Based on medical record review, review of the Pre-admission Screening and Resident Review (PASRR - screening to determine if specialized services are needed) and staff interview, the facility failed ensure PASRR screenings were accurately completed. This affected one (#19) of three residents reviewed for PASRR screenings. The facility census was 58. Findings include: Review of the medical record for Resident #19 revealed an admission date of 03/13/25. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, unspecified dementia, unspecified hearing loss, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 03/31/25, revealed Resident #19 had a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. The resident was dependent upon staff for activities of daily living (ADLs). Review of the PASRR, completed on 03/11/25, revealed Resident #19's diagnosis of unspecified psychosis not due to a substance or known physiological condition was not documented on the screening. Interview with Social Services Director (SSD) #272 verified Resident #19's PASRR did not accurately reflect the resident's mental health diagnosis and further confirmed a diagnosis of unspecified psychosis not due to a substance or know physiological condition should have been included on the PASRR screening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 05/21/25 at 12:49 P.M. of the 200-hall main medication room refrigerator, with the Director of Nursing (DON), revealed a plastic container which held eight vials of insulin. There were two vials of Novolog N 100 units per 10 milliliters (U/ml) with expiration dates of 12/31/24 and 01/31/25, a vial of Novolog R 100 U/10 ml with an expiration date of 03/31/25, two vials of Novolog 70/30 with an expiration date of 01/31/25 and one vial of Novolin R 100 U/10 ml with an expiration date of 03/31/25. Interview on 05/21/25 at 1:05 P.M. with the DON revealed the vials of insulin in the mail medication room refrigerator were used by all three halls of the facility for emergency situations, such as residents out of insulin or with new admissions. The DON verified the eight vials of insulin in the main medication room refrigerator were expired. Review of the facility policy titled, Medication Storage in the Facility, dated November 2018, revealed medications were stored safely, securely and properly, following manufactures recommendations or those of the supplier. Further review revealed outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled or without secure closures were immediately removed from inventory. All expired medications would be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Based on observation, staff interview, medical record review and review of the facility policy, the facility failed to ensure medications were not left unattended at a resident's bedside. This affected one (#111) of five residents reviewed for medication administration. In addition, the facility failed to ensure medications were removed from use and disposed of upon expiration. This had the potential to affect eight (#16, #22, #27, #30, #36, #39, #44 and #49) residents identified by the facility as receiving insulin. The facility census was 58. Findings include: 1. Review of the medical record reveal Resident #111 was admitted on [DATE]. Diagnoses included cellulitis of the left lower limb, hypertensive heart and chronic kidney disease, acute on chronic diastolic heart failure, chronic kidney disease stage III, rheumatoid arthritis, type two diabetes mellitus with diabetic neuropathy, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 03/13/25, revealed Resident #111 was cognitively intact and prescribed medications included anticoagulants, antibiotics, opioids, and anticonvulsants. Review of the Medication Administration Record (MAR) for May 2025 revealed on 05/18/25, during the morning medication administration, Resident #111 received the following medications: amiodarone (antiarrhythmic medication) 200 milligram (mg), bumetanide (diuretic) one mg, duloxetine (antidepressant) delayed release 60 mg, Eliquis (anticoagulant) five mg, folic acid (vitamin) one mg, gabapentin (antiseizure/nerve pain) 300 mg, glimepiride (diabetic medication) two mg, Jardiance (diabetic medication) 25 mg, levothyroxine (thyroid medication) 88 microgram (mcg), midodrine (antihypotensive) five mg, multivitamin tablet, oxybutynin chloride (urinary) tablet extended release 10 mg, pantoprazole (proton pump inhibitor) 40 mg, potassium chloride 20 milliequivalent (mEq), prednisone (corticosteroid) five mg, senna (supplement) 8.6 mg, and spironolactone (diuretic) 12.5 mg. Observation on 05/18/25 at 9:54 A.M. revealed Resident #111 was sitting in her wheelchair, just outside of the resident's room door. Upon entering the resident's room, with the resident, a half full medication cup was observed on the bedside table. Interview on 05/18/25 at 10:00 A.M. with Licensed Practical Nurse (LPN) #283 verified leaving Resident #111's medications unattended at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy, the facility failed to notify the physician of weight gain per physician order. This affected one (#11) of one residents reviewed for notification of change. The facility census was 55. Findings include: Review of Resident #11's medical record revealed an admission date of 04/14/22 and a readmission date of 05/20/22. Diagnoses included displaced bimalleolar fracture of right lower leg, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, seizures, cardiomyopathy, asthma, major depressive disorder, anxiety disorder, overactive bladder, morbid (severe) obesity, hypotension, unspecified intellectual disabilities, edema and unspecified mood disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was severely cognitively impaired and required extensive assistance with activities of daily living (ADLs) and had no weight loss or weight gain. Review of a plan of care, revised 10/26/22, revealed Resident #11 experienced a significant weight gain. Interventions included obtain weight as ordered. Additional review of a plan of care, revised 08/23/22, revealed Resident #11 had a potential for complications related to congestive heart failure (CHF). Interventions included weight as ordered, medications per orders, diet per physician orders and observe for and report complications as needed. Review of a physician order dated 10/31/22 revealed to weigh Resident #11 daily and to call the CHF clinic for weight gain of three pounds (lbs) in one day or five lbs. in one week. Review of weights revealed Resident #11 weighed 356 lbs on 11/04/22 and 375 lbs on 11/05/22, indicating a weight gain of 19 lbs in one day. Further review of Resident #11's medical record revealed no evidence the CHF clinic was notified of Resident #11's weight gain on 11/05/22. Interview on 11/08/22 at 8:45 A.M., Licensed Practical Nurse (LPN) #372 revealed CHF was a new diagnosis for Resident #11 and he began treatment at the CHF clinic on 10/31/22. LPN #372 confirmed Resident #11 was to be weighed daily and a weight increase of three pounds in a day was to be reported to the CHF clinic. Interview on 11/08/22 at 2:21 P.M., Regional Clinical Support (RCS) #481 confirmed Resident #11's medical record did not reflect CHF clinic notification of Resident #11's weight gain on 11/05/22. RCS #481 provided documentation weight increases were faxed to the clinic on 11/02/22 and 11/07/22 but no notification was made on 11/05/22. Review of facility policy titled Notification of Change in Condition, reviewed 12/01/21, revealed the resident representative and provider should be notified of change in condition in a timely manner.

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure weights were obtained in a consistent manner to ensure accuracy. This affected one (#11) of three residents reviewed for nutrition. The facility census was 55. Findings include: Review of Resident #11's medical record revealed an admission date of 04/14/22 and a readmission date of 05/20/22. Diagnoses included displaced bimalleolar fracture of right lower leg, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, seizures, cardiomyopathy, asthma, major depressive disorder, anxiety disorder, overactive bladder, morbid (severe) obesity, hypotension, intellectual disabilities, edema and mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/13/22 revealed Resident #11 was severely cognitively impaired, required extensive assistance with activities of daily living (ADLs) and had no weight loss or weight gain. Review of a plan of care, revised 10/26/22, revealed Resident #11 experienced a significant weight gain. Interventions included obtain weight as ordered. Additional review of a plan of care, revised 08/23/22, revealed Resident #11 had a potential for complications related to congestive heart failure (CHF). Interventions included weight as ordered, medications per orders, diet per physician orders and observe for and report complications as needed. Review of a physician order dated 11/02/22 revealed to weigh Resident #11 daily. Additional review revealed to weigh the resident on the spa scale for consistency. Review of weights revealed Resident #11 weighed 350.2 pounds (lbs.) on 11/01/22, 376.4 lbs. on 11/02/22, 356.8 lbs. on 11/03/22, 356 lbs. on 11/04/22, 375 lbs. on 11/05/22, 375.6 lbs. on 11/06/22, and 358 lbs. on 11/07/22. Interview on 11/08/22 at 2:21 P.M. with Regional Clinical Support (RCS) #481 verified significant variances in Resident #11's weights. RCS #481 stated the variances may have been due to staff not subtracting Resident #11's wheelchair on the dates he weighed 375 lbs. RCS #481 confirmed Resident #11's wheelchair weighed 58 lbs. and the weight of the wheelchair exceeded the differences in the Resident's weights. Follow up interview on 11/08/22 at 2:49 P.M., RCS #481 revealed Resident #11 had been weighed on different scales, which likely accounted for the weight variations. RCS #481 confirmed Resident #11's physician orders specified to use the spa scale to ensure consistency with weights and the spa scale and the chair scale were both being used when weighing Resident #11. Interview on 11/09/22 at 9:07 A.M., Licensed Practical Nurse (LPN) #336 revealed she had assisted in obtaining some of Resident #11's weights. LPN #336 stated she was unsure why the resident's weights were so off from each other. LPN #336 stated the spa scale was not wide enough for Resident #11's wheelchair and the only thing she could think was that some staff were pushing the wheelchair onto the spa scale, with the weight not being evenly distributed, resulting in inaccurate weights. Review of facility policy titled Guidelines for Weight Tracking, reviewed 03/16/22, revealed to the extent possible, the same scale, same person, same wheelchair (if applicable) should be used to ensure consistency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and review of facility policy, the facility failed to ensure medications were received from the pharmacy in a timeframe to allow for the timely initiation of physician's orders for new medications. This affected two (Resident #15 and #205) of seven residents reviewed for medications. The facility census was 55. Findings include: 1. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included type two diabetes mellitus with diabetic chronic kidney disease, abdominal aortic aneurysm without rupture, chronic kidney disease stage 4, vascular dementia with behavioral disturbance, schizoaffective disorder, and hypertension. Review of the physician order, dated 11/04/22, revealed an order for the antibiotic cefadroxil/duricef 500 milligram (mg) twice a day. Review of the progress note, dated 11/05/22 revealed cefadroxil/duricef was not received in tote prior night and was not able to be pulled from Cubex. Pharmacy was contacted and stated it would be in that evening's tote. Facility staff voiced concerns that the medication was put into matrix care before 2:00 P.M. on 11/04/22 so it should have been in the prior night's tote. It was reported the pharmacy will drop ship today's antibiotic doses for Resident #15. Review of Medication Administration Record (MAR), dated November 2022, revealed cefadroxil was not administered on 11/04/22 and 11/05/22. Comments included could not find medication and medication was to be dropped shipped and was not received. Interview on 11/09/22 at 11:59 P.M. with the Director of Nursing (DON) verified Resident #15 did not receive the antibiotic ordered on 11/04/22 until 11/06/22 due to not receiving the antibiotic timely from pharmacy. The DON reported a drop shipment should be received within two hours. 2. Review of the medical record revealed Resident #205 was admitted on [DATE]. Diagnoses included sepsis, acute respiratory failure with hypoxia, acute kidney failure, type two diabetes mellitus without complications, and nicotine dependence. Review of progress note, dated 11/04/22, revealed Resident #205's daughter requested a nicotine patch be ordered due to Resident #205 being a current cigarette smoker of one to two packs per day. Review of the physician order, dated 11/04/22, revealed an order for nicotine patch 24 hour 21 mg/24 hour one patch applied transdermal once a day. Review of the Medication Administration Review (MAR), dated November 2022, revealed on 11/04/22, 11/05/22, and 11/06/22 the nicotine patch 24 hour 21 mg was not administered due to the drug/item not available. Interview on 11/08/22 at 3:48 P.M. with Licensed Practical Nurse (LPN) #412 verified working on 11/06/22. LPN #412 stated he had called the pharmacy due to Resident #205 not receiving nicotine patches as ordered. Pharmacy stated their new system was the reason for delay. LPN #412 verified the nicotine patches were ordered on 11/04/22 and the resident did not receive the patch until 11/07/22. Review of policy titled Medication Ordering and Receiving from Pharmacy, revised January 2017, revealed medications and related products are received from the dispensing pharmacy.

Based on medical record review, staff interview and policy review, the facility failed to provide bed hold notice to one resident. This affected one (#52) of four sampled residents reviewed for bed holds prior to transferring to the hospital. The facility census was 55. Findings include: Review of Resident #52's medical record revealed an admission date of 06/28/19 at 2:30 P.M. and discharged on 06/29/19 at 12:26 P.M. Diagnoses include unspecified atrial fibrillation, hypertensive heart disease with heart failure, anemia, chronic systolic heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, obstructive sleep apnea, dysphagia, oropharyngeal phase and hyperlipidemia. Review of the Minimum Data Set (MDS) revealed the MDS had not yet been completed as the resident was in the facility less than 24 hours. Review of the progress note dated 07/09/19 at 9:43 A.M. revealed the Executive Director spoke with family regarding the bed hold on 07/08/19. The Executive Director mailed the Bed hold letter certified, with a self addressed stamped envelope enclosed. Interview on 09/26/19 at 2:15 P.M., with the Executive Director verified Resident #52 or their representative was not given notice of the bed hold policy within 24 hours. Review of the policy titled Bed Hold Notification, dated 09/24/18, revealed before transferring a resident to a hospital or allowing a resident to go on a therapeutic leave, the Nursing designee or other designated staff member should provide written information to the resident and a family member or legal representative of the bed hold and admission policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to monitor a resident's dialysis access per facility policy. This affected one (#17) of one resident reviewed for dialysis. The facility census was 55. Findings include: Review Resident #17's medical record revealed an admission date of 02/19/18. Diagnoses included: end stage renal disease, essential hypertension, heart failure, muscle weakness, gastro-esophageal reflux disease without esophagitis, anemia, acute myocardial infarction, overactive bladder, constipation, gout, acute embolism and thrombosis of deep veins of right upper extremity. Interview on 09/26/19 at 7:11 A.M. with Resident #17 revealed Resident #17 stated the staff don't check her arm very often here, but they do at dialysis. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #17 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15. Resident #17 had no rejection of care during the assessment period. Resident #17 received dialysis services. Review of the care plan dated 06/25/19 revealed Resident #17 had renal failure resulting in the need for dialysis. Resident will be free from complications associated with dialysis. Appropriate goal and interventions were included in the care plan specifically, monitor dialysis access as ordered. Review of the current physician orders revealed there was no order for monitoring the dialysis access. Review of the Treatment Administration Record for 08/2019 and 09/2019 revealed there was documentation of monitoring the dialysis access. Interview on 09/26/19 at 9:55 A.M. with the Director of Nursing revealed there was no order to monitor the dialysis access and there was no documentation of monitoring the dialysis access. Review of the policy titled Guidelines for Monitoring Shunt: Hemodialysis Arteriovenous Access, dated 05/22/18, revealed to monitor the Arteriovenous shunt daily for redness, swelling, signs and symptoms of infections, complaints of pain, local warmth, exudates, tenderness, numbness, tingling, and extremity swelling distal to access. Monitor the Arteriovenous shunt daily for thrill and bruit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to properly maintain the flooring in a resident's room. This affected one of 46 resident rooms observed. The facility census was 55. Findings include: Observation on 09/23/19 at 11:16 A.M., revealed three large holes in the tile flooring in resident room [ROOM NUMBER]. The three holes are approximately two inches by four inches, four inches by six inches, and six inches by nine inches. The holes are near a resident's recliner. Interview on 09/25/19 at 11:38 A.M., with the Director of Plant Operations #102 verified there are holes in the tiling flooring of resident room [ROOM NUMBER]. Director of Director of Plant Operations #102 verified a work order had not been received and the flooring definitely should have been fixed. Further interview at 12:04 P.M., verified the tile had completely ripped through to the under layment flooring. Interview on 09/26/19 at approximately 7:30 A.M., with Administrator #100 verified the flooring should have been replaced. Review of facility policy titled,Flooring Preventative Maintenance, dated 02/06/18, verified vinyl tile is inspected for chipping and cracking quarterly and replaced as necessary.

Based on observation, staff interview, and review of food menus and spreadsheets, the facility failed to serve appropriate food servings to residents with a pureed diet. This affected nine (#8, #16, #21, #22, #23, #29, #34, #38, and #44) residents with orders for pureed diets who were served food in the main and restorative dining rooms. The facility identified two (#27 and #31) additional residents with orders for pureed diets who received their meals in their rooms. The census was 55. Findings include: Observation on 09/25/19 at 12:08 P.M., revealed [NAME] #560 serving residents meals from the steam table in the main dining room. [NAME] #560 served all meals to residents in the main dining room and restorative and was asked what scoop sizes were used while serving food items. Interview on 09/25/19 at 12:14 P.M., with [NAME] #560 stated the pureed cornflake chicken breast, scalloped potatoes, and sautéed cabbage and spinach were served using a #10 (3/8 cup) scoop. Review of menu for the spring and summer Midwest 2019 week 2 revealed the lunch meal was cornflake chicken breast, scalloped potatoes, sauteed cabbage and spinach, a Southern biscuit, cherry cobbler, butter cup, coffee and tea, and garnish. Review of a spreadsheet for the spring and summer Midwest 2019 diet revealed purred cornflake chicken breast was to be served with a #6 (5/8 cup), pureed scalloped potatoes with a #8 (1/2 cup), and pureed sautéed cabbage and spinach with a #12 (1/3 cup) scoop. Interview on 09/25/19 at 12:30 P.M., with [NAME] #560 and Dietary Manager #290 verified the incorrect scoop sizes were used when serving the pureed cornflake chicken breast, scalloped potatoes, and sautéed cabbage and spinach in the main and restorative dining rooms on 09/25/19. Interview on 09/26/19 at approximately 10:30 A.M., with Director of Health Services #101 verified none of the 11 (#8, #16, #21, #22, #23, #27, #29, #31, #34, #38, and #44) residents with orders for pureed diets had any significant weight loss in the last 30 days.

Based on observation, staff interview, review of food recipes, and review of a facility policy, the facility failed to provide nutritional and appetizing bread for a pureed meal. This affected nine (#8, #16, #21, #22, #23, #29, #34, #38, and #44) residents with orders for pureed diets who were served food in the main and restorative dining rooms. The facility identified two (#27 and #31) additional residents with orders for pureed diets who received their meals in their rooms. The census was 55. Findings include: Observation on 09/25/19 at 11:25 A.M., revealed [NAME] #400 preparing pureed textured foods in the facility kitchen. [NAME] #400 explained the recipe for pureed textured foods had a minimal serving size of 25 servings, and since the facility had less than 25 residents on pureed diets they would recalculate the recipe to make it for 15 servings. [NAME] #400 asked Dietary Manager #290 to recalculate a recipe for pureed bread to make 15 servings instead of 25. Dietary Manager #290 presented [NAME] #400 with a revised recipe to aide in making pureed bread for the lunch meal. Review of an undated pureed bread recipe number 157 revealed the recipe was set up for serving sizes of 25, 50, 75, 100, and 150 and ingredients including pureed bread mix, hot water, and low-sodium chicken base. Review of the undated, unnamed and revised recipe given to [NAME] #400 revealed an example for ingredients in black and white cookies for eight, sixteen, forty, eighty, and 120 servings with ingredients of flour, baking powder, salt, and milk. The recipe did not address ingredients for pureed bread or the quantity of the ingredients needed. Further observation on 09/25/19 at 11:30 A.M., revealed [NAME] #400 removed slices of bread from the steamer and placed them in the food processor mixing it with an undetermined amount of hot water, melted butter, and chicken broth. After all food items were blended together, [NAME] #400 used a spatula to scrap the pureed bread from the food processor into a metal holding pan at which time the consistency of the pureed bread was very thin in an almost liquid form. Interview 09/25/19 at 11:40 A.M., with [NAME] #400 stated she would place the pureed bread back in the steamer and it would thicken up. Observation on 09/25/19 at 12:08 P.M., revealed [NAME] #560 serving residents meals from the steam table in the main dining room. Further observation revealed [NAME] #560 scoop pureed bread from the steam table and place it on plates. The consistency of the pureed bread was very runny and did not require [NAME] #560 to use the clicker on the side of the scoop. When [NAME] #560 placed the scoop into the pureed bread and lifted the scoop, pureed bread mixture was dripping off the scoop, and when the pureed bread was plated it did not hold a form and ran on the plate into other food items. Interview on 09/25/19 at 12:30 P.M., with [NAME] #560 and Dietary Manager #290 stated the pureed bread was too runny and should have been more formed. Dietary Manager #290 stated he did not observe the pureed bread after [NAME] #400 prepared it. The facility identified nine (#8, #16, #21, #22, #23, #29, #34, #38, and #44) residents with orders for pureed diets who were served food in the main and restorative dining rooms on 09/25/19 between 12:00 P.M. and 12:30 P.M. Review of a facility policy titled, Standardized Recipes, dated 05/31/16, revealed any recipe changes made by the Director of Food Services should be reviewed and approved by the Registered Dietitian.