Louisville Care Center

F-F5101 - (ICD-10), which is Primary Insomnia. A note was on the order of: The resident was to start this medication after completed the Elavil taper. Effective date was 11/05/2024. The start date was 11/05/2024.

A record review of Resident 7's Electronic Medical Record (EMR) did not reveal a sleep test, sleep diary, or sleep assessment had been completed.

A record review of Resident 7's Behavior Monitoring and Interventions Report dated 09/06/2024 - 01/06/2025 did not reveal the resident had any behaviors or insomnia while on the Elavil or Quetiapine.

A record review of Resident 7's Pharmacist's Recommendation to Prescriber dated 11/25/2025 revealed the pharmacy made a recommendation to the provider to discontinue the Quetiapine (that was started 11/13/2024 for insomnia) and start Trazadone (a medication used to treat depression that can be used off-label for Insomnia) 25 mg by mouth every night for sleep because Quetiapine can cause abnormal muscle movements and life-threatening neuroleptic malignant syndrome (a reaction that can cause muscle stiffness, high fever, altered mental status, irregular heart rhythms, and respiratory failure), increasing the overall risk. It did not reveal the provider responded to the recommendation.

In an interview on 01/13/2025 at 9:40 AM, ADON confirmed Resident 7's Amitriptyline (Elavil) was discontinued, and Quetiapine was started 11/05/2025 for Insomnia. The ADON confirmed that a sleep test, sleep assessment, or sleep diary had not been completed for the Insomnia diagnosis.

In an interview on 01/13/2025 at 12:47 PM, the ADON confirmed a psychotropic assessment had not been completed for Resident 7 and the last Abnormal Involuntary Movement Scale (AIMS) was 10/28/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 285267 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285267 B. Wing 01/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nye Summit 410 West 5th Street Louisville, NE 68037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 In an interview on 01/13/2025 at 1:49 PM, the ADON confirmed the provider should not have changed the resident from Elavil to Quetiapine on 11/05/2024 without documentation of behaviors or doing the sleep Level of Harm - Minimal harm or diary. The ADON confirmed Resident 7 used the resident's own provider, not the facility's provider. If the potential for actual harm resident used facility's provider, they would have done all the other needed steps. The ADON confirmed it takes months for that provider to address pharmacy recommendations, and the ADON had not attempted to Residents Affected - Few contact the provider to address the pharmacy recommendation.

In an interview on 01/13/2025 at 3:52 PM the facility's contracted pharmacist (PH)-A confirmed the provider ordered Seroquel and a pharmacy review was faxed to the ordering provider. The pharmacy did not get an addressed copy of the pharmacy review back from the provider. Quetiapine is not approved for the treatment of Insomnia and would not be a primary medication. PH-A confirmed Quetiapine could be used to treat Insomnia if the provider provided good enough rational. The consultant pharmacist recommended a sleep assessment be completed at a Quality Assurance and Performance Improvement (QAPI) meeting, and the last time they spoke to the facility, it had not been completed and should have been for that medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 285267 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285267 B. Wing 01/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nye Summit 410 West 5th Street Louisville, NE 68037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48271

Residents Affected - Many Licensure Reference Number 175 NAC ,d+[DATE REDACTED].11(E)

Based on observations and interview, the facility failed to label and date opened packages of food and failed to dispose of expired food from the walk-in refrigerator and walk in freezer to prevent the potential for food borne illness. This had the potential to affect 47 residents that consumed food from the kitchen.

Findings are:

An initial observation on [DATE REDACTED] at 8:15 AM of the walk in refrigerator in the kitchen revealed:

- an undated zip lock bag of lettuce,

- an undated zip lock bag of cut up celery.

- a container of cooked vegetables dated [DATE REDACTED], which indicated the food was expired,

- an undated open package of turkey slices exposed to the air,

- an undated zip lock bag of unknown meat,

- 2 packages of undated white cheese packages,

- an undated package of American cheese.

An observation on [DATE REDACTED] at 8:25 AM of the walk-in freezer in the kitchen revealed:

- an undated open bag of French fries exposed to the air,

-an undated zip lock bag of an unidentified white shredded substance,

- an undated zip lock bag of an unidentified brown substance.

An interview on [DATE REDACTED] at 1:30 PM with the Dietary Manager (DM) confirmed that all food items listed above should have been labeled and dated. The DM confirmed that the cooked vegetables dated [DATE REDACTED] were expired and should have been discarded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 285267 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285267 B. Wing 01/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Nye Summit 410 West 5th Street Louisville, NE 68037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0923 Have enough outside ventilation via a window or mechanical ventilation, or both.

Level of Harm - Minimal harm or 48271 potential for actual harm Licensure Reference Number 175 NAC 12-007.04(D) Residents Affected - Some Based on observation and interview, the facility failed to ensure that the ventilation system was operational in 14 occupied rooms (Rooms 201,202,203,204,205,206,208,209,210,211,212,213,214, and 215). This affected 14 bathrooms used by 20 residents. This had the potential to affect odor control in the facility. The facility census was 48.

Findings are:

An observation on 1/6/25 at 9:30 AM revealed that bathrooms in rooms 203, 204 and 206 did not have functional ventilation as tested with 1 ply square of toilet paper held flat against the ventilation cover that did not hold the paper which indicated that there was no air draw, and the ventilation system did not work.

An observation on 1/13/25 at 1:30 PM with the Maintenance Director (MD) revealed that bathrooms in rooms 201,202,203,204,205,206,208,209,210,211,212,213,214, and 215 did not have functional ventilation as tested with 1 ply square of toilet paper held flat against the ventilation cover in the resident bathroom that did not hold the paper which indicated that there was no air draw, and the ventilation system did not work.

An interview on 1/13/25 at 2:00 PM with MD confirmed that the ventilation system was not functioning in the bathrooms on the 200 hallway and the ventilation system should be working.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 285267