Based on record reviews and interviews, the facility failed to ensure physician visits were completed within the required time intervals for 2 (Resident 7, and 23) of 4 sampled residents. The facility census was 37. Findings are: A. Record review of the June 2024 Care Plan for Resident 7 revealed no in-person physician (or advanced practice professional) visits with Resident 7 between the dates of 12/04/2023 and 04/8/2024. This resulted in no physician or an advanced practice professional visit for a period of 126 days. Record review of a handwritten undated list of physician visitation dates presented by the Facility Administrator (FA) revealed a physician visited Resident 7 on 12/04/2023 and 4/8/2024. Interview with the Director of Nursing (DON) on 9/24/2024 at 4:35 PM revealed the resident was not seen by a physician for a period of 126 days. The DON revealed each facility resident is seen yearly by a physician for their individual health updates and physicals. The DON confirmed residents do not see a physician as mandated every 60 days. We didn't know about that regulation requirement. Interview with the FA on 9/24/2024 at 4:36 PM confirmed Resident 7 was not seen by a physician for a period of 126 days. The FA recognized there was no process in place for the required 60-day visit and stated a process would be enacted. B. Record review of the July 2024 Care Plan for Resident 23 revealed there were no in person physician (or advanced practice professional) visits with Resident 23 between the dates of 10/26/2023 and 3/21/2024. This resulted in no physician or an advanced practice professional visit for a period of 147 days. Record review of a handwritten u ndated list of physician visitation dates presented by the Facility Administrator (FA) on 9/24/2024 revealed a physician visited Resident 23 on 10/26/2023 and 3/21/2024. Interview with the Director of Nursing (DON) on 9/24/2024 at 4:35 PM Resident 23 had not been seen by a physician for a period of 147 days. The DON confirmed that residents are not seen routinely every 60 days by a physician. Interview with FA on 9/24/2024 at 4:36 PM confirmed Resident 23 was not seen by a physician for a period of 147 days.

Licensure Reference Number 175 NAC 12-006.05(D)(E) Based on record reviews, observations and interviews, the facility failed to inform the resident of medication changes made by the provider for 1 (Resident 14) of 1 sampled residents, and failed to re-evaluate residents or responsible parties choices for eye care needs for 1 (Resident 17) of 1 sampled residents. The facility census was 37. Findings are: A. Review of the facility supplied document labeled Resident Rights and dated 2016 revealed the following: -The resident has the right to be informed of and participate in their treatment including the right to be fully informed of their total health status. -The resident has the right to be informed in advance of the care to be furnished. -The resident has the right to be informed in advance of the risks and benefits of proposed care of treatment and treatment alternatives or treatment options and to choose the option they prefer. Review of the facility supplied document labeled Facility Assessment and dated 08/02/2024 revealed under resident preferences the facility supports a culture of person-centered care with respect to personal preferences. In an interview on 09/18/2024 at 10:35 AM with Resident14, Resident14 expressed concern due to being started on the medication Metformin (a medication that helps regulate blood sugar levels) a while back and was not informed of the medication change. The resident stated I refused to take the medication until I got notified of why my medications changed. A review of an Admitting Record not dated revealed the facility admitted Resident 14 on 06/27/2022 with diagnoses that included diabetes (when the body has trouble controlling blood sugar and using it for energy). The quarterly Minimum Data Set (MDS, a federally mandated tool used to assess the health status of residents in long-term care facilities) with an ARD of 07/17/2024 revealed Resident 14's Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score was 15 indicating the resident was cognitively intact. Review of Resident 14 Care Plan dated July 2024 revealed a goal stated of the resident would like to continue to direct their care and stay as independent as possible. No interventions were listed for this documented goal. Review of Resident 14's Medication Administration Record (MAR) for the month of August 2024 revealed documentation that Resident 14 declined to take the medication Metformin on August 13th, 14th, 17th, and 18th. No reason for the declination is listed in the resident's medical record. A review of Resident 14 Physican Orders dated 09/19/2024 revealed on 08/13/2024 Resident 14 Metfromin medication orders were changed increasing the dosage and frequency of this medication. A review of Resident 14's Progress Notes for the month of August 2024 revealed no progress notes reflecting Resident 14 was notified and consented to the changes in their Metformin medication. In an interview on 09/23/2024 at 4:45 PM with the Director of Nursing (DON), the DON revealed when resident orders are changed the nurse is to notify the resident and or responsible party and documentation of this notification should be present in the resident's progress notes. The DON confirmed that there was no documentation present confirming the resident was notified about the medication change prior to being administered the medication. C. In an interview on 09/18/2024 at 1:45 PM with Resident 17's responsible party revaled [gender] has a concern due to the resident not seeing an eye doctor in years. A review of an Admitting Record not dated revealed the facility admitted Resident 17 on 11/23/2018 with diagnoses that included dementia (an impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily activities). The comprehensive MDS with an ARD of 08/21/2024 revealed Resident 17 had adequate vision with the use of corrective lenses and had a BIMS score of 7 indicating the resident was severely cognitively impaired. Review of Resident 17's Care Plan dated August 2024 revealed under the heading Vision that the resident wore glasses, and their last appointment was probably 2-3 years ago. It is also documented that on admission to the facility the resident declined a vision exam. In an interview on 09/19/2024 at 1:24 PM with the Facility Administrator (FA), the FA confirmed that the resident was asked on admission about wanting an eye exam and had declined. The FA stated there was no documentation or records reflecting that the resident or their responsible party were re asked about wanting an appointment to have the residents vision checked since the resident admitted to the facility in 2018. The FA confirmed that the resident had not seen an eye doctor since being admitted to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview; the facility failed to accurately code residents Minimum Data Set (MDS, a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning) for 3 (Resident 4, 14, and 17) of 4 sampled residents. The facility stated census was 37. Findings are: A. A review of an Admitting Record not dated revealed the facility admitted Resident 4 on 09/10/2019 with diagnoses that included anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily activities), and psychosis(a severe mental disorder that causes abnormal thinking and perceptions). A review of a document titled Nebraska Summary of Findings Preadmission Screening and resident Review (PASRR), (a screening program mandated by the federal Centers for Medicare and Medicaid Services (CMS) to ensure that nursing home applicants and residents with mental illness and intellectual/developmental disabilities are appropriately placed and receive necessary services to meet their needs), dated 10/29/2019 revealed in the section titled Is nursing facility an appropriate option for you to choose that the PASRR determination was that Resident 4 met criteria for serious mental illness based on their diagnoses of unspecified psychosis and major depression, symptoms, and treatment needs. The comprehensive MDS with an Assessment Reference Date (ARD) of 05/29/2024 revealed in section A1500 Preadmission Screening and Resident Review (PASRR) Conditions 0 indicating that the resident was not considered by the PASRR to have a serious mental illness or related condition. In an interview on 09/18/2024 at 5:37 PM with the Social Service Director (SSD), the SSD confirmed that Resident 4 had a PASRR level II completed and confirmed that the PASRR indicated Resident # had a serious mental illness and this was not coded in A1500 on the 05/29/2024 comprehensive MDS. In an interview on 09/19/2024 at 9:45 AM with the MDS Coordinator (MDSC), confirmed that Resident 4 having a serious mental illness was not coded on the Comprehensive MDS dated [DATE]. B. A review of an Admitting Record not dated revealed the facility admitted Resident 14 on 06/27/2022 with diagnoses that included anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily activities). The quarterly MDS with an ARD of 07/17/2024 revealed in section N the resident was coded to have received antipsychotic medications and the physician had not documented that a Gradual Dose Reduction (GDR) was clinically contraindicated. Review of Resident 14 Care Plan dated July 2024 revealed in the section titled Black Box Warning/Gradual Dose Reduction (GDR) that on 12/17/2023 Resident 14's primary provider had documented that no GDR is to be done due to the resident condition being stable. In an interview on 09/24/2024 at 9:13 AM with the MDSC, the MDSC confirmed that Resident 14 provider had documented on 12/17/2023 that a GDR for this resident was contraindicated and section N of the MDS dated [DATE] was not coded correctly to reflect this. C. A review of an Admitting Record not dated revealed the facility admitted Resident 17 on 11/23/2018 with diagnoses that included dementia (an impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily activities). The comprehensive MDS with an ARD of 08/21/2024 revealed in section N the resident was coded to have received antipsychotic medications and the physician had not documented that a Gradual Dose Reduction (GDR) was clinically contraindicated. Review of Resident 17's Care Plan dated August 2024 revealed in the section titled Black Box Warning/Gradual Dose Reduction (GDR) that on 12/28/2023 Resident 17's psychiatric provider had documented that no GDR is to be done due to the risk of resident mood decompensation. In an interview on 09/24/2024 at 9:13 AM with the MDSC confirmed that Resident 17's provider had documented on 12/28/2023 that a GDR for this resident was contraindicated and section N of the MDS dated [DATE] was not coded correctly to reflect this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.11(E) Based on record reviews, observations, and interviews, the facility failed to ensure the water temperatures of the facility dishwasher reached the required temperature while washing and rinsing dishes and utensils. This affected all residents in the facility who received food and meals from the facility kitchen. The reported census was 37. Findings are: Record Review on 9/18/2024 of the undated [NAME] automatic dishwashing machine manufacturer panel decal revealed that the dishwasher was a high temperature machine which required a minimum water temperature during the wash cycle of 160 degrees Fahrenheit (F) and the rinse cycle of 180F degrees to activate the chemicals used for sanitization. This information was located on the upper right-hand corner of the dishwashing machine. Observation in the kitchen of the [NAME] dishwashing machine while in use on 9/18/2024 at 8:45 AM revealed the water for the wash cycle reached a temperature of 148F degrees. The temperature for the rinse cycle was over 180 degrees F. Observation on 9/18/24 at 8:45 AM of four wash/rinse cycles of the dishwasher revealed no temperatures above 150F degrees for the wash cycle. Interview with Dietary Aide-D (DA-D) on 9/18/2024 at 8:55 AM revealed the temperatures are recorded on the temperature log sheet by the doorway. We can't get the temperature to go above 150 most of the time for the wash cycle. When asked if the staff use the three-sink sanitization method for washing dishes, DA-D stated that the rinse cycle gets over 180 degrees, so they have been using the dishwasher not the three-sink sanitization method. Record review of the Dishwashing Temperature Log dated September (Sept) 2024 stated the required temperatures for the wash cycle is 160 degrees Fahrenheit and for the Rinse cycle is 180 Degrees Fahrenheit at the top of the log sheet. The log revealed the following temperatures during the wash cycle: -[DATE]: PM 150F, -[DATE]: AM 147F, PM 147F, -[DATE]: PM 147F, -[DATE]: AM 155F, PM 144F, -[DATE]: AM 155F, -[DATE]: AM 145F, -[DATE]: AM 146F, PM 145F, -[DATE]: PM 147F, -[DATE]: PM 156F, -[DATE]: AM 150F, PM 150F, -[DATE]: AM 159F, PM 150F, -[DATE]: AM 150F, PM 159F. Record review of the Daily Dishwashing Temperature Chart for the month of August (Aug) 2024 stated the required temperatures for the wash cycle was 160 degrees Fahrenheit and for the Rinse cycle is 180 Degrees Fahrenheit at the top of the log sheet. The log revealed the following temperatures during the wash cycle: -[DATE]: AM (morning)154F degrees F: PM (afternoon)144F degrees -[DATE]: PM 150F, -[DATE]: PM 150F, -[DATE]: PM 155F, -[DATE] PM 155F, -[DATE]: AM 148F, -[DATE]: AM 150F, -[DATE]: AM 145F, -[DATE]: AM 145F, -[DATE]: PM 159F, -[DATE]: PM 153F, -[DATE]: PM 145F, -[DATE]: AM 156F, PM 152F, -[DATE]:PM 148F, -[DATE]:PM 148F, -[DATE]: AM 148F, PM 145F, -[DATE]: AM 158F, PM 146F, -[DATE]: AM 158F, -[DATE]: AM 146F, PM 146F, -[DATE]: AM 158F, PM 146F, -[DATE]: AM 142F, PM 148F, -[DATE]: AM 146F, -[DATE]:PM 154F, -[DATE]: PM 154F, -[DATE]: PM 146F. During the Month of August 2024; The rinse cycle did not reach the minimum required temperature of 180 Degrees Fahrenheit on the following dates: -[DATE]th 160F, -[DATE]th 160F, -[DATE]th 170F, -[DATE]st 175F, -[DATE]nd 175F, and -[DATE]th 145F. Record review of an Email sent on 1/19/2024 to the FSS (Food Service Supervisor), regarding the dietary staff training courses, revealed that kitchen staff had gone through the National Restaurant Association ServSafe Training. (ServSafe training covers a variety of topics related to food safety and beverage handling including instructions on cleaning and sanitizing: How to clean and sanitize food preparation areas and utensils.) Interview with Facility Administrator (FA) on 9/18/2024 at 9:05 AM confirmed the temperature for the wash cycle was not at or above the required 160F degrees as mandated by the manufacturer instructions seen on the [NAME] dishwasher. Kitchen staff had to use the three-sink method of cleaning and sanitizing dishes until the dishwasher was fixed. I don't care how long it takes to fix it; the staff will be using the three-sink sanitization method until our temperatures are within the correct parameters. Interview with the Infection Control Nurse (ICC) on 9/18/2024 at 9:08 AM. When asked about the temperatures for the washing and rinse cycles, the ICC revealed that because the temperature of the Rinse cycle reached 180 degrees that the temperature for the wash cycle would not be as important. Interview with the Maintenance personnel (Maint) on 9/18/2024 at 9:15 AM confirmed the temperatures on the dishwasher didn't meet the required temperatures for the wash cycle as the temperatures did not reach the required 160 degrees F. Maint had worked on the machine. Maint is waiting on supplies and has been on the list for a technician to come to the facility for a while.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview the facility failed to notify the physician of a significant weight loss for 1 (Resident 17) of 3 sampled residents. The facility identified a census of 40. Findings are: Record review of the H&P dated 8/18/23 for Resident 17 revealed Resident 17's admitting diagnoses included Coronary Artery Disease (caused by plaque buildup in the wall of the arteries that supply blood to the heart) and Chronic Congestive Heart Failure (the heart works less efficiently than normal). Record review of the Comprehensive Care Plan (CCP) dated September 2023 revealed no indication of Resident 17 being at risk for weight loss. Record review of the Medication Administration Record and the Treatment Administration Record, both dated September 2023, indicated no monitoring of edema had occurred. Record review of the documented weights for the last 6 months for Resident 17 revealed on 03/11/2023, Resident 17 weighed 327.8 lbs (pounds) and on 09/07/2023, Resident 17 weighed 284.6 lbs which is a -13.18 % Loss. Record review of Resident 17's Dietary Note (DN) dated 8/22/23 revealed Resident 17 had a 11.9% weight loss in the previous 6 months. Further review of Resident 17's DN dated 8-22-23 revealed there was no indication Resident 17's practitioner had been notified of the weight loss. A record review of the Progress Notes dated 3/15/23 through 9/13/23 for Resident 17 revealed no documented notification to the physician regarding a significant weight loss. An interview on 09/14/23 at 01:33 PM with the DON confirmed that no evidence existed regarding physician notification of the significant weight loss for Resident 17.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1b Based on observation, record review and interview; the facility failed to assist 1 (Resident 2) of 1 sampled resident with meal intake within a time frame to ensure palatability and to prevent the potential for foodborne illness. The facility identified a census of 40. Findings are: Review of Resident 2's admitting record revealed that Resident 2 admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. Review of Resident 2's comprehensive care plan (written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) revealed: -Nutrition: Eating Habits: Please offer and encourage me to drink plenty of fluids at and between meals. I am at an assist table to help improve my intakes. Review of Resident 2's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 6/28/23, revealed: -Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function): 5 -Eating: required supervision (oversight, encouragement or cueing) after set up help from staff -Received a mechanically altered diet (a diet that requires a change in texture of food or liquids) Review of physician visit report, dated 8/21/23, revealed that Resident 2 required set up and max assist total care while eating. An observation on 9/13/23 at 11:28 AM revealed Resident 2's lunch plate and drinks were placed in front of Resident 2 by Medication Aide (MA)-A. The observation further revealed, Resident 2's head in a lowered position and both hands placed in Resident 2's lap. A continuous observation on 9/13/23 from 11:28 AM to 11:42 AM revealed Resident 2's positioned with Resident 2's head lowered, and hands placed in Resident 2's lap. The observation further revealed, no interaction between staff and Resident 2. An observation on 9/13/23 at 11:42, MA-B sat next to Resident 5, on the opposite side of Resident 2, and proceeded to assist Resident 5 with eating. A continuous observation on 9/13/23 from 11:42 AM to 12:04 PM revealed no interaction between MA-B and Resident 2. The observation further revealed, Resident 2's head lowered, and hands placed in Resident 2's lap. An interview on 9/13/23 at 12:05 PM, Nursing Assistant (NA)-C confirmed that Resident 2 needed assistance with eating and that Resident 2 had not been assisted with eating. NA-C further confirmed that Resident 2 should not have had to wait 36 minutes to be assisted with the meal and that MA-B should have assisted Resident 2 with the meal while MA-B assisted Resident 5. Review of the facility's, Serving and Feeding Residents, dated 8/14/22, revealed the following: -J. Offer assistance if necessary. -K. Feed patient when necessary. Place apron across patient's chest. Sit down at table with resident. Engage in conversation that revolves around resident. -N. Food should not be served to resident's that need assistance until staff is available to feed them immediately, so food does not get cold.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility failed to ensure wound care was completed for 1 (Resident 38) of 1 sampled resident as ordered by the practitioner. The facility census was 40. Findings are: Record review of Resident 38's admitting record revealed that Resident 38 admitted to the facility on [DATE] with diagnosis of weakness and cellulitis (bacterial infection of the skin). Record review of Resident 38's initial 48-hour care plan, undated, revealed the following: -Medications/Treatments per Doctor's orders -Other care notes: significant edema- weeping on bilateral lower extremities (BLE), dressing changes Record review of Resident 38's treatment administration record (TAR) for September 2023 revealed the following orders: -Wound care to left second toe: wash with soap and water. Place Aquacel AG (AG-silver, dressing applied to wounds that are at risk for infection) on wound bed cover with bandaid on MWF (Monday, Wednesday, Friday) -Wound care: paint black areas daily on toes with betadine (antiseptic used for the treatment of skin infections) An observation on 9/13/23 from 1:39 PM to 1:40 PM of wound care provided by Licensed Practical Nurse (LPN)-D for Resident 38 revealed LPN-D placed gloves on hands and applied betadine to the anterior aspect of Resident 38's second toe and the posterior aspect of Resident 38's third toe. The observation further revealed a bandaid to the tip of Resident 38's third toe. An interview on 9/13/23 at 2:36 PM LPN-D confirmed that the bandaid was intact to Resident 38's third toe and that Resident 38's second toe had betadine applied. LPN-D further confirmed that the order for Resident 38's second toe was to wash with soap and water, apply Aquacel AG and then apply a bandaid and that LPN-D had not followed the orders when the treatment was completed. Review of the facility policy titled Dressings, dated 5/3/21, revealed that the policy did not address that wound care should be completed as ordered by the practitioner.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, record review and interview, the facility failed to dispose of food in a timeframe to prevent foodborne illness and cross contamination. This had the potential to affect 40 residents that ate food prepared in the facility kitchen. The facility census was 40. Findings are: An observation on 09/11/23 from 8:19 AM to 8:30 AM revealed the following during the initial kitchen tour: -a carton of heavy whipping cream opened on 8/7 -a container of classic egg salad opened on 8/27 -a container of labeled cinnamon roll frosting dated 5/11 An observation on 9/14/23 from 8:18 AM to 8:28 AM revealed the following during the final kitchen tour: -a carton of heavy whipping cream opened on 8/7 -a container of classic egg salad opened on 8/27 -a container of labeled cinnamon roll frosting dated 5/11 -a pitcher labeled strawberry kiwi juice dated 9/8 -a container labeled chicken broth dated 9/10 Review of the facility policy, Food Service Policies and Procedure: Infection Prevent, dated 9/28/15 revealed the following: -10. Food mixture high in protein, such as cream soup, custards, egg mixtures, mayonnaise in meat are not to be kept longer than one day under refrigeration. -11. Main dishes, vegetables will be discarded after 3 days; fruits that are open and fruit juices within 4 days. An interview on 9/14/23 at 8:28 AM the Dietary Manager confirmed that the heavy whipping cream, egg salad, cinnamon roll frosting, and the strawberry kiwi juice should have been thrown out three days after the date on the container. An interview on 9/14/23 at 8:30 AM the [NAME] confirmed that the chicken broth should have been thrown out three days after the date on the container and confirmed that all 40 residents receive food from the kitchen.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation, interview and record review, the facility failed to ensure respiratory equipment was stored in a manner to prevent potential cross contamination when not in use for Resident 4. The sample size was 2. The facility census was 30. FINDINGS ARE: An observation on 08/01/22 at 04:00 PM revealed Resident 4 to have a band-aid on the bridge of (gender) nose and voiced it was caused from the CPAP (Continuous Positive Airway Pressure -- a treatment that uses mild air pressure to keep your breathing airways open) mask. The observation on 08/01/22 at 04:00 PM revealed a CPAP mask and tubing to be intact and hanging over medicine cabinet in Resident 4's bathroom, with the mask touching the wall. The observation revealed an undated laminated sign sitting on the bathroom counter with instructions related to care of the CPAP equipment which read as follows: Steps to Cleaning CPAP Equipment 1,Remove the CPAP tubing from the device output valve and the water chamber from the device. Take the mask off the headgear. 2. Make a soapy solution using warm water and a few drops of mild dish soap. Instead of using soap, you can also make a 1:1 solution with white vinegar. 3. Place the parts in the solution. Allow each part to soak for a few minutes and make sure that the water and soap (or vinegar) is allowed to flow through the entire length of the hose. 4. Rinse each part with clean water. 5. Use a clean towel to remove any excess water and pat each piece dry. 6. Let them air dry for about an hour. 7. Once the parts are fully dry, carefully put them back together. Refer to the instruction manual if you are unsure how to reassemble the CPAP pieces correctly. During an interview on 08/02/22 at 11:28 AM, Resident 4 voiced wearing the CPAP last night. An observation on 08/02/22 at 11:28 AM, revealed Resident 4's CPAP mask to be intact, connected to the tubing but not the machine and hanging over the medicine cabinet in the bathroom with the mask touching the cabinet. An interview on 08/02/22 at 04:08 PM with the DON (Director of Nursing), after review of the CPAP mask findings for Resident 4, confirmed that the expectation of the facility is to use the black infection prevention bags when tubing was not in use. When a request was made for a copy of the facility respiratory equipment cleaning and storage policy, a copy of the laminated signage posted in Resident 4's bathroom was provided.

B. A record review of current physician's orders revealed Tylenol and Tramadol ordered for pain control for Resident 15. A record review of an order for Pain Assessment read ask resident if having pain twice daily. Pain assessments documented in Resident 15's medication administration record dated July 2022, revealed 0, meaning no pain for all of the days of July except for 4 days. A record review of Resident 15's Medication Administration Record dated July 2022, revealed that Resident 15 had received PRN Tylenol 2 times in the month of July with no non pharmacological interventions noted. A record review of Resident 15's Monthly Medication Review dated 6/14/22 revealed no pharmacy recommendations. A record review of Daily Pain Monitoring Policy last revised 6/27/17, revealed under documentation that pain rating (1-10) and interventions are to be recorded twice daily. A record review of the Pain Management Flow Sheet last revised 6/28/17, revealed under Documentation that pain rating (1-10) and interventions are to be recorded. An interview with the Director of Nurses (DON) on 8/3/22 at 9:06 AM confirmed that the pain documentation did not indicate the need to continue with 2 pain medications and confirmed that non pharmacological interventions had not been documented and should have been. LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted and that pain monitoring documentation had been completed and reflected the need to continue duplicate pain medications for Resident 15 and 17. The sample size was 2. The facility census was 30. FINDINGS ARE: A. A record review of the MAR (Medication Administration Record) dated July 2022 revealed Resident 17 takes the following medications which require some type of monitoring or follow up such as labs, vitals, pain levels, behavior monitoring etc; -Acetaminophen 325mg TID for pain -Gabapentin 300mg BID for pain -Ativan 1mg TID for anxiety disorder -Quetiapine 25mg at bedtime for anxiety disorder -Trazadone 50mg 1/2 tab every bedtime for anxiety disorder A record review of the MAR dated July 2022 for Resident 17 revealed an order for Pain Assessment, Ask resident twice daily about pain which had responses of dashes (---) and a reasoning of unable to vocalize for every entry except 2 throughout July 2022. The record review of the MAR dated July 2022 for Resident 17 did not indicate non-pharmacological interventions had been attempted prior to pain medication administration. A record review of the policy titled Daily Pain Monitoring dated 4/2005, revised 6/27/17 revealed the following directions; II. Policy: All residents will be asked twice daily if they are having pain. B. For cognitively impaired residents, you may need to use more observational skills to detect pain: a. grimacing b. negative behaviors c. pacing d. wandering e. anything that is not routinely done An interview on 08/03/22 at 09:06 AM, with the DON (Director of Nursing), after review of the pain documentation, confirmed pain monitoring documentation did not indicate the need to continue with 2 pain medications and confirmed that non-pharmacological interventions had not been documented and should have been.

C. A record review of current Physician's Orders for Resident 15 revealed orders for the following: Escitalopram (a medication used to treat depression), Lorazepam (a medication used to treat anxiety) and Quetiapine (an antipsychotic medication used to treat certain mental or mood disorders.) A record review of Resident 15's Medication Administration Record (MAR) dated June 2022 through July 2022 revealed escitalopram, lorazepam and quetiapine medications were given every day in the months of June and July of 2022. A record review of Resident 15's Behavior Detail Report dated 5/24/22 through 7/2/22 revealed None of these behaviors apply were charted every day except for 3 days in the month of June. A record review of Resident 15's comprehensive care plan Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) last revised on 5/1/22 listed the medications escitalopram, lorazepam and quetiapine and no target behaviors. An interview on 8/3/22 at 08:47 AM with the Director of Nursing (DON) confirmed the target behaviors should be listed on the CCP. D. A record review of current Physician's Orders for Resident 19 revealed orders for the following: Risperdone (an antipsychotic medication used to treat certain mental or mood disorders.) A record review of Resident 19's MAR dated June 2022 and July 2022 revealed risperdone was given every day in the months of June and July of 2022. A record review of Resident 19's Behavior Detail Report dated 7/5/22 through 8/3/22 revealed None of these behaviors apply was documented every day. A record review of Monthly Medication Review dated June and July 2022 revealed no pharmacy recommendations. A record review of Resident 19's CCP last revised 4/19/2022 listed risperdone medication and no target behaviors. An interview on 8/3/22 at 08:47 AM with the DON confirmed the target behaviors should be listed on the CCP. LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B Based on record review and interview, the facility failed to identify target behaviors for residents with MI/DD (Mental Illness/Developmental Disability) and ensure behavior monitoring occurred related to psychotropic medication use for Resident 1, 15, 17 and 19. The sample size was 4. The facility census was 30. FINDINGS ARE: A. A record review of the MAR/TAR dated July 2022 revealed Resident 1 takes the following medications which require some type of monitoring or follow up such as MMR's (Monthly Med Review) or GDR's (Gradual Dose Reductions), labs, vitals, pain levels, behavior monitoring etc; -Amiodarone 200mg once daily for hypertension -Bupropion HCL XL150mg once daily for Major Depressive Disorder -Trazadone 100mg every bedtime for insomnia A record review of the document titled Behavior Detail Report dated 8/2/22 and covering the timeframe of 6/3/22 through 8/1/22 and documented by the CNA's revealed that on 6/29/22 Resident 1 had displayed sexually inappropriate behavior towards female staff. The Behavior Detail Report dated 8/2/22 and covering the timeframe of 6/3/22 through 8/1/22 revealed no other behaviors or s/s depression. A record review of the Progress Notes dated 5/17/22 through 7/8/22 for Resident 1 did not indicate any negative or sexually inappropriate behaviors during that time frame. An interview on 08/03/22 at 08:41 AM with the DON (Director of Nursing), after review of the behavior charting and progress notes for Resident 1 confirmed that the facility expectation related to negative behaviors was that if the CNA's (Certified Nurse Aide) documented behaviors occurring in their task charting, the nurses were expected to have follow up charting in the Progress Notes. The interview with the DON confirmed that the Progress Notes for Resident 1 did not address the sexual behaviors displayed on 6/29/22. The interview on 08/03/22 at 08:41 AM with the DON, after review of the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 1, confirmed that it did not indicate Resident 1 had a history of sexually inappropriate behaviors and should have. The interview on 08/03/22 at 08:41 AM with the DON, confirmed that target behaviors should be found on the Resident's CCP and was not. The interview confirmed that the facility had not assessed Resident 17 for target behaviors. A record review of the policy titled Medication Administration dated 2/2004 and revised 6/4/2020 revealed it did not contain direction related to hypnotic use. An interview on 08/03/22 at 10:35 AM with the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) confirmed that no sleep diary had been completed since Resident 1's admission related to the Trazadone use or diagnosis of insomnia. B. A record review of the MAR/TAR dated July 2022 revealed Resident 17 takes the following medications which require some type of monitoring or follow such as MMR's, GDR's, labs, vitals, pain levels, behavior monitoring etc; *Acetaminophen 325mg TID (Three times a day) for pain *Gabapentin 300mg BID (Two times a day) for pain *Ativan 1mg TID for anxiety disorder *Quetiapine 25mg at bedtime for anxiety disorder *Trazadone 50mg 1/2 tab every bedtime for anxiety disorder An interview on 08/03/22 at 08:41 AM with the DON, after review of behavior documentation for Resident 17 confirmed that the facility expectation is that if negative behaviors are noted by NA's, it will be reported to the Nurse on duty and the Nurse will follow up and document in the Progress Notes. The interview confirmed that no follow up documentation by the nurses in the Progress Notes had been completed and should have. The interview on 08/03/22 at 08:41 AM with the DON, confirmed that target behaviors should be found on the Resident's CCP and was not. The interview confirmed that the facility had not assessed Resident 17 for target behaviors.

Licensure Reference 175 NAC 12-006.11E Based on record review, observations, and interview; the facility failed to ensure food was served at temperatures to prevent the potential for food borne illness. This had the potential to affect all residents. The facility identified a census of 30 at the time of survey. Findings are: An observation of temperature checks on 08/03/22 at 11:15 AM of the steam table in the main dining room performed by [NAME] D revealed the following temperatures: Mixed fruit cup, 44 degrees chopped tomatoes, 46 degrees An observation of temperature checks on 08/03/22 at 12:10 PM, of the last room tray served, performed by [NAME] D, revealed the following temperatures: salmon, 115 degrees baked potato, 129 degrees cream corn,124 degrees Sour cream raisin bar, 74 degrees An interview on 8/3/22 at 12:15 with [NAME] D confirmed all the food on this tray was not within the required temperatures. Record review of the Nebraska State Food Code 81-2,272.01 Time/Temperature control for Safety Food, Hot and Cold holding revealed: Time/temperature control for safety food shall be maintained at: a.) One hundred thirty - five degrees Fahrenheit or above b.) Forty - one degrees Fahrenheit or less A record review of the facility policy, revised 9/28/2015 titled Food Service Policies and Procedures Infection Prevention revealed under Preparation and Service, #4 states that entry and growth of contaminants in food depends on the length of time these foods are held between 41-135 degrees Fahrenheit. In an interview on 08/03/22 at 01:02 PM with Dietary Manager (DM) confirmed the holding temperatures taken by [NAME] D were above 41 degrees and below 135 degrees and that the steam table temperature logs are not monitored and they should have been.

Licensure Reference NAC 12-006.17 Licensure Reference NAC 12-006.17D Based on record review, observations, and interviews; the facility failed to ensure hand hygiene was performed after glove removal in the kitchen, after touching hair and prior to assisting a resident with their meal and that dishes were carried in a manner to prevent potential cross contamination. This had the potential to affect all residents. The facility identified with a census of 30 at the time of survey. Findings are: A kitchen observation on 08/03/22 at 10:49 AM revealed Dietary Aide (DA) F taking off gloves in the kitchen, without performing hand hygiene and then picking up a bowl of dessert. An interview with DA F on 8/3/22 at 10: 51 AM confirmed hand hygiene should have been performed after removing gloves. An observation in the dining room on 08/03/22 at 11:40 AM revealed Nursing Assistant (NA) H touching hair, not doing hand hygiene prior to assisting residents with their meals. On 8/3/22 at 1:02 PM the Director of Nursing (DON) confirmed everyone should be doing hand hygiene in the dining room. A kitchen observation on 08/03/22 at 10:50 AM revealed DA G carrying clean plate lids against the employee's shirt. An interview on 8/3/22 at 10:55 AM with DA confirmed the clean dishes should not have touched the employee shirt. A kitchen observation on 08/03/22 at 10:42 AM revealed [NAME] D taking the temperature of the cooked food in the kitchen using the same alcohol wipe to clean off the thermometer in between foods in order to take the food temperatures. An interview on 8/3/22 at 10:45 AM with the cook confirmed that usually they just use one alcohol wipe. A record review of facility policy last reviewed on 9/13/2018 titled Hand Hygiene Policy and Procedure revealed the 6 moments for hand hygiene, # 5 states before and after handling food. A record review of facility policy last reviewed on 10/1/2017 titled Dress Code revealed under procedures in section F that all long and medium length hair should be worn up or tied securely back when working with residents. An interview with the Dietary Manager (DM) on 8/3/22 at 1:02 PM confirmed that the dietary staff should have washed their hands when removing gloves, nothing clean should touch the uniform, and the cook should have used a clean alcohol wipe in between foods in order to clean the thermometer. An interview with the DON on 8/3/22 at 1:05 PM confirmed the nursing assistant should have performed hand hygiene after touching hair and before assisting residents with their meals.