**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to ensure call lights were within residents' reach and easily accessible for 2 of 4 residents reviewed for accommodation of needs, Resident (R)126 and R61. Findings include: Review of the facility policy with a revision date of October 2023, titled, Call Light documented, Purpose: To provide a means of communication of needs from the residents to the staff . 8. When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light . 11. Be sure all call lights are placed on the bed at all times and the cords are off the floor. Review of R126's Face Sheet revealed R126 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dementia, psychotic disturbance, anxiety, rhabdomyolysis and a history of falling. Review of R126's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/24, revealed R126 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R126 was cognitively intact. During an observation on 03/09/25 at 11:44 AM, R126's call light was not in reach, the call light was located on the floor behind the bed. During an observation on 03/09/25 at 12:40 PM, R126's call light was on the floor, under the bed. During an observation and interview on 03/10/25 at 12:02 PM, R126's call light was on the floor under the bed. R126 stated that she didn't think that she had a call light anymore. During an interview on 03/10/25 at 1:17 PM, Licensed Practical Nurse (LPN)2 stated that R126 can use their call light and holler for him. LPN2 stated that he conducts routine checks on his residents throughout the day. LPN2 stated that he usually goes to the room when the resident presses the call light. LPN2 further stated he conducts safety checks which consist of providing for the needs of the resident, positioning and ensuring the bedside table is within reach. LPN2 verified that the call light was out of R126's reach. LPN2 picked the call light up off the floor and attached the call light to R126's bed sheet. LPN2 concluded this isn't his normal practice, and there is no reason it should've been missed, staff should've known the call light was out of place. During an interview on 03/10/25 at 1:30 PM, Certified Nursing Assistant (CNA)3 stated the call light is answered by whomever is closest to it. CNA3 stated that routine checks are conducted throughout the day, ensuring call lights are in place, water is at bedside, curtains are pulled, and the room temperature is to the liking of the resident. CNA3 stated R126 takes her call light and throws it on the floor often. CNA3 stated that resident can ambulate, so she notifies them vocally if she can't reach her call light. Review of R61's Face Sheet revealed R61 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dementia, acute embolism and thrombosis of left femoral vein, history of falling, cognitive communication deficit and chronic kidney disease. Review of R61's Quarterly MDS with an ARD of 01/16/25, revealed R61 had a BIMS score of 5 out of 15, indicating R61 was severely cognitively impaired. During an observation on 03/09/25 at 9:00 AM, R61's call light was not visible in the resident's room. During an observation on 03/09/25 at 12:14 PM, R61's call light still could not be located in the resident's room. During an observation on 03/10/25 at 12:02 PM, R61's call light was found on the floor behind the bed by staff. During an interview on 03/10/25 at 1:22 PM, Licensed Practical Nurse (LPN)2 stated that R61 is a closely watched resident. LPN2 stated that R61 doesn't comprehend how to use the call light. R61 vocally expresses herself and is a high fall risk. LPN2 stated there are no excuses warranted, the call light should've been in reach of the resident. LPN2 safety checks consist of providing for the needs of the resident, positioning and ensuring the bedside table is within reach. LPN2 picked the call light off the floor and attached call light to R61 bed sheet so it can be within reach. During an interview on 03/11/25 at 7:23 PM, the DON stated that her expectations of her staff is for all call lights to be answered as prompt as possible and to be able to complete the need if able. Anybody can answer the call lights on the halls, and call lights are to always be in reach of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation, and interview, the facility failed to ensure respiratory equipment (Bipap, CPAP, and Nebulizer Masks) were functioning, maintained, and stored appropriately for 4 of 4 residents (Resident (R)19, R14, R46 and R59) reviewed for respiratory care out of total sample of 12 residents. The facility's deficient practice increased the resident's risk of respiratory complications. Findings include: Review of the facility policy titled, 306 Respiratory- Respiratory Therapy Equipment with a revision date of February 2025 revealed, 3. Respiratory equipment (i.e., nasal cannula, aerosols, etc.) at bedside will be covered with a plastic bag when not in use. Respiratory therapy services are important in preventing and managing health care acquired infections in the health care setting. The center's Respiratory Therapy Department will follow established guidelines for cleaning, disinfecting and refilling humidifiers and H2O reservoirs. Disposable tubing and refillable reservoirs will be replaced according to center schedule, Suctioning equipment will be disinfected according to center procedures. Review of a document provided by the facility titled Specific Medication Administration Procedures with a revision date of 02/25/25, documented, When equipment is completely dry, store in a plastic bag with resident's name and the date on it. Review of R19's Face Sheet revealed R19 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute recurrent sinusitis, chronic maxillary sinusitis, and mild intermittent asthma. Review of R19's Physician Orders revealed, Prescription ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/; amt: 1 neb; inhalation Twice A Day - PRN, PRN 1, PRN 2 Open Ended with a start date of 02/17/25. Review of R19's Care Plan last revised on 01/13/25, revealed, Complications, at risk for related to disease processes of hypertensive CKD stage 4, iron deficiency anemia, hypothyroidism, primary generalized osteoarthritis, depression, mild intermittent asthma, other chronic pain, GERD, other B12 deficiency anemia, hypokalemia, hypomagnesemia, prurigo nodularis, polyneuropathy, left shoulder pain, chronic sinusitis, insomnia, anxiety disorder, vitamin D deficiency, dysphagia, constipation, hallucinations, difficulty walking, cramp and spasm, localized edema, non-pressure chronic ulcer to left foot, abnormalities of gait and mobility, unspecified lack of coordination, and generalized muscle weakness, [R19] has history of C1 displaced vertebra fracture. Approaches directed staff to, NEBULIZER MASK - CHANGE NEBULIZER TUBING AND MASK EVERY 3 DAYS Edited: 02/02/2024 Nebulizer Care: RINSE MASK AND CHAMBER WITH TAP WATER. LET DRY ON PAPER TOWEL AFTER EACH NEBULIZER TREATMENT Created: 02/02/2024. Observe resident for signs of respiratory distress such as shortness of breath, wheezing, gasping, shallow breathing Created: 08/19/2021. Review of R19's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/25, revealed Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R19's cognition was intact. During an observation and interview on 03/09/25 at 12:58 PM, of R19's room revealed a Medline Nebulizer machine, near the resident's bedside. The Jet nebulizer cap was empty, the adult mask was hooked up to the Jet Nebulizer chamber. The mask was uncovered. The machine was located beside an artificial plant. The artificial plan had dust particles. The tubing on the machine was dated 03/06/25. R19 stated she used the machine as needed. R19 stated she used the machine a few days ago. R19 could not recall the last time staff cleaned the machine or replaced the mask. An observation on 3/10/2025 at 9:09 AM, at 12:18 PM, and on 03/11/25 at 9:09 AM, revealed the Jet nebulizer cap was empty, the adult mask was hooked up to the Jet Nebulizer chamber. The mask was uncovered. The tubing on the machine was dated 03/06/25. During an interview on 03/11/25 at 4:16 PM, Registered Nurses (RN)3 and RN4 confirmed R19 uses her nebulizer PRN (as needed) and that R19 had a treatment a few days ago, however, could not recall the exact date. Both nurses confirmed tubing should have been changed, and confirmed the date on the sticker was the date it was changed, and it was supposed to be changed on the 9th or 10th, even if it's not in use. Both nurses stated it's the nurse's responsibility to ensure nebulizers are covered when not in use, and tubing is changed every 3 days per order. Both nurses confirmed R19 did not have her nebulizer covered until a few minutes ago. Review of R59's Facesheet revealed R59 was admitted to the facility on [DATE], with diagnoses including but not limited to chronic obstructive pulmonary disease and obstructive sleep apnea. Review of R59's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R59 was cognitively intact. Review of R59's Physician Orders revealed an order for CPAP, to use CPAP from home at night, pressure 13, at bedtime 9:00 PM. Review of R59's Medication Administration Record (MAR) dated March 2025 revealed nurse signatures were signed every night at 9:00 PM for usage. During an observation and interview on 03/09/25 at 3:30 PM, revealed a CPAP (Continuous Positive Airway Pressure) in R59's room. R59 stated, Something is wrong with it for about 2 weeks. They turned it on last night, it worked for a while then it just cut off. I've been asking about getting it fixed, I need it. No-one has said anything, I'm just waiting. During a follow up interview on 03/10/25 at 2:51 PM, R59 stated, I used the CPAP last night, it cut off twice. There is supposed to be someone coming to look at it. The CPAP is in the drawer. Observation revealed the CPAP machine in R59's dresser drawer. During an interview on 03/10/25 at 4:55 PM, Licensed Practical Nurse (LPN)1 entered R59's room and retrieved the CPAP machine and turned it on. LPN1 stated, It's set for 13 pressure, when it gets to 4 it stops, it runs for 10-15 seconds. LPN1 tried it with the mask on also and confirmed it wasn't working. During an interview on 03/10/25 at 5:02 PM, Registered Nurse (RN)1 stated, The charge nurse was aware. He let the niece know and there is a pulmonology appointment April 24th. We asked her niece to come pick it up. RN1 confirmed that R59 was not able to use the machine. During a phone interview on 03/10/25 at 5:12 PM, R59's niece stated, [R59] has been on the CPAP for years. I thought she was using it at night. I don't recall them telling me that it wasn't working. I've never had it serviced. She was on a CPAP at home. Most of her stuff, the nursing home takes care of. R59's spouse spoke up and stated he was not aware of any problems with the machine. During an interview on 03/10/25 at 5:15 PM, LPN2 stated he checked it an hour or two ago. It popped on and it only went to 4. LPN2 confirmed R59's CPAP was not working correctly. During a follow up interview on 03/10/25 at 5:20 PM, RN1 stated on January 20th, the family was called about the machine needing service. RN2 stated, [R59] has an appointment with Pulmonology April 24th. We asked her niece to come pick up the CPAP. During an interview on 03/10/25 at 6:08 PM, the Nurse Practitioner (NP) stated she's had more issues than we've been successful with it. The mask was replaced at least 2 times. R59 has obstructive sleep apnea and COPD. R59 had a sleep study, her O2 (oxygen) saturation (oxygen in the blood) was dropping in the 80s. The NP further stated, The facility should provide medical equipment. They own one CPAP machine in the facility. When it works it's great. The NP concluded, My preference would be that [R59] use oxygen every night. We knew she didn't use the machine all through the night. She was averaging about 4 hours. During a follow up interview on 03/11/25 at 10:57 AM, LPN2 stated, Aero Care was supposed to call [R59's] family. They called the husband a few months ago, he has advanced Parkinson's. I did not know it [CPAP machine] was broken all this time. There is an appointment for Thursday, I called them first thing this morning. The niece is coming to pick it up and take it to them to fix. I spoke to her yesterday. She said she was not made aware back then. [R59's] husband would not have been able to tell her or remember to tell her with his advanced Parkinson's. During an interview on 03/11/25 at 5:07 PM, the Director of Nursing (DON) stated, I was made aware of [R59's] CPAP machine yesterday. I should have been made aware if they weren't able to get it resolved. Most residents bring there own. My expectations are for me to be notified. Review of R46's Face Sheet revealed R46 was admitted to the facility on [DATE], with diagnoses including, but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left side, aphasia, obstructive sleep apnea, and morbid obesity. Review of R46's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/24, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating that the resident is cognitively intact. Review of R46's Progress Note dated from January - March 2025 revealed no progress notes related to OSA or breathing difficulties. Review of R46's Medication Administration Record (MAR) reviewed for the months of January-March 2025, revealed the following: that continuous positive airway pressure (CPAP) is ordered to be used at bedtime with start date 10/10/22 to 03/10/25. CPAP care daily- once a day, wash c-pap mask daily with soap and water and air dry. CPAP care weekly- once a day on Sunday. Wash tubing and head gear with soap and water on Sunday and air dry on 7a- 7p. CPAP filters- once a day on Friday every two weeks, change disposable filters. CPAP humidifier- once a day. Empty and refill humidifier daily with sterile/distilled water on 7p-7a. During an observation on 03/09/25 at 11:57 AM, R46's CPAP machine and mask were located at bedside. The CPAP mask was uncovered laying on the nightstand. During an observation on 03/10/25 at 1:07 PM, R46's CPAP facemask was uncovered on the nightstand. Review of Resident (R)14's Face Sheet revealed R14 was admitted to the facility on [DATE], with diagnoses including, but not limited to: chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, hypertension, osteoarthritis, and anxiety disorder. Review of R14's Quarterly MDS with an ARD of 01/07/25, revealed R14 had a BIMS score of 5 of 15, indicating that the resident was severely cognitively impaired. Review of R46's Medication Administration Record (MAR) for the months of January-March 2025, revealed the following: Nebulizer care is performed on every shift- rinse mask and chamber with tap water. Let dry on paper towel after each nebulizer treatment. Nebulizer mask change is once a day every three days- change nebulizer tubing and mask every three days 7p-7a shift. Budesonide suspension for nebulization; 0.5mg/2ml; 1 unit dose; inhalation every 12 hours for COPD. During an observation on 03/09/25 at 12:27 PM, R46's nebulizer mask was uncovered at bedside. During an observation on 03/10/25 at 10:00 AM, R46's nebulizer mask was uncovered on bedside table. During an interview on 03/10/25 at 1:45 PM, Licensed Practical Nurse (LPN)4 stated that there is a protocol in place for CPAP storage. Staff follows the orders in the chart and staff changes the face mask once a week and uses distilled water in the humidifier. LPN4 stated the mask must be washed and cleaned after use and placed on a barrier to allow for drying. LPN4 observed R46's CPAP face mask uncovered at bedside. LPN4 stated that the face mask must be protected from germs when not in use. During an interview on 03/11/25 at 3:31 PM, Registered Nurse (RN)1 stated once the resident is complete with nebulizer or CPAP, the face mask is washed out and laid to dry on a waterproof barrier. RN1 stated when the mask is not in use, it is placed in a bag for infection control purposes. The CPAP face mask and tubing is changed every three months, and the nebulizer is washed in soap and water daily. RN1 stated the tubing is washed weekly, and the filters are changed every two-weeks. RN1 stated the face cushion is changed every month, the mask is placed in a plastic bag after use. During an interview on 03/11/25 at 7:21 PM, the Director of Nursing (DON), stated that she expects respiratory care is being provided per the physician's orders and face masks are stored in their designated storage bags when not in use. The DON encourages patients to utilize the storage bags as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to ensure used Personal Protective Equipment (PPE) was disposed of properly in accordance with professional standards. Specifically, used PPE was observed hanging outside of the resident's rooms who were currently on droplet precautions for 6 of 9 rooms observed. Findings include: Review of the facility's policy titled, 704 Droplet Precautions, documented, Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whether one patient or both patients are on Droplet Precautions. Review of the CDC Infection Control Summary of Recommendations with a revision year of 2007, states, Slide 10. PPE must be removed at the point of exit; do not reuse face masks. During an observation on 03/09/25 at 10:45 AM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/09/25 at 10:45 AM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/09/25 at 1:15 PM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/09/25 at 1:17 PM, there were used gloves balled up on the handrail outside of room [ROOM NUMBER], a droplet precaution room. During an observation on 03/09/25 at 2:10 PM, there was a used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/09/25 at 2:31 PM, there was an used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/09/25 at 2:33 PM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/10/25 at 9:00 AM, there was a used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/10/25 at 10:08 AM, there were two used uncovered face masks hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/10/25 at 10:14 AM, there was a used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an interview on 03/09/25 at 1:10 PM, the Director of Nursing (DON) stated that she is the infection control nurse, and the facility now has nine Covid positive patients. The outbreak started on 02/17/25 with 22 positive residents. The facility is maintaining the same staff on the units and reducing community activities to prevent residents from being around others to contain the spread of Covid. During an interview on 03/10/25 at 9:57 AM, the Administrator stated that he would have to get with the nursing department on the mask policy guidelines for masking when Covid is in the building. During a follow up interview on 03/11/25 at 7:24 PM, the DON stated that she expects her staff to don (put on) and doff (take off) their PPE per wherever the isolation is, and PPE should be stored in the bags that are hanging outside the door that contains clean PPE not used PPE. The DON further expects new PPE to be used every time staff enters in a resident's room that is on precautions.