagnoses that include chronic kidney disease, repeated falls, muscle weakness and cognitive communication deficit. Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 8/15/22 indicated Resident #23 scored a 13 out of 15, on the brief interview of mental status indicating he/she is cognitively intact. On 8/30/22 at 8:19 A.M., Resident #23 was observed sitting up in a chair in his/her room eating his/her breakfast. Resident #23's arm was uncovered, and a dressing was on his/her left forearm, initialed and dated 8/26/22. Resident #23 said he/she had a fall at home and had bruises and injuries. Resident #23 said the nurse change the bandage, daily. He/she then acknowledged that today's date was 8/30/22 which was four days since the last dressing change. Review of Resident #23's medical record indicated the following physician's order dated 8/11/22, left forearm skin tear, wash with normal saline, pat dry, cover with xerofoam and change daily until healed. Review of the nursing progress notes indicated the following: * 8/26/22 at 15:02 (3:02 P.M.) indicated skin tear to left forearm dry, OTA (open to air.) * 8/28/22 at 23:07 (11:07 P.M.) skin tear to left forearm dry, OTA. The nursing progress notes dated 8/26/22 and 8/28/22 fail to indicate the presence of a dressing on Resident #23's forearm dated and initialed 8/26/22. During an interview on 8/30/22 at 3:33 P.M., Nurse #1 said Resident #23 had a skin tear on his/her left arm that was dry and did not need a dressing. Review of the electronic treatment administration record (E-TAR) with Nurse #1, indicated the daily dressing had stopped on 8/27/22. Nurse #1 and the surveyor went to Resident #23's room and observed the left forearm dressing dated 8/26/22.

Based on interview, record review and policy review, the facility failed to notify residents, resident representatives and families of a new COVID-19 positive staff member by 5:00 P.M. the next calendar day. Findings include: Review of the facility policy entitled, IC 405 Covid-19, dated 11/15/21, indicated that the centers (facility) must inform residents, their representatives and families of those residing in the Center by 5:00 P.M. the next calendar day following the occurrence of a single confirmed infection of Covid-19. During review of the Covid-19 Staff Surveillance Testing Log, indicated that on 8/20/22, Certified Nurse Assistant (CNA) #1 reported to work for the 3:00 P.M.-11:00 P.M. shift and was tested utilizing the Binex system. CNA #1 was found to be positive for Covid-19. During review of the progress notes, within the clinical records for 2 sampled residents (#3 and #5), from 8/20/22 through 8/31/22, indicated there was no documentation that either resident or their families/representatives were notified that a facility staff member had tested positive for Covid-19 on 8/20/22. During an interview on 8/31/22 at 11:33 A.M., the Administrator said that staff contact residents verbally and families or their representatives by phone. He said that they used to document the conversations in the resident chart, but stopped doing that in May 2022 because it was difficult to find the time to get all the information in the residents' chart.