Based on record review and interview the facility failed to complete a Level II Pre-admission Screening and Resident Review (PASRR, a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability), evaluation for a resident who was identified with a newly diagnosed serious mental illness and psychotropic medication change for 1 (Resident 10) of 1 sampled resident. The facility census was 58. Findings Are: A record review of the undated NE PASRR Provider Portal Frequently Asked Questions (FAQ) document on the website https://nepasrr.acentra.com/wp-content/uploads/sites/26/2024/04/NE-PASRR-Atrezzo-FAQs-1.pdf revealed that if a Level I PASRR was completed prior to resident admission to the facility and then new information is received, the nursing facility should complete a Resident Review for significant change and request a PASRR Level II evaluation and determination. A record review of a PASRR dated 05/02/2024 revealed a Level 1 PASRR was completed for Resident 10 on 05/02/2024. Documentation was present that the resident did not have a diagnosis of serious mental illness and was receiving routine antidepressant and opioid medications. A record review of Resident 10's electronic medical health record revealed Resident 10 was assigned the diagnosis of delusional disorder (a serious mental health condition characterized by persistent, false beliefs that are not based on reality) on 05/09/2024. A record review of Resident 10's electronic medical health record revealed that on 11/14/2024 Resident 10 was prescribed Seroquel (an antipsychotic medication used to treat mental health conditions by assisting to balance chemicals in the brain). In an interview completed on 02/19/2025 at 4:30 PM with the facility Social Services Director (SSD), the SSD confirmed that there was no Level II PASRR completed for Resident 10 reflecting the diagnosis of a serious mental illness or the use of an antipsychotic medication.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, record review, and interview the facility failed to ensure that refrigerated foods were maintained within the required temperatures to ensure food safety. This had the potential to affect 58 of 58 residents that ate food prepared by the facility kitchen. Findings are: Record review of the Nebraska Food Code, Effective date 7/21/16, 3-202.11 Temperature revealed that refrigerated, Time/Temperature Control for Food Safety (TCS, a method of preventing foodborne illness by controlling the temperature and time of TCS foods. TCS foods are also known as potentially hazardous foods (PHF) including meat, cut or sliced fruits, milk, and dairy products that must be kept at 41 degrees Fahrenheit or below), shall be at a temperature of 41 degrees Fahrenheit (F) or below when received. Observation on 2/18/25 at 9:57 AM in the facility main kitchen revealed that the thermometer inside the walk-in refrigerator displayed a temperature of 44 degrees F. Plastic gallon jugs of milk were on the shelf just inside the door of the walk-in refrigerator. Containers of cottage cheese sat on the shelf above the milk. Two tubes of raw ground beef sat in a gray tub on a bottom shelf. Observation on 2/19/25 at 12:45 PM in the facility main kitchen revealed that the thermometer inside the walk-in refrigerator displayed a temperature of 44 F. Plastic gallon jugs of milk were on the shelf just inside the door of the walk-in refrigerator. Containers of cottage cheese sat on the shelf above the milk. Observation on 2/20/25 at 7:25 AM in the facility main kitchen revealed that the thermometer inside the walk-in refrigerator displayed a temperature of 44 F. Gallon jugs of milk sat on the third shelf and containers of cottage cheese sat on the shelf above the milk. No staff had opened the door and entered the walk-in refrigerator between 7:25 AM and 7:33 AM. The thermometer inside the walk-in refrigerator displayed 43 F when checked at 7:33 AM. Interview on 2/20/25 at 8:36 AM with Dietary [NAME] (DC)-J revealed that DC-J does the recording of refrigerator and freezer temperatures on the temp log but has not yet done them that morning. DC-J confirmed that staff were to record the temperature reading displayed on the thermometer inside of the facility refrigerators and freezers. Observation on 2/20/25 at 9:06 AM in the facility main kitchen DC-J revealed that they would now check refrigeration temperatures. DC-J entered the walk-in refrigerator and read the temperature displayed on the thermometer at 44 F. DC-J recorded the temperature of 44 F on the Fridge/Freezer Temp Log. Gallons of milk sat on the 3rd shelf and containers of cottage cheese sat on the shelf above the milk inside the walk-in refrigerator. Interview on 2/20/25 at 9:08 AM with DC-J revealed that refrigerator temperatures were to be at 40 F or below. This surveyor asked DC-J what actions DC-J would take if refrigeration temperatures were out of range. DC-J revealed that if the temperatures were out of range DC-J would circle the temperature on the temperature log. DC-J revealed that if out of range temperatures continued, the Dietary Manager was notified. Record review of the Fridge/Freezer Temp Log dated February 2025 revealed that 26 of 38 temperatures recorded on the log for the temperature of the walk-in refrigerator were above 41 F. Out of range temperatures recorded on the log were: -On 2/1/25 in the PM the temperature was 42 F, -On 2/2/25 in the AM the temperature was 45 F, -On 2/2/25 in the PM the temperature was 45 F, -On 2/4/25 in the AM the temperature was 45 F, -On 2/5/25 in the AM the temperature was 42 F, -On 2/5/25 in the PM the temperature was 44 F, -On 2/6/25 in the AM the temperature was 45 F, -On 2/6/25 in the PM the temperature was 42 F, -On 2/7/25 in the AM the temperature was 44 F, -On 2/7/25 in the PM the temperature was 42 F, -On 2/8/25 in the PM the temperature was 43 F, -On 2/9/25 in the AM the temperature was 42 F, -On 2/10/25 in the AM the temperature was 42 F, -On 2/10/25 in the PM the temperature was 44 F, -On 2/11/25 in the PM the temperature was 42 F, -On 2/12/25 in the AM the temperature was 45 F, -On 2/12/25 in the PM the temperature was 42 F, -On 2/15/25 in the AM the temperature was 45 F, -On 2/15/25 in the PM the temperature was 42 F, -On 2/16/25 in the AM the temperature was 42 F, -On 2/16/25 in the PM the temperature was 44 F, -On 2/17/25 in the PM the temperature was 43 F, -On 2/18/25 in the PM the temperature was 43 F, -On 2/19/25 in the AM the temperature was 42 F, -On 2/19/25 in the PM the temperature was 44 F, and -On 2/20/25 in the AM the temperature was 44 F. None of the out of range temperatures for the walk-in refrigerator documented on the Fridge/Freezer Temp Log were circled. Observation on 2/20/25 between 9:55 AM and 10:06 AM in the facility main kitchen revealed that there were no staff in the kitchen. The walk-in refrigerator door remained closed during this timeframe. At 10:06 AM this surveyor entered the walk-in refrigerator and closed the refrigerator door. The thermometer inside the walk-in refrigerator displayed a temperature of 44 F. The compressor turned on and the temperature rose to 46 F. Gallons of milk sat on the 3rd shelf and containers of cottage cheese sat on the shelf above the milk inside the walk-in refrigerator. Interview on 2/20/25 at 10:46 AM with the facility Dietary Manager (DM) revealed that refrigeration temperatures were monitored and documented on the temp log twice daily. DM revealed that the DM reviewed the refrigeration temperature logs periodically. DM revealed that the expected temperature for the facility refrigerators was 45 F or below. DM revealed that the freezers were to be at 0 to 10 degrees. Interview on 2/20/25 at 11:29 AM with the facility Registered Dietitian (RD) confirmed that refrigerated temperatures were required to be kept at 40 degrees Fahrenheit or below for food safety. The RD confirmed that approximately 2/3 of the temperatures documented on the February 2025 temperature log for the walk-in refrigerator were above 40 F. Observation with the RD at the walk-in refrigerator in the facility main kitchen confirmed that the thermometer inside the walk-in refrigerator displayed 42 F and was out of range. RD revealed that the DM would complete a work request for maintenance to fix the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interview, the facility failed to ensure 3 of 5 sampled nursing aides (NA) had at least 12 hours of ongoing training. This had the potential to affect all residents residing at the facility. The facility identified a census of 58. Findings Are: A record review of a Facility Assessment for [NAME] Park with a date of 9/1/24-11/21/24 revealed under nursing staffing plans, staff are provided with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through the assessment which include mental health, dementia and infectious diseases. A record review of an untitled and undated document that included a list of employees, their job titles, department, and hire date revealed the following employee hire dates: -NA-H was hired on 06/02/2021. -NA-G was hired on 03/07/2023. -NA-I was hired on 07/07/2020. A record review of a document titled, symplr learning transcript with a date range of 01/29/2024-12/02/2024 for NA-H revealed a total of 6.82 training hours over the prior 12 months. A record review of a document titled, symplr learning transcript with a date range of 03/27/2024-11/24/2024 for NA-G revealed a total of 6.38 training hours over the prior 12 months. A record review of a document titled, symplr learning transcript with a date range of 02/10/2024-12/28/2024 for NA-I revealed a total of 9.69 training hours over the prior 12 months. An interview on 02/18/2025 at 2:40 PM with the Director of Nursing Services (DNS) and Human Resources (HR) confirmed that nursing aides should have at least 12 hours of training each year. The interview also confirmed NA-H, NA-G, and NA-I had not met these requirements in the prior 12 months.

Licensure Reference Number 175 NAC 12-006.18A(1) Based on observation, record review, and interview the facility failed to ensure wheelchairs were clean which affected 3 (Resident 4, 45, and 16) of 3 sampled residents. The facility census was 61. Findings are: A. A review of the admission record for Resident #4 reflected an admission date of 09/18/2022. A review of Resident #4 MDS (The Long-Term Care Minimum Data Set (MDS) which is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and or Medicaid-certified long term care facility) with the ARD (Assessment Reference Date) of 10/23/2023 reflected Resident #4 used a wheelchair for mobility. A review of Resident #4 current care plan reflected a focus of ADL (activities of daily living) self-care performance deficit related to impaired mobility and cognitive loss. Interventions included Resident #4 is dependent on a wheelchair to move from one place to another. In an observation on 11/28/23 at 10:10 AM Resident #4 was observed sitting in a wheelchair in the resident's room. The observation revealed a black bolstered cushion on left arm rest of wheelchair soiled with dried clear fluid drips to the top and down the outside and front of the cushion. In an observation on 11/29/23 at 8:07 AM Resident #4 was observed sitting in a recliner in the resident's room. The observed black bolstered cushion on left arm rest of wheelchair soiled with dried clear fluid drips to the top and down the outside and front of the cushion. B. A review of the admission record for Resident #45 reflected and admission date of 08/03/2023. A review of Resident #45 MDS (The Long-Term Care Minimum Data Set (MDS) which is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and or Medicaid-certified long term care facility) with the ARD (Assessment Reference Date) of 10/30/2023 reflected Resident #45 used a wheelchair for mobility. A review of Resident #45 current care plan reflected a focus of ADL (activities of daily living) self-care performance deficit related to stroke with left side being affected and impaired vision. Interventions included Resident #45 is dependent on a wheelchair to move from one place to another. In an observation on 11/27/2023 at 10:20 AM Resident #45 was observed sitting in resident room in the wheelchair. The observation revealed dried brown crusted material to the right front corner of the wheelchair extending down to the seat. Further, the observation revealed small dry yellow brown and white particles on the bottom frame of the wheelchair on both sides. In an observation on 11/28/2023 at 7:51 AM Resident #45 was observed sitting in resident room in the wheelchair. The observation revealed dried brown crusted material to the right front corner of the wheelchair extending down to the seat. Further, the observation revealed small dry yellow brown and white particles on the bottom frame of the wheelchair on both sides and dried fluid drips on the front right side of the wheelchair frame. In an observation on 11/29/2023 at 8:01 AM Resident #45 was observed sitting in resident room in the wheelchair. The observation revealed dried brown crusted material to the right front and back corner of the wheelchair seat extending down to the seat. Further the observation revealed small dry yellow brown and white particles on the bottom frame of the wheelchair on both sides and dried fluid drips on the front right side of the wheelchair frame. C. A review of the admission record for Resident #16 reflected an admission date of 06/06/2023. A review of Resident #16 MDS (The Long-Term Care Minimum Data Set (MDS) which is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and or Medicaid-certified long term care facility) with the ARD (Assessment Reference Date) of 09/15/2023 reflected Resident #16 used a wheelchair for mobility. A review of Resident #16 current care plan reflected a focus of ADL (activities of daily living) self-care performance deficit related to impaired mobility and cognitive loss. Interventions included Resident #16 is dependent on a wheelchair to move from one place to another. In an observation on 11/28/2023 at 7:44 AM Resident #16 was observed sitting in resident's wheelchair in the hallway. The observation revealed yellow brown crumbs on the frame of the seat of the wheelchair on both sides. Further, the observation revealed dried brown crust stuck to the left front corner of the wheelchair cushion. In an observation on 11/29/2023 at 7:50 AM Resident #16 was observed sitting in resident's wheelchair in resident's room. The observation revealed yellow brown crumbs on the frame of the seat of the wheelchair on both sides. Further, the observation revealed dried brown crust stuck to the left front corner of the wheelchair cushion. In an interview with NA-E (Nurses' Aide) on 11/29/2023 at 9:53 AM NA-E stated if wheelchairs are visibly dirty staff wipe them off immediately. NA-E stated all wheelchairs are cleaned weekly on a rotation for day and night staff. NA-E stated if wheelchair cushion covers are dirty, they are sent to laundry for cleaning, then replaced when return from laundry. In an interview with the DON (Director of Nursing) on 11/29/2023 at 10:05 AM the DON stated wheelchairs are cleaned on a weekly schedule by the night shift nursing staff. The DON stated this is tracked in a book that is kept at the nurse's station. DON stated the facility does not have a wheelchair cleaning policy or procedure. DON unable to provide documentation of Residents #4, #45, and #16's wheelchairs being cleaned in the last 60 days. In a record review of the wheelchair owner's manual for Resident #45 and #16 wheelchairs reflected to clean painted surfaces with a mild soap or detergent. In a record review of the Centers for Disease Control (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 Update: May 2019, section labeled Recommendations for Disinfection and Sterilization in Healthcare Facilities, revealed in item four letter c Ensure that, at a minimum, non-critical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly).

Licensure Reference Number 175 NAC 12-007.04D Based on observation, interview, and record review the facility failed to ensure adequate mechanical ventilation in resident's bathrooms for five Residents (#5, #12, #31, #38 and #27). The facility stated census of 61. Findings are: In an observation performed on 11/27/2023 at 1:40 PM Resident #5 and #12's (roommates) bathroom ceiling vent was unable to pull up one square of single ply toilet paper. In an observation performed on 11/27/2023 at 2:11 PM Resident #31 bathroom ceiling vent was unable to pull up one square of single ply toilet paper. In an observation performed on 11/27/2023 at 3:38 PM Resident #38 bathroom ceiling vent was unable to pull up one square of single ply toilet paper. In an observation performed on 11/27/2023 at 3:57 PM Resident #27 bathroom ceiling vent was unable to pull up one square of single ply toilet paper. In an observation on 11/30/2023 at 8:25 AM with Facility Administrator and the Maintenance Supervisor it was verified that residents #5, #12, #31, #27 and #38's bathroom ceiling vents were unable to pull up one square of single ply toilet paper. A strong odor of stale urine was detected upon entering this unit. On 11/30/2023 in an interview with Maintenance Supervisor (MS) at 8:25 AM it was stated that the bathroom vents had been turned off to control the temperature and that MS would go and turn the unit back on at this time. On 11/30/2023 in an interview with MS at 9:10 AM MS stated that that the ventilation unit for that area was not working and MS had notified a service repair individual to come and repair the unit. MS revealed that a monthly check of the bathroom vent on a couple of resident bathrooms per month were completed but did not track or document the bathrooms checked. MS revealed they are made aware of the ventilation system not working by staff alerting them that the temperature has increased in that area. Record review of the undated facility supplied document labeled Direct Supply Tels revealed instructions to inspect exhaust fans for proper operation and clean if necessary, on a monthly basis. Instructions on the form stated to check all exhaust fans in bathrooms to ensure that air flow is sufficient to hold a piece of paper to the vent when operating.

Licensure Reference Number 175 12-006.04D2 Based on observations, interviews and record review, the facility failed to have employed a Certified Dietary Manager (CDM). This had the potential to affect all the resident who reside in the facility. The facility census was 61. Findings are: Interview on 11/27/23 at 9:45 AM with the Food Service Supervisor (FSS) revealed that (gender) have been employed since May of 2023 and enrolled in the CDM class since July 2023. The FSS revealed the facility Registered Dietician (RD) comes every 2 weeks for 1 day. Record review of a list of key personal and their License/Certification number revealed the Food Service Supervisor (FSS) was not identified as the CDM. Interview with the facility's administrator on 11/29/23 at 2:04 PM confirmed that the facility does not have a CDM employed. Record review of FSS employment file revealed a copy of Food Handler Essentials Course that that was dated 11/27/23. On 11/30/23 at 9:40 AM an interview with the FSS confirmed that (gender) does not have a bachelor's degree or any other classes/certificates in food service. Dietary Supervisor Job Description undated reviewed. Personal Qualifications: Dietary Supervisors are qualified as a food service supervisor and must be or become a Certified Dietary Manager within one year of hire. Dietary Supervisors have a working knowledge of dietary procedures, related laws, regulations, and guidelines pertaining to hospital and nursing home operations.

Licensure Reference Number: 175 NAC 12-006.12B(5) Based on record review and interview, the facility failed to ensure Medication Regimen Reviews (MRR) identified potential unnecessary medications related to prophylactic antibiotic use for 1 of 5 residents reviewed (Resident 5). The facility census was 57. Findings are: Review of Resident 5 Physician orders revealed Resident 5 has an order for Keflex Capsule (antibiotic) 250 MG (Cephalexin) daily with a diagnosis of Urinary Tract Infection (UTI) written in 2019. Review of Resident 5's MRR progress notes revealed no notes regarding the rationale for the use of prophylactic antibiotics since 2019. Review of www.webmd.com article dated April 30, 2021 revealed; The biggest concern with prophylactic antibiotics is antibiotic resistance. Antibiotic resistance happens when germs such as bacteria and fungi learn to defeat the antibiotics that previously killed them. Interview on 11/07/2022 at 10:22 AM with the Infection Control Practitioner revealed the pharmacist has not been identifying prophylactic antibiotic use during the MRR process.

Based on record review and interviews, the facility failed to document the clinical rationale in Resident 49's medical record for the use of Ativan (a medication used to treat anxiety disorders) as needed (PRN) with the order being longer than 14 days. This affected 1 (Resident 49) of 5 sampled residents. The facility identified a census of 57. Findings are: Record review of a Physician order dated 9/26/22 revealed there was no clinical rationale documented for the use of the PRN Ativan 0.5 mg (milligrams), give 1 tablet by mouth every 12 hours as needed order for Resident 49, the order was written for 180 days. Record review of Resident 49's medication administration record for September 2022, revealed the PRN Ativan 0.5 mg was administered to the resident 3 times in September 2022. Record review of the facility's Out of Character Response Prevention and Medication Managment policy with a revised date of 1/2017 revealed under Duration that the clincial rationale for continued use of a medication should be documented in the clinical record. Interview with the Assistant Director of Nursing (ADON) on 11/7/22 at 4:40 PM confirmed there was no clinical rationale documented for Resident 49's PRN Ativan order dated 9/26/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Resident 54 was admitted to the facility on [DATE] with a Diagnosis of Acute Embolism and Thrombosis of other specified deep vein of left lower extremity and a diagnosis of Micturition (The act of voiding frequently and a scant amount). The Minimum Data Set (MDS) (a Federally mandated process for clinical assessment of residents) dated 10/18/22 revealed a Brief Interview for Mental Status (BIMS) (assessment to identify a resident's cognitive status) score of 15. This indicates this resident is cognitively intact. Record review of Physician Visit Notes revealed Resident 54 was seen on 9/28/22 by Resident 54's physician: The Plan included the following: Resident has some stress incontinence that is chronic. Denies any dysuria (painful urination) or foul odor. Resident has been very concerned about urine for years. The resident wonders if they should have serial UA's (urinalysis assessment) performed to ensure that the resident is not getting repeat infections. The physician discussed that unless the resident is having more symptoms, he does not recommend routine UA's. The physician asked that the resident inform nursing staff if develops any further symptoms. Record review of a Physician Visit/Communication form dated 10/7/22 revealed the Physician was notified that the resident reported having to use an incontinence pad in the residents brief now, and was having new incontinence of urine and frequency. The resident denied pain with urination and was afebrile. Resident requested a UA. No SBAR (a communication tool used to notify the physician of Situation Background Assessment Recommendation), was found. The physician wrote an order for a UA. Record review of lab results for the UA dated 10-8-22 revealed negative Nitrates (which can indicate an infection if positive), 3+ Bacteria and [NAME] Blood Cells. The Physician ordered OMNICEF (an antibiotic used to treat different types of infections) 300 milligram (mg) orally twice a day (BID) for 7 days, without the documentation of the clinical rationale for use. Record review of the UA and culture results dated 10/11/22 revealed the specimen was likely contaminated from uro-genitalia (indicating the specimen that was collected was contaminated from improper cleansing of the female genitalia), and there was a <50,000 colony count of Streptococcus (a bacteria)(cultures that are less than 100,000 and are contaminated are not recommended to be treated). The Physician ordered to continue antibiotic without the documentation of the clinical rationale for use. Review of Electronic Medical Administration Record (EMAR) (a legal record of the medications administered to a patient at a facility by a health care professional) for the month of October revealed Omnicef 300mg BID was taken from 10/8/22 to 10/15/22 for a total of 14 doses. Record review of a Urinary Tract Infection (UTI) SBAR on 10/20/22 sent to the physician revealed Acute Dysuria (painful urination) alone marked as the only symptom. Recommendations on the SBAR were for the resident to have a UA with culture or an antibiotic. The physician ordered Augmentin (an antibiotic used to treat infections) 875 mg/125 mg orally BID for 7 days. This was ordered without clinical rationale for use. Further review of the SBAR tool for suspected Urinary Tract Infection revealed that there was criteria that was to be followed prior to initiating antibiotics, the criteria on this SBAR tool was incorrect as the resident had been having dysuria off and on for over 3 weeks. Record review of Progress Notes from 10/7/22 to 10/20/22 revealed that the Resident had been having dysuria off and on for over 3 weeks. Record review of EMAR for the month of October revealed Augmentin 875-125 mg BID was taken from 10/21/22 to 10/27/22, for a total of 14 doses. Interview with Resident 54 on 11/02/22 at 09:50 AM, revealed that the resident had been having diarrhea for 3 days and stomach felt gurgly. Interview with Resident 54 on 11/02/22 01:59 PM revealed the resident thinks the loose stools were possibly from the antibiotics. Resident is independent with hygiene toileting and uses prevail wipes for hygiene, and wears incontinent pads. The Resident stated the staff does not assist with toileting or hygiene. Interview with the Infection Preventionist (IP) on 11/08/22 at 08:20 AM confirmed that Resident 54 was on the Omnicef and Augmentin in October for UTI without clinical rational. Interview with the IP on 11/08/22 at 8:51 AM confirmed there was no further documentation to support the clinical rationale or resident education (specifically for personal hygiene, antibiotic actions and side effects). Record review of the facilities Antimicrobial Stewardship Program with a revised date of 7/28/22 revealed: This multidisciplinary team will regularly review appropriateness of antibiotic courses and make recommendations for adjustment in practice. Interview with the IP on 11/8/22 at 8:51 AM confirmed that the multidisciplinary team did not review appropriateness of this residents' antibiotics. C. Interview on 11/7/22 at 10:19 AM with the facility Infection Preventionist (IP) confirmed that the facility had not reviewed prophylactic antibiotics (antibiotics given as a precaution to prevent, rather than treat, an infection). The IP revealed that the IP plans to visit about it with the Medical Director at the 11/17/22 Quality Assurance meeting. Interview on 11/7/22 at 4:37 PM with the facility Director of Nursing (DON) confirmed that the facility antibiotic stewardship program is to include review of prophylactic antibiotics. The DON revealed that the DON participates as part of the facility antibiotic stewardship committee. The DON confirmed that the antibiotic stewardship committee is to look at prophylactic antibiotic use. Based on record review and interview, the facility failed to follow Antibiotic Stewardship polices [efforts to measure and improve how antibiotics are prescribed by clinicians and used by patients to protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance (when germs like bacteria develop the ability to defeat the drugs designed to kill them)] to review the need of antibiotic use for 2 residents (Residents 5 and 54) to prevent the potential for antibiotic resistance and the potential for adverse antibiotic side effects. The facility census was 57. Findings are: A. Review of Resident 5 Physician orders revealed Resident 5 has an order for Keflex Capsule (antibiotic) 250 MG (Cephalexin) daily with a diagnosis of Urinary Tract Infection (UTI) written in 2019. Interview on 11/07/2022 at 10:22 AM with the Infection Control Practitioner revealed the pharmacist has not been identifying prophylactic antibiotic use for antibiotic stewardship during the medication regimen review process. Review of a www.webmd.com article dated April 30, 2021, revealed; The biggest concern with prophylactic antibiotics is antibiotic resistance. Antibiotic resistance happens when germs such as bacteria and fungi learn to defeat the antibiotics that previously killed them. Review of the facility policy titled Antimicrobial Stewardship Program revised on 7/28/22 revealed: -The Antibiotic Stewardship Program (ASP) team will regularly review appropriateness of antibiotic courses and make recommendations for adjustment in practice where necessary, establish new or revise existing protocols relevant to appropriate antibiotic prescribing, monitor and report patterns of antibiotic use and resistance - the ASP aims to improve antibiotic prescribing practices through the development and implementation of antibiotic use protocols and a system to monitor antibiotic use. -The goal of the Antimicrobial Stewardship Program is to promote the appropriate us of antimicrobials to maximize treatment outcome and minimize unintended consequences of antimicrobial therapy. The ASP aims to improve antibiotic prescribing practices through the development and implementation of antibiotic use protocols and a system to monitor antibiotic use. Interview on 11/07/22 at 11:58 AM with the Infection Preventionist revealed the Antibiotic Stewardship program has not been tracking prophylactic antibiotic use.

Licensure Reference Number: 175 12-006.11E Based on record review, observations, and interview; the facility failed to test the 146 Multi Quat sanitizer solution according to manufacturer's recommendations prior to use when sanitizing surfaces and equipment in the kitchen. This had the potential to cause foodborne outbreak for all residents in the facility. The facility identified a census of 57. Findings are: Interview with Dietary [NAME] -E (DC-E) on 11/7/22 at 1:50 PM confirmed that the Multi Quat sanitizer solution is used in both kitchens. Interview with the Maintenance Superviser (MS) on 11/7/22 at 1:55 PM confirmed that the facility follows manufacturer's recommendation for the sanitizer solution and this is used as their policy and procedure. Record review of the aide daily cleaning schedule logs for the month of October 2022, revealed the Sanitizer solution testing had not been completed for the entire month. Interview with DA-F on 11/7/22 at 2:38 PM revealed they test the solution like once a week and they are probably not recording it because the top cover is missing. Interview with the MS on 11/7/22 at 2:35 PM confirmed the test strips for the 146 Multi Quat Sanitizer were open and the top cover of the strip case was missing, which is where the color code of the test strips is located. MS stated I'm not sure the test strips are working. Interview with the Dietary Manager (DM) on 11/7/22 at 2:40 PM confirmed the sanitizer solution was not being tested prior to use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that staff Covid-19 testing was completed as required for 3 sampled facility staff to prevent the potential for Covid-19 infection. The facility census was 57. Findings are: A. Record review of the facility Covid-19 Vaccine Mandate Policy and Procedure dated 10/5/22 revealed that all eligible team members are vaccinated against Covid-19 pursuant to applicable federal, state, and local guidelines including regulations issued by the Centers for Medicare and Medicaid Services (CMS). All team members are required to receive vaccinations as determined by CMS unless an exemption is approved and the team member accepts a reasonable accommodation. Team members, who provide any care, treatment, or other services for the facility and/or its residents regardless of clinical responsibility or resident contact are required to be fully vaccinated against Covid-19. The facility will implement additional precautions to mitigate the transmission and spread of Covid-19 for all staff who are not fully vaccinated for Covid-19 including but not limited to Covid-19 testing once per week. Interview on 11/7/22 at 1:36 PM with the facility Director of Nursing (DON) confirmed that routine staff testing for Covid-19 had changed as of 10/24/22. The DON confirmed that the Covid-19 Vaccine Mandate Policy and Procedure was updated to reflect the CMS changes for staff Covid-19 testing that went into effect on 10/24/22. The DON confirmed that the facility was conducting Covid-19 testing for not up to date staff (staff that had an exemption from being vaccinated for Covid-19 and staff that had not received eligible Covid-19 booster vaccination) two times weekly prior to 10/24/22 to mitigate the transmission and spread of Covid-19. Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that Nursing Assistant-A (NA-A) had a facility approved exemption from being vaccinated for Covid-19. NA-A was required to be tested two times a week for Covid-19 prior to 10/24/22. Interview on 11/7/22 at 1:41 PM with NA-A confirmed that NA-A had an exemption from Covid-19 vaccination and was not vaccinated for Covid-19. NA-A revealed that staff not vaccinated for Covid-19, including NA-A, were required to be tested for Covid-19 two times per week prior to 10/24/22. NA-A revealed that starting 10/24/22 NA-A is now only required to be tested for Covid-19 one time per week. Record review of the undated Staff POC (Point of Care) Testing Results (a log of Covid-19 test results for tests performed by the facility) from 9/1/22 to 11/7/22 revealed that NA-A was tested for Covid-19 on 9/2/22 (negative result), 9/8/22 (negative result) (6 days after the previous test on 9/2/22. The only test performed for the week of 9/4/22 through 9/10/22), 9/13/22 (negative result), 9/15/22 (negative result), 9/19/22 (negative result), 9/22/22 (negative result), 9/26/22 (negative result), 9/29/22 (negative result), 10/6/22 (negative result) (7 days after the previous test on 9/29/22. The only test performed for the week of 10/2/22 through 10/8/22), 10/9/22 (negative result) (the only test performed for the week of 10/9/22 through 10/15/22), 10/18/22 (negative result) (9 days after the previous test. The only test performed for the week of 10/16/22 through 10/22/22), 10/24/22 (negative result) (6 days after the previous test), 11/3/22 (negative result). NA-A was not tested for Covid-19 twice per week as required. Record review of the undated Timecard for NA-A revealed that between 9/2/22 (date of previous test for Covid-19) and 9/10/22 NA-A worked on 9/2/22, 9/3/22, 9/4/22, 9/7/22, and 9/8/22 and was available for Covid-19 testing. NA-A was only tested on [DATE] for the week of 9/4/22 through 9/10/22. NA-A was not tested for Covid-19 two times per week as required the week of 9/4/22 through 9/10/22. Record review of the undated Timecard for NA-A revealed that between 9/29/22 (date of previous test for Covid-19) and 10/8/22 NA-A worked on 9/29/22, 9/30/22, 10/1/22, 10/2/22, 10/4/22, 10/5/22, 10/6/22, 10/7/22, and 10/8/22 and was available for Covid-19 testing. NA-A was only tested on [DATE] for the week of 10/2/22 through 10/8/22. NA-A was not tested for Covid-19 two times per week as required the week of 10/2/22 through 10/8/22. Record review of the undated Timecard for NA-A revealed that between 10/6/22 (date of previous test for Covid-19) and 10/15/22 NA-A worked on 10/6/22, 10/7/22, 10/8/22 10/9/22, 10/10/22, 10/12/22, 10/13/22, and 10/14/22 and was available for Covid-19 testing. NA-A was only tested on [DATE] for the week of 10/9/22 through 10/15/22. NA-A was not tested for Covid-19 two times per week as required the week of 10/9/22 through 10/15/22. Record review of the undated Timecard for NA-A revealed that between 10/9/22 (date of previous test for Covid-19) and 10/22/22 NA-A worked on 10/9/22, 10/10/22, 10/12/22, 10/13/22, 10/14/22, 10/18/22, 10/19/22, 10/20/22, and 10/21/22 and was available for Covid-19 testing. NA-A was only tested on [DATE] for the week of 10/16/22 through 10/22/22. NA-A was not tested for Covid-19 two times per week as required the week of 10/16/22 through 10/22/22. Interview on 11/7/22 at 4:37 PM with the DON confirmed the facility expectation is for unvaccinated staff to be tested for Covid-19 per the facility policy for unvaccinated staff which was two times per week prior to 10/24/22. The DON confirmed the expectation is for all facility staff to be vaccinated for Covid-19 or have an exemption from being vaccinated. B. Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that Medication Aide-B (MA-B) received only the 2-dose primary vaccination for Covid-19. MA-B did not receive any booster vaccinations. MA-B was required to be tested two times a week for Covid-19 prior to 10/24/22 to mitigate the transmission and spread of Covid-19. Record review of the undated Staff POC (Point of Care) Testing Results (a log of Covid-19 test results for tests performed by the facility) from 9/1/22 to 11/7/22 revealed that MA-B had no documented Covid-19 testing performed. Interview on 11/7/22 at 1:36 PM with the DON revealed that MA-B was not feeling well so the facility directed MA-B to go get tested at their physician. The DON confirmed that MA-B went to their physician and was found positive for Covid-19 on 10/3/22. Record review of the undated Timecard for MA-B revealed that between 9/1/22 and 11/7/22 MA-B worked in the facility on 9/15/22, 9/16/22, 9/18/22, 9/22/22, 9/23/22, 9/24/22, 9/27/22, 9/30/22, 10/2/22, 10/3/22, 10/9/22, 10/10/22, 10/11/22, 10/13/22, 10/16/22, 10/17/22, 10/18/22, 10/22/22, 10/25/22, 10/26/22, 10/28/22, 10/29/22, 11/1/22, 11/4/22, and 11/6/22 and was available for Covid-19 testing. MA-B was not tested for Covid-19 two times per week as required between 9/1/22 and 10/3/22 (the date that MA-B tested positive for Covid-19). Interview on 11/7/22 at 11:15 AM with the facility Infection Preventionist (IP) confirmed that staff without Covid-19 booster doses were required to test two times per week before the CMS guidance for testing changed. C. Record review of the undated facility Covid-19 Staff Vaccination Status for Providers revealed that Nursing Assistant-C (NA-C) received only the 2-dose primary vaccination for Covid-19. NA-C did not receive any booster vaccinations. NA-C was required to be tested two times a week for Covid-19 prior to 10/24/22 to mitigate the transmission and spread of Covid-19. Record review of the undated Staff POC (Point of Care) Testing Results (a log of Covid-19 test results for tests performed by the facility) from 9/1/22 to 11/7/22 revealed that NA-C was tested for Covid-19 on 9/3/22 (negative result), 9/6/22 (negative result), 9/8/22 (negative result), 9/12/22 (negative result), 9/15/22 (negative result), 9/19/22 (negative result) (The only test performed for the week of 9/18/22 through 9/24/22), 9/26/22 (negative result), 9/27/22 (negative result), 9/29/22 (negative result), 10/3/22 (negative result), and 10/6/22 (positive result). Record review of the undated Timecard for NA-C revealed that between 9/15/22 (date of previous test for Covid-19) and 9/24/22 NA-C worked in the facility on 9/15/22, 9/17/22, 9/19/22, 9/20/22, and 9/22/22 and was available for Covid-19 testing. NA-C was only tested on [DATE] for the week of 9/18/22 through 9/24/22. NA-C was not tested for Covid-19 two times per week as required the week of 9/18/22 through 9/24/22. Interview on 11/7/22 at 11:15 AM with the facility Infection Preventionist (IP) confirmed that staff without Covid-19 booster doses were required to test two times per week before the CMS guidance for testing changed.