**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide visual privacy for two residents (Resident (R) 114 and R24) of thirty sampled residents during tracheostomy care. On 3/23/25 at 2:47 PM and again at 2:53 PM, a respiratory therapist suctioned the resident's tracheostomy with the door open and without pulling the privacy curtain. Visitors, staff, and other residents in the hallway could see into the room during the procedure. The findings include: A review of the facility's Routine Trach Care policy, revised in June 2021, instructs staff to provide privacy as part of the procedure. The LTC Resident's Rights to Privacy policy, revised in May 2017, states, The resident is granted the privacy of his/her body during provision of personal care and services. Staff failed to follow both policies and did not protect the resident's right to Privacy. A review of R43's admission Face Sheet revealed the facility admitted R114 on 02/07/2025. A review of R114's admission Minimum Data Set with an Assessment Reference Date (ARD) of 02/13/2025 indicated that a Brief Interview for Mental Status (BIMS) wasn't conducted, indicating that R114 is rarely/never understood. A review of R24's admission Face Sheet revealed the facility admitted R24 to the facility on [DATE]. A review of R24's admission Minimum Data Set with an Assessment Reference Date (ARD) of 01/02/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3/15, indicating that R24 had severe cognitive impairment. During an observation at 2:47 PM on 03/23/2025 Respiratory Therapist (RT) 1 suctioned R114's tracheostomy with the door open and without pulling the privacy curtain, failing to provide visual privacy during the procedure. During observation on 03/23/2025 at 2:53 PM, RT 1 suctioned R24's tracheostomy without closing the door or pulling the privacy curtain. R24 and his roommate had visitors in the room. RT 1 only pulled the privacy curtain after she saw the State Survey Agent (SSA) outside the doorway. During an interview on 03/23/2025 at 3 PM, RT 1 stated, It's just suctioning; it doesn't require privacy like a bed bath. During the interview on 03/23/2025 at 3:05 PM, Family Member 1 stated, R24 is provided trach care often with the door open and the curtain not pulled. Sometimes, I think people passing by the room looking in may embarrass him. During an interview on 03/25/2025 at 11:40 AM, the Respiratory Director stated, Privacy should be provided during patient care, which includes trach care. I would be embarrassed if the door was left open during care, and I know it is the same for our residents here. During an interview on 03/26/2025 at 11:20 AM, the Chief Nurse Officer stated, My expectation for staff is to respect our residents and provide them privacy during patient care by closing the door.

Based on observations and staff interviews, the facility failed to post the required Nurse Staffing Information (i.e., total number and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care) on the North, South, East, and [NAME] units for the following dates: 03/21/2025, 03/22/2025, 03/23/2025, and 03/24/2025. The findings include: A review of the facility ' s policy titled, Nurse Staffing Information, with a revision date of March 2021, revealed that the facility must post the total number, and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care daily at each station by the beginning of each shift. Observation, on 03/23/2025 at 3:45 PM, revealed that the Rockcastle Respiratory Care Center Nurse Staffing Information, postings on the North, South, East, and [NAME] units had not been updated since 03/20/2025. Observation, on 03/24/2025 at 3:00 PM, revealed that the Rockcastle Respiratory Care Center Nurse Staffing Information, posted for the same units had still not been updated or exchanged since 03/20/2025. During an interview with the Nursing Administrative Assistant on 03/25/2025, at 11:00 AM, she stated that she was responsible for updating the staffing postings and typically posted this information daily. She further explained that she prepared the postings for Friday, Saturday, Sunday, and Monday each Thursday afternoon, with the weekend updates expected to be managed by the assigned nurse or weekend manager. However, the Nursing Administrative Assistant admitted to failing to deliver the postings for March 21, 22, 23, and 24, 2025 on 03/20/2025 which resulted in the units not having the information to post. In an interview with the Chief Nurse Officer on March 26, 2025, at 11:20 AM, she stated that it was the Nursing Administrative Assistant's responsibility to update the staffing postings. The Chief Nurse Officer also mentioned that she was unaware the postings had not been updated daily to inform residents and visitors of daily staffing information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure one (Resident (R )43) of 30 sampled residents had access to a functional and accessible communication system to request staff assistance. On 03/23/2025, Resident (R) 43 was not equipped with a functional and accessible communication system to request staff assistance compromising R43's safety and well-being. On 03/23/2025, R43 activated the call light system but did not receive assistance, as the call was manually deactivated at the central staff station. On 03/24/2025, the call light was positioned on the resident's ventilator machine, out of the resident ' s reach, preventing the resident from alerting staff when suctioning was needed. These failures delayed staff response to the resident's needs, potentially compromising the resident ' s safety and well-being. The findings include: A review of the facility policy, Organizational Top Ten Behavior Standards—Call Lights (undated), revealed that call lights were to be acknowledged by the third ring and answered with How may I help you? According to the policy, staff should respond with care, courtesy, and respect. A review of R43's admission Face Sheet revealed R43's was admitted to the facility on [DATE]. A review of R43's admission Minimum Data Set with an Assessment Reference Date (ARD) of 03/05/2025 indicated a Brief Interview for Mental Status (BIMS) score of 14, indicating that R43 was cognitively intact. On 03/23/2025, at 2:18 PM, R 43 was observed making a gurgling sound from the tracheostomy and activated the call light to request assistance. At 2:21 PM, the unit secretary deactivated the call system without calling or checking on the resident. At 2:22 PM, the State Survey Agent (SSA) instructed R43 to press the call light again. At 2:25 PM, the State Registered Nurse Aide (SRNA) 1 entered the room. At that time, R43 reported she needed respiratory therapy for suctioning. During an interview at 2:18 PM on 03/23/2025, R43 stated, I turn my light on, and they just turn it off without checking on me. R43 also reported feeling afraid and said, Sometimes I feel like I'm drowning in my secretions. During an interview at 2:43 PM on 03/23/2025, Unit Secretary 1 stated that she frequently deactivated resident call lights from the central location without calling into the room. She added, If the resident needs something, they will push the call light again. During an observation on 03/24/2025 at 3:10 PM, R 43 was observed in bed searching for the call light. R43 had an audible gurgling sound from the tracheostomy area. The SSA discovered the call light button was on the ventilator machine out of the resident's reach. When the Licensed Practical Nurse entered the room, R43 stated, No one calls into my room or checks when I push my light. I didn't think it was working. During an interview at 3:16 PM on 03/24/2025 with Licensed Practical Nurse (LPN) 1, she confirmed that the call light was misplaced during patient care. LPN 1 further stated that R43 was new to the facility and may accidentally hit the light. She added that the unit secretary often deactivated the light without follow-up but acknowledged that the staff should check on the resident for safety when the call light was activated. During an interview on 03/24/2025 at 3:25 PM, R43 stated, I need my light to work because I get scared when no one comes. What if I needed respiratory therapy because I need suctioning? During an interview on 03/25/2025 at 9:35 AM, the Administrator acknowledged that the call lights were a known issue in the facility. The Administrator attributed part of the problem to the layout of the newly constructed resident unit and a shortage of staff wanting to work the unit due to the distance between rooms, which caused increased fatigue. He stated, however, that this was not an excuse and that both floor staff and management should respond to all call lights to ensure resident needs were met, including alleviating fears of choking and lack of timely assistance.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (1) of thirty-three (33) sampled residents received a preadmission screening (Resident #84). Resident #84 had a Level I Pre-admission Screening and Resident Review (PASARR) on 02/09/18 that indicated the resident required a Level II Screening; however, the facility failed to ensure a Level II screening was completed. The findings include: Interview with the Chief Nursing Officer revealed the facility did not have a policy related to the PASARR. Observation and interview with Resident #84 on 08/29/18 at 2:30 PM revealed the resident had resided at the facility for a few months, but was hoping to go home soon. Review of Resident #84's medical record revealed the facility admitted the resident on 02/12/18 with diagnoses of Chronic Respiratory Failure, Respirator Dependence, Diastolic Heat Failure, and Bipolar Disorder. Further review revealed a PASARR Level I was completed for the resident on 02/09/18, prior to admission, and indicated the resident should have a Level II PASARR due to a diagnosis of Bipolar Disorder. However, record review revealed no documented evidence a Level II PASARR was completed for Resident #84. Interview on 08/30/18 at 3:26 PM with Social Service Worker #1 revealed the facility should have made a referral to the appropriate agency requesting that a Level II PASARR be completed prior to the 40th day of the resident's admission, but Social Service Worker #1 was unable to explain why the referral was not made. Interview on 08/30/18 at 4:45 PM with the Director of Social Services revealed all residents were screened for PASARR and if the resident triggered, a PASARR II should be conducted. He stated a diagnosis of Bipolar Disorder should have triggered a Level II PASARR, and did not know why Resident #84 had not had a Level II screening.