Licensure Reference Number 175 NAC 12.006.18(B) & 1-005.06 Based on observation, interview, and record review; the facility failed to secure a urinary catheter bag to prevent the potential for cross contamination for 1 (Resident 14) of 2 residents sampled. The facility census was 62. The Findings Are: Record review of Resident 14's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 9-17-2024 revealed the facility staff assessed the following about the resident: -Diagnoses of Diabetes Mellitus Type 2, heart failure and obstructive uropathy (structural or functional hindrance of normal urine flow). -Required partial assistance with personal hygiene and rolling right and left. -Required total assistance with lower body dressing, transfers and toileting. -Has an indwelling urinary catheter (a thin, hollow tube that's inserted into the bladder to drain urine). An observation on 9-30-2024 at 9:05 AM revealed Resident 14 sitting in a recliner with a urinary catheter bag hanging from the trash can with the bottom of the bag touching the floor. An observation on 10-3-2024 at 8:52 AM revealed Resident 14 sitting in a recliner with a urinary catheter bag hanging from the trash can with the bottom of the bag touching the floor. An interview with Nursing Assistant (NA)-A on 10-03-2024 at 9:30 AM confirmed Resident 14's catheter drainage bag was touching the floor. An interview with Licensed Practical Nurse (LPN)-B on 10/3/24 at 9:40 AM confirmed catheter drainage bags should not touch the floor. An interview with the Director of Nursing (DON) on 10-03-2024 at 11:57 AM confirmed catheter bags should not touch the floor or be hung on a trash can. Record review of the facility's policy Catheter Care dated 7-30-2024 revealed: -catheters are always properly secured, connected and maintained using a sterile closed drainage system.

Licensure Reference Number 175 NAC 12-006.19 Based on observations and interview, the facility failed to maintain the cleanliness of the bathroom ceiling ventilation covers and the condition of the base of the toilets in 15 (Rooms 207, 211, 302, 311, 314, 315, 402, 403, 404, 405, 406, 411, 504, 505 and 506) of 62 occupied resident rooms in the facility. The facility census was 62. Findings are: Observation on 9/30/24 between 3:00 PM and 4:00 PM revealed the following: - Ventilation covers were coated with a collection of a dark fuzzy substance resembling dust in resident bathrooms in rooms 207, 211, 314, 315, 402, 403, 404, 405, 406, 411, 504, and 506. - There was corrosion surrounding the base of the toilet with a dark brown substance present and cracked caulking around the base of the toilet in resident bathrooms in rooms 207, 211, 302, 311, 314, 402, 403, 404, 405, 406, 411, 504, 505, and 506. Observation on 10/02/24 between 7:53 AM and 8:55 AM with the facility Maintenance Director (MD) and the facility Administrator confirmed the following observations during the environmental tour of the facility: - Ventilation covers were coated with a collection of a dark fuzzy substance resembling dust in resident bathrooms in rooms 207, 211, 314, 315, 402, 403, 404, 405, 406, 411, 504, and 506. - There was corrosion surrounding the base of the toilet with a dark brown substance present and cracked caulking around the base of the toilet in resident bathrooms in rooms 207, 211, 302, 311, 314, 402, 403, 404, 405, 406, 411, 504, 505, and 506. Interview on 10/02/24 at 8:56 AM with the facility MD confirmed the dust coated ventilation covers in resident bathrooms in rooms 207, 211, 314, 315, 402, 403, 404, 405, 406, 411, 504, and 506. The MD confirmed that there was corrosion surrounding the base of the toilet with dark brown substances present and cracked caulking around the base of the toilets in resident bathrooms in rooms 207, 211, 302, 311, 314, 402, 403, 404, 405, 406, 411, 504, 505, and 506. The MD confirmed those areas needed to be cleaned and recaulked around the toilet base. The MD confirmed that there were no active work orders for the concerns identified during the environmental tour.

Licensure Reference Number 175 NAC 12.006.11(E) Nebraska Food Code 2017 Section 4-602.13 Based on observation, interview, and record review; the facility failed to maintain the cleanliness of a fan and the walls inside the walk in cooler and 2 ventilation covers above a food preparation area in a manner to prevent the potential for food borne illness. The facility also failed to ensure that a plastic scoop handle was not in contact with flour inside a flour bin. This had the potential to affect 62 residents that ate foods prepared in the facility kitchen. The facility census was 62. Findings are: Record review of the Nebraska Food Code dated 2017 Section 4-602.13 revealed that non-food contact surfaces of equipment shall be cleaned at a frequency necessary to prevent the accumulation of soil residues. Observations on 9/30/24 between 8:20 AM and 8:35 AM, and on 9/30/24 between 9:15 AM and 10:15 AM revealed the following environmental concerns in the facility kitchen: - A condenser fan in the walk in cooler was turned on and was functional. It was coated with a dark gray/black substance. There was also a coating of a dark grey fuzzy substance on the interior walls and ceiling of the walk in cooler. - Two large air conditioner covers in the ceiling above the food preparation table were coated with a dark grey/black substance. - A plastic scoop was present in the flour bin on top of the flour with the handle of the scoop in contact with the flour product. Observation on 9/30/24 between 11:00 AM and 11:30 AM with the Dietary Manager (DM) confirmed the following environmental concerns: - A condenser fan in the walk in cooler was turned on and was functional. It was coated with a dark gray/black substance. There was also a coating of a dark grey fuzzy substance on the interior walls and ceiling of the walk in cooler. - Two large air conditioner covers in the ceiling above the food preparation table were coated with dark grey/black substance. - A plastic scoop was present in the flour bin on top of the flour with the handle of the scoop in contact with the flour product. Interview on 9/30/24 at 11:35 AM with the DM confirmed the presence of dust on the 2 air conditioner covers, dust on the condenser fan in the walk in cooler, dust on the walls and ceiling of the walk in cooler and a scoop present in the flour bin. The DM confirmed the scoop should have been stored outside of the bin and should not have been in contact with the flour. The DM confirmed that the air conditioner covers (2) were directly over a food preparation area which could have the potential to cause food borne illness if the dust dropped down into the foods. The DM confirmed that the fan in the cooler was not on a cleaning schedule and was unsure of the last time it had been cleaned. The DM confirmed that the air conditioner covers were not on the dietary cleaning schedule and was unsure of the last time they had been cleaned. Record review of undated dietary cleaning schedules revealed that the cleaning schedules did not identify the condenser fan in the walk in cooler or the air conditioner covers on the cleaning schedules. Interview on 10/01/24 at 10:36 AM with the facility Registered Dietician confirmed that all 62 residents that resided in the facility ate foods that had been prepared in the facility kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record review of Resident 47's PASSAR level 1 dated 12-01-2016 revealed The PASSAR level 1 did not identify Resident 47 had any Serious Mental Illness (SMI). Record review of a Orders Summary Sheet dated 3-07-2022 revealed on 11-10-2016 revealed Resident 47 had a diagnoses of Schizophrenia. Review of Resident 47's medical record revealed a new PASSAR had not been completed. On 3-07-2022 at 12:36 PM an interview was conducted with the Social Services Assistant (SSA) B. During the interview SSA B confirmed a new PASSAR had not been completed and should have been. Based on record review and interview, the facility failed to ensure a new PASRR (Pre-admission Screening and Resident Review) review had been completed after a diagnoses of mental illness was identified for 2(Resident 16 and 47 )out of 2 reviewed for PASRR. The facility census was 55. Findings are: A. Review of Resident 16's admission PASRR was completed on 1/27/14 as a level 1. The rationale documented on the level 1 screen determined that Resident 16 exhibited no evidence to suggest presence or known conditions of mental illness, intellectual disability, or a condition related to intellectual disability. As such, no further level 1 screening was required unless the individual was later suspected or found to have a mental illness or intellectual disability condition. Record review of Resident 16's admission Face Sheet printed on 3/7/22 revealed that Resident 16 was admitted to the facility on [DATE] and a diagnoses of Bipolar Disorder [a serious mental illness characterized by extreme mood swings] was received on 9/7/18. Record review of Resident 16's annual Minimum Data Set [ MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 12/29/21 section A1500 for PASRR revealed that Resident 16 was not considered by the State level 2 PASRR process to have a serious mental illness or intellectual disability or a related condition. The MDS further identified Resident 16 to have a current Psychiatric Diagnoses of Bipolar and Depression. Review of Resident 16's Psychiatric Note dated 1/7/22 indicated that Resident 16 had exhibited a behavioral change with increased agitation and yelling out. The note indicated that Resident 16 had a diagnoses of Unspecified Bipolar and related Disorder and Major Depressive Disorder single episode Record review of Resident 16's Electronic Medical Record revealed that a new PASRR had not been completed since 9/7/18 while the resident did have a new mental illness diagnosis of Bipolar Disorder. Interview on 03/07/22 at 12:39 PM with the Social Services Assistant [SSA] B confirmed that Resident 16 had a diagnoses of Bipolar Disorder and that a new PASARR had not been completed after 9/7/18 to determine if a Level 2 PASRR was indicated.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview the facility staff failed to monitor for side effect for the use of anti-psychotic medications for 2 (Resident 11 and 47) of 5 reviewed. The facility staff identified a census of 55. Findings are; A. Record review of Resident 11's Order Summary Sheet dated 3-07-2022 revealed Resident 11's practitioner order medications that included Abilify (an anti-psychotic medication) 5 milligrams (mg) to be given daily. Review of Resident 11 medical record that included Progress Notes, Medication Administration Records (MAR) for March 2022 and Practitioners order revealed there was not indications the facility staff were monitoring Resident 11 for side effect related to the use of the Abilify medication. On 3-07-2022 at 2:50 PM an interview was conducted with Licensed Practical Nurse(LPN) C. During the interview LPN C confirmed side effects were not being monitored for Resident 11. B. Record review of Resident 47's MAR for March 2022 revealed Resident 47 had medications ordered that included Risperdal (anti-psychotic medication) 0.25 mg every morning. Review of Resident 47's medical record that included Progress Notes, MAR for March 2022 and Practitioners order revealed there was not indications the facility staff were monitoring Resident 47 for side effect related to the use of the Abilify medication. On 3-07-2022 at 2:50 PM an interview was conducted with LPN C During the interview LPN C confirmed side effects were not being monitored for Resident 47. On 3-07-2022 at 2:50 PM an interview was conducted with Registered Nurse (RN) D. During the interview RN D confirmed the side effect of using the Risperdal were not being monitored for Resident 47. Record review of the facility policy for Psychotropic Medicationsd revised on 12-01-2021 revealed the following information: - Procedure: -D. Monitor for effectiveness and potential adverse consequences.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A Based on observation and interview, the facility failed to ensure light fixtures in the dining area by the kitchen, were free of pests. This affected 12 of 24 sampled residents. The facility census was 55. Findings are: On 03/03/22 at 0842 AM, observation of the light fixtures in the dining room nearest to the kitchen had dead insects in multiple light fixtures. On 03/08/22 at 8:35 AM, observation of the dining room revealed multiple pests in each light fixture. On 03/08/22 at 9:51 AM, an interview with the Administrator revealed the expectation of cleaning the light fixtures in the dining room had been for maintenance to clean these each month. The Administrator confirmed that the cleaning of the light fixtures from pests had not been completed by the maintenance personnel.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review, and interview; the facility failed to serve food and fluids in a manner to prevent food borne illness. This affected 14 of 20 residents in the 100 dining room. The facility census was 55. Finding are: Observation on 03/07/22 at 1230 PM in the 100 dining room refrigerator revealed juices were outdated with a date of 2-11-22. 03/07/22 at 2:40 PM an interview with the Dietary Manager confirmed that the outdated juice was in the refrigerator and should have been discarded by the 11th of February, 2022. Record Review of the 7/21/2016 version of the Food Code based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service practices revealed that outdated food and fluids should be discarded by the expiration date.