**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide respiratory care and services for tracheostomy dependent residents according to professional standards of practice for four residents (#14, #15, #16, and #19) out of five residents with a tracheostomy. On [DATE] a grievance was filed by Resident #16's family related to tracheostomy care and suctioning. The grievance process was not followed through by the facility to a resolution for the resident. On [DATE] Resident #15 requested his tracheostomy to be suctioned. The certified nursing assistant (CNA) notified the nurse. By the time the nurse got to the room, Resident #15 was unresponsive. A code was called, Cardiopulmonary Resuscitation (CPR) was initiated with no evidence the airway was cleared prior to providing breaths, the resident was transported to the hospital where he expired. During the survey, two residents (#14 & #16) were observed in the facility needing tracheostomy suctioning whom staff had not responded to their requests. There was inaccurate and incomplete documentation related to tracheostomy care. Staff expressed lack of confidence and access to supplies related to care and services to residents with tracheostomies. A tracheostomy (also called a tracheotomy/trach) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. The person with a tracheotomy (trach) breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/tracheostomy accessed on [DATE]. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #14, #15, #16, and #19 and resulted in the determination of Immediate Jeopardy starting on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity was reduced to an E. Findings included: Review of a progress note written by Staff B, Licensed Practical Nurse (LPN), dated [DATE] at 11:44 p.m., showed, Around 11:30pm this writer was attending to another resident when a CNA informed me that [Resident #15] wants to be suctioned. This writer then proceeds to [Resident #15's room] and observed resident to be non-responsive after calling out his name and gentle chest rub on the chest. No pulse, no respiration, pale looking, warm to touch, O2 [oxygen] sat [saturation] reading 76%, full code status, code blue paged, CPR initiated while another nurse called 911. EMS [Emergency Medical Services] arrived in the facility around 11:38 pm and took over. Resident was taken to [Hospital] around 12:05am. MD [Medical Doctor], [name of family member], and DON [Director of Nursing] notified. A code blue is called if a patient goes into cardiac arrest, respiratory arrest, has respiratory issues, or experiences another medical emergency. Oxygen saturation is a measure of how well the lungs are working based on oxygen levels in the blood vessels. Review of the admission Record showed Resident #15 was admitted on [DATE] with diagnoses to include lack of coordination, chronic respiratory failure, tracheostomy, gastrostomy, dysphagia, major depressive disorder, ventricular premature depolarization, and myasthenia gravis with acute exacerbation. Review of Resident #15's admission Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed he had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Section O - Special Treatments, Procedures, and Programs showed he needed continuous oxygen, suctioning, and tracheostomy care. A review of Resident #15's physician orders showed the following: -Maintain suction set up at bedside. Date [DATE]. -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date [DATE]. -Change suction canister every 72 hours and/or when ¾ full. Date [DATE]. -Change small tubing between canister and suction machine monthly. Starting on the 15th. Date [DATE]. -Full Resuscitation. Date [DATE]. -Humidified Oxygen per trach continuous 4 Liters (L) 28%. Date [DATE]. -Maintain ambu bag at bedside and replacement trach of equal size and one size down maintained at bedside. Date [DATE]. -Tracheostomy type: Shiley size 6. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Every shift. Date [DATE]. Review of Resident #15's [DATE] Treatment Administration Record (TAR) showed no documentation that the resident was suctioned on [DATE] evening shift and [DATE] day shift. It showed there was no documentation that the ambu bag and replacement trach was at the bedside or suction was set up at the bedside on [DATE] evening shift and [DATE] day shift. Review of Resident #15's hospital History and Physical, showed he had his tracheostomy procedure on [DATE] and he was decannulated (trach was removed) on [DATE]. The resident's chief complaint was respiratory failure and he had to have a repeat tracheostomy on [DATE]. Review of Resident #15's Respiratory Notes, dated [DATE], showed the resident was tolerating a speaking valve on his trach and was in no respiratory distress. It showed the resident had yellow drainage and nursing was made aware. The Respiratory Note, dated [DATE], showed the resident was alert and pleasant, sitting in his wheelchair. He had no signs or symptoms and denied any distress. He had a moderate amount of thick white/pale yellow secretions. Trach care was done with inner cannula and tie changed. An interview was conducted on [DATE] at 9:44 a.m. with Staff A, CNA. She said she took care of Resident #15 starting at 11:00 p.m. on [DATE]. She said right around change of shift she was walking down the hall checking on each resident like she did every shift change. Staff A said she saw Resident #15 had his light on, so she went to check on him. She said the resident told her he needed his trach suctioned. She said he didn't seem distressed. She said she did notice his feet looked different, they were uncovered and were very pale. She told the resident it was the middle of shift change but she would let the nurse know and the resident told her thank you. Staff A said when she left Resident #15's room the nurse, Staff B, Licensed Practical Nurse (LPN) was in the hall. She said Staff B was checking her resident rooms since the shift just started. Staff A, CNA told Staff B, LPN the resident needed to be suctioned and Staff B went to the room and came right back out. Staff A said Staff B went to the nurses' station and Staff A assumed the nurse was getting supplies. Staff A said it was about 10 minutes later when Staff B, LPN went back to Resident #15's room and found him unresponsive, and a code blue was called. An interview was conducted on [DATE] at 3:46 p.m. with Staff B, LPN. She said she worked from 11:00 p.m. on [DATE] to 7:00 a.m. on [DATE] and was assigned to care for Resident #15. She said she got report from the nurse who was leaving then did her rounds. Staff B said she went to check on another resident and was suctioning that resident when Staff A, CNA came and told her Resident #15 needed suctioning. She said she finished up with the other resident and went to Resident #15's room. She said it was only 1-2 minutes. She said she went to Resident #15's room around 11:30 p.m. Staff B said when she got to his room, called his name, and rubbed his chest when he didn't respond. She said Resident #15 was not breathing and she yelled for another nurse to call a code blue. Staff B said she took out the inner cannula of his trach and everyone else arrived and they attached the bag to his trach. She said the resident was not suctioned prior to or during CPR. Staff B said she had cared for Resident #15 previously and was familiar with him. She said when he asked to be suctioned, she would go do it. She said he would let staff know if he needed suctioning. Staff B said sometimes he would want to be suctioned before he went to bed around midnight and sometimes he didn't get suctioned at all during her 11:00 p.m. to 7:00 a.m. shift. She said when she suctioned him on previous shifts he was mucousy and wanted to clear his throat. She said sometimes his secretions were a little thick. Staff B said Resident #15 couldn't really cough. A follow-up interview was conducted on [DATE] at 4:56 p.m. with Staff A, CNA. She confirmed when she checked on Resident #15 and came out of his room and Staff B, LPN was in the hall walking behind me going to rooms and stuff. She said Staff B was not in another resident room. She said Staff B walked in the room, talked to the resident for a minute then came back out and went to nurses' station. Staff A said she continued to check on her residents, finishing her last rooms. She said she then came out and started fixing ice water cups for residents that may want them. Staff A said she had fixed a few cups when Staff B went into Resident #15's room, and the code was called. She said it was about 10 minutes after she told the nurse the resident needed suctioning. An interview was conducted on [DATE] at 10:56 a.m. with the facility's Respiratory Therapist (RT). She said she comes to the facility once a month to do full trach changes on the residents with tracheostomies. She said each trach resident had a supply bag at their bedside for emergencies that contained a suction catheter, inner cannula, lubricant, trach cleaning kit and trach ties. The RT said if a resident asked to be suctioned, they should be suctioned right then. She said no resident wants to be suctioned, it is not comfortable, so if they are asking for it, they need it. She said the suctioning should be done right when the resident asks. The RT said Resident #15 had been doing really good. She said when she came in, the resident always needed a deep suctioning, and he needed continuous oxygen. She said he needed to be checked because even when his oxygen saturation was in the 80's he did not report shortness of breath. She said he did not have a good cough and couldn't get anything up, even part of the way. She said for him it would not have been okay to wait 10 minutes if he said he needed suctioning. The RT said if Resident #15 was not suctioned quickly, it would cause distress for him. She said she practiced coughing with him, and he just did not have a good cough. She said the resident had thick secretions. The RT said if he asked for suctioning and it took 10 minutes for someone to do it, it could have caused respiratory arrest. The RT said in her training with the nurses she taught them if the inner cannula is not open that is the easiest way to code a patient. On [DATE] at 4:03 p.m. an interview was conducted with the Director of Nursing (DON) regarding Resident #15. The DON stated Resident #15 was a trach patient. She stated she was notified the resident had notified a CNA he needed to be suctioned and by the time the nurse got to him, he had coded. The DON stated she was shocked. She said, I had seen him earlier. He was just fine. The only question I had in my mind was how long he had been waiting to be suctioned and how soon did our staff respond. She stated she had not had a chance to review the record or interview the CNA and nurse on their timeline. She stated it was something in the back of her mind. She said, It is hard to tell what really happened. A follow-up interview was conducted on [DATE] at 11:54 a.m. with the DON. She said when she called the hospital, she found out Resident #15 had passed away. She said she hadn't talked to the nurse or CNA about the situation or what happened. She said there are emergency supplies in each trach resident's room, but routine suctioning supplies are not necessarily in the room. She said some nurses keep supplies in the drawer of the room, but they are in the supply closet that isn't far away. She said, I feel like when a resident needs suctioning that needs to be done right away. Suctioning should be immediate you don't know if it is stopped their airway. It is very important they are suctioned right away. Within 2 minutes. If right outside door, less than a sec[second]. When asked if she felt like nurses responded to the resident's need for trach suctioning timely, she responded, I am going to plead the fifth on that one. It is a work in progress. The DON said the process needs structure and No, they don't respond. They don't respond quick enough for me. The DON said, I think it is more they need more training and more confidence. Some nurses have just graduated out of school. She said that is why she had the RT do training last week. The DON said during training the nurses didn't do return demonstration or competencies. They just went over the information on trach care. The DON said management, or the Respiratory Therapist had not watched nurses do trach care to ensure they knew what they were doing. She said she is going to start that. She said not 100% of their nurses were comfortable doing trach care and some of the newer nurses needed more training. The DON agreed a resident was placed at risk if their trach was clogged and said if a resident asked to be suctioned a nurse should respond immediately. She added, That patient is in danger. They could be where they can't breathe. The DON read the grievance filed on [DATE]. She said she was not made aware of the grievance and had not addressed it. She said if a person did not receive trach care and suctioning, it was a lack of care and services, and I think that is neglect. The DON said Monday, [DATE] at approximately 10:00 a.m., management had a morning clinical meeting where they looked back at what happened the past 72 hours. She said she saw the note about Resident #15 and her first question was why. She said her thought when she read the progress note was how long did it take that nurse to get in that room. Where was the nurse? The DON said, I was shocked. I literally was shocked. I talked to him on Friday. He was sitting in the dining room. An interview was conducted on [DATE] at 2:38 p.m. with Staff C, Registered Nurse (RN). He said he knew Resident #15 and was surprised when he heard he passed away. Staff C stated Resident #15 was pleasant and sometimes asked to be suctioned or have his trach inner cannula changed. Staff C said Resident #15 was not the type that asked all the time. So, if he asked for suctioning, then he really needed it. A John Hopkins Medical article titled, Living with a Tracheostomy Tube and Soma, accessed on [DATE], showed, The upper airway warms, cleans, and moistens the air we breathe. The trach tube bypasses these mechanisms so that the air moving through the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. Suctioning clears mucus from the tracheostomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop. Avoid suctioning too frequently as this could lead to more secretion buildup. The article also informed readers that suctioning a tracheostomy is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/living-with-a-tracheostomy-tube-and-stoma#:~:text=Suctioning%20clears%20mucus%20from%20the,lead%20to%20more%20secretion%20buildup. A review of the admission Record showed Resident #19 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include cerebral palsy, other specified diseases of the jaw, chronic obstructive pulmonary disease (COPD), epilepsy, dementia, respiratory failure, tracheostomy, and gastrostomy. Review of Resident #19's Discharge MDS, dated [DATE], showed his BIMS was unable to be conducted. Review of Resident #19's physician orders showed the following: -Change small tubing between canister and suction machine monthly starting on the 15th. Date [DATE]. -Tracheostomy Type: Shiley Size 4. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Date: [DATE]. -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date [DATE]. -Maintain suction set up at bedside, every shift and as needed. Date [DATE]. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date [DATE]. -Change trach collar, mask and oxygen weekly as well as PRN. Every Sunday for preventative. Date [DATE]. -Humidified oxygen per trach continuously 28 L every shift for Shortness of Breath. Date [DATE]. Review of Resident #19's [DATE] TAR showed no documentation for trach care on 3/5, 3/6, and [DATE]. It showed no documentation for continuous humidified oxygen at 28 L or trach suctioning on [DATE] evening shift, [DATE] day shift, [DATE] day and evening shift, [DATE] day and evening shift, [DATE] night shift, and [DATE] evening shift. Review of Resident #19's [DATE] Medication Administration Record (MAR) showed the resident was taking the antibiotic, Ciprofloxacin 500 milligram (mg) for a trach site infection from [DATE] to [DATE]. Review of Resident #19's Change in Condition Evaluation, dated [DATE], showed the resident was observed bleeding from his mouth and trach. He was transferred to a higher level of care. Review of Resident #19's Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form (3008), dated [DATE], showed the resident's primary diagnosis was tracheostomy issue. Review of Resident #19's Respiratory Notes, dated [DATE], showed the resident was slightly tachypneic (rapid shallow breathing) with oxygen saturation at 88% on room air. Resident was placed on oxygen via trach mask at 2L with oxygen saturation increasing to 95%. The Respiratory Therapist's recommendations were monitor symptoms (tachypnea and low sats [oxygen saturation.] A Respiratory Note, dated [DATE], showed his breath sounds were course with mild expiratory wheeze, sputum sample obtained related to a moderate amount of yellowish green sputum with a foul odor. Review of Resident #19's Weights and Vitals showed the resident's oxygen saturation was not documented on 2/10, 2/11, [DATE] and only once on [DATE] at 2:03 p.m. During the interview with the RT on [DATE] at 10:56 a.m. the RT said Resident #19 was currently on antibiotics due to a trach site infection. She said the resident had pneumonia, but she felt like it started as a trach site infection then progressed to his lungs. When asked how the staff were with the resident's trach care she said she was not in the facility on a consistent basis, but sometimes when she came It may not be like I would like it. The RT said, I am not sure how good they do. With the newer staff I am not sure how comfortable with trach stuff they are. Review of the facility's Grievance Log for March of 2024 revealed a grievance filed on [DATE] by the family of Resident #16. They wrote that on many occasions the resident's equipment and trach were not working and his tracheostomy tube was clogged on [DATE] when they came to visit. The family wrote the evening nurse got an attitude when they mentioned the tracheostomy tube being clogged. The grievance showed the Nursing Home Administrator (NHA) and Unit Manager (UM) were designated to take action for this grievance. It was assigned on [DATE] showing the action to resolve the grievance was Nursing will educate staff. During a facility tour on [DATE] at 9:49 a.m., an observation was made of Resident #16 in bed, he summoned this surveyor pointing to his suction equipment. The suctioning hose and mask were observed on the floor. The resident's suctioning piece was in his hand. The resident only spoke Spanish. He pointed to the cup on his bedside table. He nodded yes to needing water. This Surveyor exited the room and could not locate the CNA assigned to this hall. When the nurse had finished administering meds in the room adjacent to Resident #16, surveyor notified the nurse (Staff G, LPN) that Resident #16 needed water. The nurse said, Hang on. I'll get with him. After approximately 5 minutes, she entered the room to respond to the resident. Review of the admission Record showed Resident #16 was admitted on [DATE] with diagnoses to include respiratory failure, unspecified with hypoxia, shortness of breath, Parkinson's disease without dyskinesia, without mention of fluctuations, tracheostomy status, gastrostomy status, personal history of pneumonia (Recurrent), iron deficiency anemia, unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, essential (Primary) hypertension, hyperglycemia, unspecified, elevated white blood cell count, Unspecified, and paralysis of vocal cords and larynx, unspecified. Review of Resident #16's MDS admission assessment, dated [DATE], revealed a BIMS in Section C - Cognitive Patterns: he was not assessed due to being rarely/never understood related to his diagnosis of paralysis of vocal cords and larynx. Review of Resident #16's physician orders showed the following: -Tracheostomy Type: Cuffless Size: 6XL Tracheostomy change or replace as needed if displaced or dislodged. every 24 hours as needed. Date [DATE]. -Tracheostomy Type: Cuffless Size: 6XL Trach care daily and as needed. Cleanse tracheostomy site with normal saline, pat dry. Change inner cannula. Cover with drain sponge daily and as needed. every day shift AND as needed. Date [DATE]. -Maintain suction set up at bedside, every shift and as needed. Date [DATE]. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date [DATE]. Resident #16 did not have any tracheostomy cleaning or change orders prior to the start of the survey on [DATE]. Review of Resident #16's [DATE] TAR revealed missing documentation showing suction was set up at the bedside and an ambu bag and replacement trach was at the bedside on 3/18, 3/21, 3/25, and [DATE]. During a tour of hall 200 on [DATE] at 9:54 a.m., an observation was made of Resident #14. The resident was non-verbal and pointed to her trach site. The resident was asked if she needed to be suctioned. She nodded her head up and down indicating, yes. A nurse or CNA could not be located in the hall, the NHA was notified the resident needed care. The NHA went to the resident's room and notified Resident #14 she would let the nurse know. An observation was conducted on [DATE] at 12:45 p.m. Two call lights were observed on. Staff C, RN was observed sitting at the nurses' station on the phone. Staff C was asked what the beeping noise was, and he stated it was because a resident had turned on a call light. Staff H, CNA was observed responding to the call light in Resident #14's room. Staff H stepped out of the room and stated Resident #14 needed something to do with her trach and she was letting the nurse know. Staff C, RN overheard the CNA speaking to surveyor. He said to the surveyor, I'm on break, am I not entitled to my break? The nurse was observed remaining seated at the nurse's desk. A tour with the DON was conducted on [DATE] at 3:46 p.m. of Resident #14's room. The resident was again observed pointing to her trach site. The DON asked the resident if she needed to be suctioned. The resident nodded yes. The DON notified Staff G, LPN. An observation was made with the DON on [DATE] at 3:54 p.m. Resident #16 was observed in his room. The resident's yankauer (a ridged oral suctioning tool) was observed on the resident's bedside table, exposed to the elements. The hose was observed to have some dust and crusted matter on it from being on the floor earlier in the day. The resident spoke Spanish. The DON stated the equipment should be maintained in a sanitary manner. She stated anything that goes into a resident should be bagged and dated. She stated she had noted there was need for training related to trach care. A follow-up interview was conducted on [DATE] at 5:03 p.m. with the DON. She stated the nurse told her Resident #14's trach was cleaned and changed by the Staff F, RN/UM at approximately 4:45 p.m. The DON stated there was no documentation that the resident had received trach care. The DON stated if it was not documented it did not happen. An interview was conducted on [DATE] at 5:18 p.m. with Staff E, RN, who was the 7:00 a.m. to 3:00 p.m. Unit Manager (UM) on the 300/400 hall. She stated she went to Resident #16's room with Staff D, LPN about an hour earlier. She stated they replaced the hose and the suction catheter. She said, Sometime after 4 p.m. [Staff D] came to me. She was looking for the right hose, suction catheter, and connecting hose. She was not sure what size he needed. She asked me for help. I went in, made sure we changed the hose, told the resident to make sure he is not setting it on the table, and told him to keep it clean. Staff E said she wasn't sure what staff were doing previously for him to keep the suction catheter clean, but they are now giving him the bag the suction catheter comes in and encouraging him to place it in the bag when he isn't using it. An observation was conducted on [DATE] at 5:22 p.m. of Resident #14 with mucous coming out of her trach site. The resident had her call light on and was observed pointing to her trach site. The nurse and the CNA assigned to this hall could not immediately be found. The surveyor notified the NHA Resident #14 had a call light on, and she was pointing to her trach site. On [DATE] at 5.24 p.m. the DON confirmed there was no documentation in Resident #14's medical record to show she was suctioned at 4:45 p.m. The DON was notified of the observation of Resident #14's trach site at 5:22 p.m. She had the nurse and the unit manager go suction the resident at that time and said she would make sure they documented. An interview was conducted on [DATE] at 2:38 p.m. with Staff F, RN/UM, Staff C, RN and Staff G, LPN. Staff F said there were concerns about getting sterile gloves, need for the trach suctioning procedure, for both himself, Staff C, and three other male nurses. He said they did not have access to XL (extra large) sterile gloves. Staff C said he did not provide trach care with the inner cannula of the trach because he didn't have gloves. He said he will get another nurse to do the care that fits in the sterile gloves. He said he documented the care because he is in the room when it is done. Staff C said on [DATE] he worked from 7:00 a.m. to around 2: 45 p.m. He said he did not provide trach care to Resident #14. He said he had a problem with supplies and couldn't find stuff. He said he is new here and sometimes provides his own supplies. Staff F, RN/UM stated the expectations is for the facility to provide the supplies needed to care for residents. He said to ensure the product was sanitary, staff needed to use only facility provided supplies. Staff C, RN said, You need the sterile gloves when you do the deep suctioning. We don't have them. I have never received sterile gloves from the facility. It makes it hard to do my job. Staff F said on [DATE] around 2:25 p.m. he suctioned and cleaned Resident #14. He said she was not junky and didn't cough anything out. He confirmed he did not document anything related to this care stating, It is not documented it did not happen. Staff F said prior to this time, he was not aware Resident #14 needed trach care or suctioning. Staff G said she was assigned to Resident #14 on [DATE]. Staff G said Staff F suctioned Resident #14 before he left and a couple hours later the resident kept pointing to her trach site. Staff G said she suctioned her and applied new gauze. She said Resident #14 is always asking to be suctioned because she felt like something was stuck in her throat. Staff G, LPN and Staff C, RN both said they attended a class with the RT the previous week and Staff F, RN/UM said he attended two weeks ago. They said the RT went over the specific cannula sizes for each resident and where the emergency replacements are located. They said other than that, the RT did general trach teaching and did not give specifics that pertain to the residents at the facility. All three staff members said they were not sure about the RT's documentation and had never seen any notes or documentation from respiratory about the trach residents. Staff F, RN/UM reviewed the missing documentation from the residents with trachs and said it looks like it was not done. He said if care was completed, it should be documented. If it is not documented, it did not happen. Staff F said, I don't know if anyone audits documentation. I am not aware of who is in charge of reviewing files for completeness or accuracy. An interview was conducted on [DATE] at 9:11 a.m. with Staff F, RN/UM. He stated he had been notified by the nurse Resident #16's trach equipment was not working. He stated that was why he came in the room with the canister. He said he needed to figure out what happened. Staff F said the nurse assigned to the resident had not worked with trach patients before and was still learning. Staff F was observed trying to communicate with Resident #16 but there was a language barrier. When asked if there was an interpreter, Staff F, RN/UM stated the Business Office Manager (BOM) could interpret. The BOM came to the room and the resident stated he could not eliminate the phlegm in his throat. Staff F stated he had just figured out the equipment was turned off and he did not know how long it had been off. He stated if the machine was off the resident could not suction himself. Staff F then exited the room. During the continued interview the resident stated through an interpreter there was a nurse that does not respond to him when he calls. He stated the 3:00 p.m.-11:00 p.m. nurse (Staff D, LPN) does not care for him and does not understand him. The resident said, through an interpreter, When I ask her for help, she gives me an attitude. She does not want to help me. Resident #16 reported he was currently having shortness of breath and was observed trying to clear his throat. He said to the interpreter, I am not okay. The interpreter left the room to get a nurse. At 9:23 a.m. Staff F, RN/UM responded with a pulse oximeter to check the resident's oxygen saturation. The resident's oxygen saturation was 96% and 98% upon recheck. The resident stated, through an interpreter, he was having anxiety and he needed to be repositioned to clear his air way. A follow-up interview was conducted on [DATE] at 1:05 p.m. with Staff F, RN/UM. He said if Resident #16 is trying to disrupt equipment and his own care, it should be care planned. He said that morning, [DATE], when he went to the resident's room there was a bag over the motor part of the suction machine and the resident could not remove it from where he was sitting due to it being behind him. He said the resident could not see the switch to turn it on/off. He said Resident #16 shuts the suction machine off, but it can shut off if the canister is full. He said the nurses should know that. Staff F said Resident #16 is not care planned for that behavior and if he had behaviors, it should be in the care plan. An interview was conducted on [DATE] at 9:35 a.m. with Staff G, LPN. She stated she had last seen Resident #16 shortly before[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the nursing staff was competent to provide appropriate tracheostomy care, respond to resident's request for tracheostomy suctioning, and document tracheostomy care for four residents (#14, #15, #16, and #19) out of five residents reviewed for tracheostomy care. On 3/22/24 a grievance was filed by Resident #16's family related to tracheostomy care and suctioning. On 3/24/24 Resident #15 requested his tracheostomy to be suctioned. The CNA notified the nurse. By the time the nurse got to the room, Resident #15 was unresponsive. A code was called, CPR initiated with no evidence the airway was cleared prior to providing breathes, the resident was transported to the hospital where he expired. Two residents (#14 and #16) were observed in the facility needing tracheostomy suctioning whom staff had not responded to their requests. There was inaccurate and incomplete documentation related to tracheostomy care. Staff expressed lack of confidence and access to supplies during the survey related to care and services to residents with tracheostomies. A tracheostomy (also called a tracheotomy/trach) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/tracheostomy accessed on 4/1/24. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #14, #15, #16, #19 and resulted in the determination of Immediate Jeopardy starting on 3/22/24. The findings of Immediate Jeopardy were determined to be removed on 3/29/24 and the severity and scope was reduced to an E. Findings included: Review of a progress note written by Staff B, Licensed Practical Nurse (LPN), dated 3/24/24 at 11:44 p.m., showed, Around 11:30pm this writer was attending to another resident when a CNA informed me that [Resident #15] wants to be suctioned. This writer then proceeds to [Resident #15's room] and observed resident to be non-responsive after calling out his name and gentle chest rub on the chest. No pulse, no respiration, pale looking, warm to touch, O2 [oxygen] sat [saturation] reading 76%, full code status, code blue paged, CPR initiated while another nurse called 911. EMS [Emergency Medical Services] arrived in the facility around 11:38 pm and took over. Resident was taken to [Hospital] around 12:05am. MD [Medical Doctor], [name of family member], and DON [Director of Nursing] notified. Review of the admission Record showed Resident #15 was admitted on [DATE] with diagnoses to include lack of coordination, chronic respiratory failure, tracheostomy, gastrostomy, dysphagia, major depressive disorder, ventricular premature depolarization, and myasthenia gravis with acute exacerbation. Review of Resident #15's admission Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed he had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Section O - Special Treatments, Procedures, and Programs showed he needed continuous oxygen, suctioning, and tracheostomy care. A review of Resident #15's physician orders showed the following: -Maintain suction set up at bedside. Date 3/12/24. -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date 3/12/24. -Change suction canister every 72 hours and/or when ¾ full. Date 3/12/24. -Change small tubing between canister and suction machine monthly. Starting on the 15th. Date 3/12/24. -Full Resuscitation. Date 3/12/24. -Humidified Oxygen per trach continuous 4 Liters (L) 28%. Date 3/12/24. -Maintain ambu bag at bedside and replacement trach of equal size and one size down maintained at bedside. Date 3/12/24. -Tracheostomy type: Shiley size 6. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Every shift. Date 3/12/24. Review of Resident #15's March 2024 Treatment Administration Record (TAR) showed no documentation that the resident was suctioned on 3/17/24 evening shift and 3/20/24 day shift. It showed there was no documentation that the ambu bag and replacement trach was at the bedside or suction was set up at the bedside on 3/17/24 evening shift and 3/20/24 day shift. Review of Resident #15's Respiratory Notes, dated 3/20/24, showed the resident was tolerating a speaking valve on his trach and was in no respiratory distress. It showed the resident had yellow drainage and nursing was made aware. The Respiratory Note, dated 3/22/24, showed the resident was alert. He had a moderate amount of thick white/pale yellow secretions. Trach care was done with inner cannula and tie changed. An interview was conducted on 3/27/24 at 9:44 a.m. with Staff A, CNA. She said she took care of Resident #15 starting at 11:00 p.m. on 3/24/24. She said right around change of shift she was walking down the hall checking on each resident like she did every shift change. Staff A said she saw Resident #15 had his light on, so she went to check on him. She said the resident told her he needed his trach suctioned. She said he didn't seem distressed. She said she did notice his feet looked different, they were uncovered and were very pale. She told the resident it was the middle of shift change but she would let the nurse know and the resident told her thank you. Staff A said when she left Resident #15's room the nurse, Staff B, Licensed Practical Nurse (LPN) was in the hall. She said Staff B was checking her resident rooms since the shift just started. Staff A, CNA told Staff B, LPN the resident needed to be suctioned and Staff B went to the room and came right back out. Staff A said Staff B went to the nurses' station and Staff A assumed the nurse was getting supplies. Staff A said it was about 10 minutes later when Staff B, LPN went back to Resident #15's room and found him unresponsive, and a code blue was called. An interview was conducted on 3/27/24 at 3:46 p.m. with Staff B, LPN. She said she worked from 11:00 p.m. on 3/24/24 to 7:00 a.m. on 3/25/24 and was assigned to care for Resident #15. She said she got report from the nurse who was leaving then did her rounds. Staff B said she went to check on another resident and was suctioning that resident when Staff A, CNA came and told her Resident #15 needed suctioning. She said she finished up with the other resident and went to Resident #15's room. She said it was only 1-2 minutes. She said she went to Resident #15's room around 11:30 p.m. Staff B said when she got to his room, called his name, and rubbed his chest when he didn't respond. She said Resident #15 was not breathing and she yelled for another nurse to call a code blue. Staff B said she took out the inner cannula of his trach and everyone else arrived and they attached the bag to his trach. She said the resident was not suctioned prior to or during CPR. Staff B said she had cared for Resident #15 previously and was familiar with him. She said when he asked to be suctioned, she would go do it. She said he would let staff know if he needed suctioning. Staff B said sometimes he would want to be suctioned before he went to bed around midnight and sometimes he didn't get suctioned at all during her 11:00 p.m. to 7:00 a.m. shift. She said when she suctioned him on previous shifts he was mucousy and wanted to clear his throat. She said sometimes his secretions were a little thick. Staff B said Resident #15 couldn't really cough. A follow-up interview was conducted on 3/27/24 at 4:56 p.m. with Staff A, CNA. She confirmed when she checked on Resident #15 and came out of his room and Staff B, LPN was in the hall walking behind me going to rooms and stuff. She said Staff B was not in another resident room. She said Staff B walked in the room, talked to the resident for a minute then came back out and went to nurses' station. Staff A said she continued to check on her residents, finishing her last rooms. She said she then came out and started fixing ice water cups for residents that may want them. Staff A said she had fixed a few cups when Staff B went into Resident #15's room, and the code was called. She said it was about 10 minutes after she told the nurse the resident needed suctioning. An interview was conducted on 3/27/24 at 10:56 a.m. with the facility's Respiratory Therapist (RT). She said she comes to the facility once a month to do full trach changes on the residents with tracheostomies. She said each trach resident had a supply bag at their bedside for emergencies that contained a suction catheter, inner cannula, lubricant, trach cleaning kit and trach ties. The RT said if a resident asked to be suctioned, they should be suctioned right then. She said no resident wants to be suctioned, it is not comfortable, so if they are asking for it, they need it. She said the suctioning should be done right when the resident asks. The RT said Resident #15 had been doing really good. She said when she came in, the resident always needed a deep suctioning, and he needed continuous oxygen. She said he needed to be checked because even when his oxygen saturation was in the 80's he did not report shortness of breath. She said he did not have a good cough and couldn't get anything up, even part of the way. She said for him it would not have been okay to wait 10 minutes if he said he needed suctioning. The RT said if Resident #15 was not suctioned quickly, it would cause distress for him. She said she practiced coughing with him, and he just did not have a good cough. She said the resident had thick secretions. The RT said if he asked for suctioning and it took 10 minutes for someone to do it, it could have caused respiratory arrest. The RT said in her training with the nurses she taught them if the inner cannula is not open that is the easiest way to code a patient. On 3/26/24 at 4:03 p.m. an interview was conducted with the Director of Nursing (DON) regarding Resident #15. The DON stated Resident #15 was a trach patient. She stated she was notified the resident had notified a CNA he needed to be suctioned and by the time the nurse got to him, he had coded. The DON stated she was shocked. She said, I had seen him earlier. He was just fine. The only question I had in my mind was how long he had been waiting to be suctioned and how soon did our staff respond. She stated she had not had a chance to review the record or interview the CNA and nurse on their timeline. She stated it was something in the back of her mind. She said, It is hard to tell what really happened. An interview was conducted on 3/27/24 at 2:38 p.m. with Staff C, Registered Nurse (RN). He said he knew Resident #15 and was surprised when he heard he passed away. Staff C stated Resident #15 was pleasant and sometimes asked to be suctioned or have his trach inner cannula changed. Staff C said Resident #15 was not the type that asked all the time. So, if he asked for suctioning, then he really needed it. A John Hopkins Medical article titled, Living with a Tracheostomy Tube and Soma, accessed on 4/1/24, showed, The upper airway warms, cleans, and moistens the air we breathe. The trach tube bypasses these mechanisms so that the air moving through the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. Suctioning clears mucus from the tracheostomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop. Avoid suctioning too frequently as this could lead to more secretion buildup. The article also informed readers that suctioning a tracheostomy is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/living-with-a-tracheostomy-tube-and-stoma#:~:text=Suctioning%20clears%20mucus%20from%20the,lead%20to%20more%20secretion%20buildup. A review of the admission Record showed Resident #19 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include cerebral palsy, other specified diseases of the jaw, chronic obstructive pulmonary disease (COPD), epilepsy, dementia, respiratory failure, tracheostomy, and gastrostomy. Review of Resident #19's physician orders showed the following: -Change small tubing between canister and suction machine monthly starting on the 15th. Date 1/31/24. -Tracheostomy Type: Shiley Size 4. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Date: 1/31/24. -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date 1/31/24. -Maintain suction set up at bedside, every shift and as needed. Date 1/31/24. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date 1/31/24. -Change trach collar, mask, and oxygen weekly as well as PRN. Every Sunday for preventative. Date 1/31/24. -Humidified oxygen per trach continuously 28 L every shift for Shortness of Breath. Date 1/31/24. Review of Resident #19's March 2024 TAR showed no documentation for trach care on 3/5, 3/6, and 3/7/24. It showed no documentation for continuous humidified oxygen at 28 L or trach suctioning on 3/2/24 evening shift, 3/5/24 day shift, 3/6/24 day and evening shift, 3/7/24 day and evening shift, 3/12/24 night shift, and 3/21/24 evening shift. Review of Resident #19's March 2024 Medication Administration Record (MAR) showed the resident was taking the antibiotic, Ciprofloxacin 500 milligram (mg) for a trach site infection from 3/20/24 to 3/26/24. Review of Resident #19's Change in Condition Evaluation, dated 1/24/24, showed the resident was observed bleeding from his mouth and trach. He was transferred to a higher level of care. Review of Resident #19's Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form (3008), dated 1/28/24, showed the resident's primary diagnosis was tracheostomy issue. Review of Resident #19's Respiratory Notes, dated 2/9/24, showed the resident was slightly tachypneic (rapid shallow breathing) with oxygen saturation at 88% on room air. Resident was placed on oxygen via trach mask at 2 L with oxygen saturation increasing to 95%. The Respiratory Therapist's recommendations were monitor symptoms (tachypnea and low sats [oxygen saturation.] A Respiratory Note, dated 3/15/24, showed his breath sounds were course with mild expiratory wheeze, sputum sample obtained related to a moderate amount of yellowish green sputum with a foul odor. Review of Resident #19's Weights and Vitals showed the resident's oxygen saturation was not documented on 2/10, 2/11, 2/12/24 and only once on 2/13/24 at 2:03 p.m. During the interview with the RT on 3/27/24 at 10:56 a.m. the RT said Resident #19 was currently on antibiotics due to a trach site infection. She said the resident had pneumonia, but she felt like it started as a trach site infection then progressed to his lungs. When asked how the staff were with the resident's trach care she said she was not in the facility on a consistent basis, but sometimes when she came It may not be like I would like it. The RT said, I am not sure how good they do. With the newer staff I am not sure how comfortable with trach stuff they are. Review of the facility's Grievance Log for March of 2024 revealed a grievance filed on 3/22/24 by the family of Resident #16. They wrote that on many occasions the resident's equipment and trach were not working and his tracheostomy tube was clogged on 3/20/24 when they came to visit. The family wrote the evening nurse got an attitude when they mentioned the tracheostomy tube being clogged. It was assigned on 3/22/24 showing the action to resolve the grievance was Nursing will educate staff. During a facility tour on 3/26/24 at 9:49 a.m., an observation was made of Resident #16 in bed, he summoned this surveyor pointing to his suction equipment. The suctioning hose and mask were observed on the floor. The resident's suctioning piece was in his hand. The resident only spoke Spanish. He pointed to the cup on his bedside table. He nodded yes to needing water. This surveyor exited the room and could not locate the CNA assigned to this hall. When the nurse had finished administering meds in the room adjacent to Resident #16, surveyor notified the nurse (Staff G, LPN) that Resident #16 needed water. The nurse said, Hang on. I'll get with him. After approximately 5 minutes, she entered the room to respond to the resident. Review of the admission Record showed Resident #16 was admitted on [DATE] with diagnoses to include respiratory failure, unspecified with hypoxia, shortness of breath, Parkinson's disease without dyskinesia, without mention of fluctuations, tracheostomy status, gastrostomy status, personal history of pneumonia (Recurrent), iron deficiency anemia, unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, essential (Primary) hypertension, hyperglycemia, unspecified, elevated white blood cell count, Unspecified, and paralysis of vocal cords and larynx, unspecified. Review of Resident #16's MDS admission assessment, dated 3/18/2024, revealed a BIMS in Section C - Cognitive Patterns: he was not assessed related to his diagnosis of paralysis of vocal cords and larynx. Review of Resident #16's physician orders showed the following: -Tracheostomy Type: Cuffless Size: 6XL Tracheostomy change or replace as needed if displaced or dislodged. every 24 hours as needed. Date 3/27/24. -Tracheostomy Type: Cuffless Size: 6XL Trach care daily and as needed. Cleanse tracheostomy site with normal saline, pat dry. Change inner cannula. Cover with drain sponge daily and as needed. every day shift AND as needed. Date 3/27/24. -Maintain suction set up at bedside, every shift and as needed. Date 3/16/24. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date 3/16/24. Resident #16 did not have any tracheostomy cleaning or change orders prior to the start of the survey on 3/26/2024. Review of Resident #16's March 2024 TAR revealed missing documentation showing suction was set up at the bedside and an ambu bag and replacement trach was at the bedside on 3/18, 3/21, 3/25, and 3/26/24. During a tour of hall 200 on 3/26/24 at 9:54 a.m., an observation was made of Resident #14. The resident was non-verbal and pointed to her trach site. The resident was asked if she needed to be suctioned. She nodded her head up and down indicating, yes. A nurse or CNA could not be located in the hall, the NHA was notified the resident needed care. The NHA went to the resident's room and notified Resident #14 that she would let the nurse know. An observation was conducted on 3/26/24 at 12:45 p.m. Two call lights were observed on. Staff C, RN was observed sitting at the nurses' station on the phone. Staff C was asked what the beeping noise was, and he stated it was because a resident had turned on a call light. Staff H, CNA was observed responding to the call light in Resident #14's room. Staff H stepped out of the room and stated Resident #14 needed something to do with her trach and she was letting the nurse know. Staff C, RN overheard the CNA speaking to surveyor. He said to the surveyor, I'm on break, am I not entitled to my break? The nurse was observed remaining seated at the nurse's desk. A tour with the DON was conducted on 3/26/24 at 3:46 p.m. of Resident #14's room. The resident was again observed pointing to her trach site. The DON asked the resident if she needed to be suctioned. The resident nodded yes. The DON notified Staff G, LPN. An observation was made with the DON on 3/26/24 at 3:54 p.m. Resident #16 was observed in his room. The resident's Yankauer (a ridged oral suctioning tool) was observed on the resident's bedside table, exposed to the elements. The hose was observed to have some dust and crusted matter on it from being on the floor earlier in the day. The resident spoke Spanish. The DON stated the equipment should be maintained in a sanitary manner. She stated anything that goes into a resident should be bagged and dated. She stated she had noted there was need for training related to trach care. A follow-up interview was conducted on 3/26/24 at 5:03 p.m. with the DON. She stated the nurse told her Resident #14's trach was cleaned and changed by the Staff F, RN/UM at approximately 4:45 p.m. The DON stated there was no documentation that the resident had received trach care. The DON stated if it was not documented it did not happen. An interview was conducted on 3/26/24 at 5:18 p.m. with Staff E, RN, who was the 7:00 a.m. to 3:00 p.m. Unit Manager (UM) on the 300/400 hall. She stated she went to Resident #16's room with Staff D, LPN about an hour earlier. She stated they replaced the hose and the suction catheter. She said, Sometime after 4 p.m. [Staff D] came to me. She was looking for the right hose, suction catheter, and connecting hose. She was not sure what size he needed. She asked me for help. I went in, made sure we changed the hose, told the resident to make sure he is not setting it on the table, and told him to keep it clean. Staff E said she wasn't sure what staff were doing previously for him to keep the suction catheter clean, but they are now giving him the bag the suction catheter comes in and encouraging him to place it in the bag when he isn't using it. An observation was conducted on 3/26/24 at 5:22 p.m. of Resident #14 with mucous coming out of her trach site. The resident had her call light on and was observed pointing to her trach site. The nurse and the CNA assigned to this hall could not immediately be found. The surveyor notified the NHA Resident #14 had a call light on, and she was pointing to her trach site. On 3/26/24 at 5.24 p.m. the DON confirmed there was no documentation in Resident #14's medical record to show she was suctioned at 4:45 p.m. The DON was notified of the observation of Resident #14's trach site at 5:22 p.m. She had the nurse and the unit manager suction the resident at that time and said she would make sure they documented. An interview was conducted on 3/27/24 at 2:38 p.m. with Staff F, RN/UM, Staff C, RN and Staff G, LPN. Staff F said there were concerns about getting sterile gloves, need for the trach suctioning procedure, for both himself, Staff C, and three other male nurses. He said they did not have access to XL (extra-large) sterile gloves. Staff C said he did not provide trach care with the inner cannula of the trach because he didn't have gloves. He said he will get another nurse to do the care that fits in the sterile gloves. He said he documented the care because he is in the room when it is done. Staff C said on 3/26/24 he worked from 7:00 a.m. to around 2: 45 p.m. He said he did not provide trach care to Resident #14. He said he had a problem with supplies and couldn't find stuff. He said he is new here and sometimes provides his own supplies. Staff F, RN/UM stated the expectations is for the facility to provide the supplies needed to care for residents. He said to ensure the product was sanitary, staff needed to use only facility provided supplies. Staff C, RN said, You need the sterile gloves when you do the deep suctioning. We don't have them. I have never received sterile gloves from the facility. It makes it hard to do my job. Staff F said on 3/26/24 around 2:25 p.m. he suctioned and cleaned Resident #14. He said she was not junky and didn't cough anything out. He confirmed he did not document anything related to this care stating, It is not documented it did not happen. Staff F said prior to this time, he was not aware Resident #14 needed trach care or suctioning. Staff G said she was assigned to Resident #14 on 3/26/24. Staff G said Staff F suctioned Resident #14 before he left and a couple hours later the resident kept pointing to her trach site. Staff G said she suctioned her and applied new gauze. She said Resident #14 is always asking to be suctioned because she felt like something was stuck in her throat. Staff G, LPN and Staff C, RN both said they attended a class with the RT the previous week and Staff F, RN/UM said he attended two weeks ago. They said the RT went over the specific cannula sizes for each resident and where the emergency replacements are located. They said other than that, the RT did general trach teaching and did not give specifics that pertain to the residents at the facility. All three staff members said they were not sure about the RT's documentation and had never seen any notes or documentation from respiratory about the trach residents. Staff F, RN/UM reviewed the missing documentation from the residents with trachs and said it looks like it was not done. He said if care was completed, it should be documented. If it is not documented, it did not happen. Staff F said, I don't know if anyone audits documentation. I am not aware of who is in charge of reviewing files for completeness or accuracy. An interview was conducted on 3/27/24 at 9:11 a.m. with Staff F, RN/UM. He stated he had been notified by the nurse Resident #16's trach equipment was not working. He stated that was why he came in the room with the canister. He said he needed to figure out what happened. Staff F said the nurse assigned to the resident had not worked with trach patients before and was still learning. Staff F was observed trying to communicate with Resident #16 but there was a language barrier. When asked, Staff F, RN/UM said the Business Office Manager (BOM) could interpret. The BOM came to the room and the resident stated he could not eliminate the phlegm in his throat. Staff F stated he had just figured out the equipment was turned off and he did not know how long it had been off. He stated if the machine was off the resident could not suction himself. Staff F then exited the room. During the continued interview the resident stated through an interpreter there was a nurse that does not respond to him when he calls. He stated the 3:00 p.m.-11:00 p.m. nurse (Staff D, LPN) does not care for him and does not understand him. The resident said, through an interpreter, When I ask her for help, she gives me an attitude. She does not want to help me. Resident #16 reported he was currently having shortness of breath and was observed trying to clear his throat. He said to the interpreter, I am not okay. The interpreter left the room to get a nurse. At 9:23 a.m. Staff F, RN/UM responded with a pulse oximeter to check the resident's oxygen saturation. The resident's oxygen saturation was 96% and 98% upon recheck. The resident stated, through an interpreter, he was having anxiety and he needed to be repositioned to clear his air way. A follow-up interview was conducted on 3/27/24 at 1:05 p.m. with Staff F, RN/UM. He said if Resident #16 is trying to disrupt equipment and his own care, it should be care planned. He said that morning, 3/27/24, when he went to the resident's room there was a bag over the motor part of the suction machine and the resident could not remove it from where he was sitting due to it being behind him. He said the resident could not see the switch to turn it on/off. He said Resident #16 shuts the suction machine off, but it can shut off if the canister is full. He said the nurses should know that. Staff F said Resident #16 is not care planned for that behavior and if he had behaviors, it should be in the care plan. An interview was conducted on 3/27/24 at 9:35 a.m. with Staff G, LPN. She stated she had last seen Resident #16 shortly before 8:00 a.m., during medication administration. She stated she had cleaned his equipment and covered it after she was done. She said, I did not check if it was working. I did not notice anything. He did not say anything at that time. He was not using it at the time. An interview was conducted on 3/27/24 at 11:21 a.m. with the RT. She stated Resident #14 should not have waited all day on 3/26/24 to receive the care she needed. The RT confirmed Resident #14 can clearly articulate her needs by yes/no by nodding. She said if the resident said she needed suctioning it should have been done and there was no excuse for it not to be. The RT said Resident #14 was assigned to the male nurse, Staff C, RN, who did not have access to sterile gloves. She said he is not able to provide the care he needs because he needs sterile gloves that fit him, and the facility doesn't have any. The RT said she notified the previous administration and just notified the current administration. She said the trach care kits only come with very small sterile gloves that do not fit larger hands. The RT said she did not know what the facility's plan was. An interview was conducted using an interpreter on 3/28/24 1:48 p.m. with Resident #16's family member regarding care. He stated the resident had the trach for one month, so it was new to the family. The first day he arrived at the facility, a food tray was delivered to him, and a staff was started to feed the resident, when he was not supposed to eat anything by mouth. The following day the family found Resident #16 soiled with urine on the bed. The family member said on another day the trach machine did not have liquid and they noticed the suction machine was not working. The resident told his family that a male nurse turned the suction machine off around 9:00 p.m. saying if he kept it on, it would catch fire. He said on four different occasions the family had concerns with Resident #16's trach, he and another family member spoke to the nurse. He said they told her the resident wanted the trach cap to be removed because it smelled bad. He said the other family member told Staff D, LPN the cap was stuck, and it was smelling. He said Staff D told them everything was fine and ignored their concerns. The family member said Resident #16 was readmitted to the hospital on [DATE] for an unrelated issue but the doctor told them the resident was having problems breathing because he was not being suctioned at the facility. He confirmed he filed a grievance on 3/22/24 and complained about the resident having trouble breathing because the trach tube was clogged. He said one of the nurses told the family he could not suction the resident because he didn't have gloves. An interview was conducted on 03/28/24 at 5.20 p.m. with the second family member of Resident #16. She said three days ago, on a Tuesday, she asked Staff D, LPN how often they clean the resident's trach site and change the dressing because in the hospital it was done daily. She said Staff D told her, I don't know about that, that is a question for the respiratory person. She said she would ask the nurses when the resident had been cleaned because he smelled, and they couldn't ever tell her. The family member said she never saw staff clean the trach site. She said the past couple of days the resident tried to remove the trach cap so he can speak, but it had accumulated phlegm and wouldn't come off. She said the resident complained to the family about the one female staff member being mean and the nurses dismissing their concerns. The family member said Resident #16 was in the hospital and she called and spoke the respiratory therapist in the hospital. She said the therapist told her they had checked and cleaned the resident's trach site and it was dirty. She said at [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident related to residents with a tracheostomy not being cared for in a safe and sanitary manner for four residents (#14, #15, #16, and #19) out of five residents sampled. On [DATE] a grievance was filed by Resident #16's family related to tracheostomy care and suctioning. The grievance process was not followed through by the facility to a resolution for the resident. On [DATE] Resident #15 requested for his tracheostomy to be suctioned. The CNA notified the nurse. By the time the nurse got to the room, Resident #15 was unresponsive. A code was called, CPR initiated with no evidence airway was cleared prior to providing breathes, resident was transported to hospital where he expired. During the survey, two residents (314 and #16) were observed in the facility needing tracheostomy suctioning whom staff had not responded to their requests. There was inaccurate and incomplete documentation related to tracheostomy care. Staff expressed lack of confidence and access to supplies during the survey related to care and services to residents with tracheostomies. A tracheostomy (also called a tracheotomy/trach) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube) rather than through the nose and mouth. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/tracheostomy accessed on [DATE]. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #14, #15, #16, and #19 and resulted in the determination of Immediate Jeopardy starting on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity was reduced to an E. Cross reference to F695 and F726. Please see F695 and F726 for additional infomation related to Residents #14, #15, #16, and #19. Findings included: Review of a progress note written by Staff B, Licensed Practical Nurse (LPN), dated [DATE] at 11:44 p.m., showed, Around 11:30pm this writer was attending to another resident when a CNA informed me that [Resident #15] wants to be suctioned. This writer then proceeds to [Resident #15's room] and observed resident to be non-responsive after calling out his name and gentle chest rub on the chest. No pulse, no respiration, pale looking, warm to touch, O2 [oxygen] sat [saturation] reading 76%, full code status, code blue paged, CPR initiated while another nurse called 911. EMS [Emergency Medical Services] arrived in the facility around 11:38 pm and took over. Resident was taken to [Hospital] around 12:05am. MD [Medical Doctor], [name of family member], and DON [Director of Nursing] notified. Review of the admission Record showed Resident #15 was admitted on [DATE] with diagnoses to include lack of coordination, chronic respiratory failure, tracheostomy, gastrostomy, dysphagia, major depressive disorder, ventricular premature depolarization, and myasthenia gravis with acute exacerbation. Review of Resident #15's admission Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed he had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Section O - Special Treatments, Procedures, and Programs showed he needed continuous oxygen, suctioning, and tracheostomy care. A review of Resident #15's physician orders showed the following: -Maintain suction set up at bedside. Date [DATE]. -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date [DATE]. -Change suction canister every 72 hours and/or when ¾ full. Date [DATE]. -Change small tubing between canister and suction machine monthly. Starting on the 15th. Date [DATE]. -Full Resuscitation. Date [DATE]. -Humidified Oxygen per trach continuous 4 Liters (L) 28%. Date [DATE]. -Maintain ambu bag at bedside and replacement trach of equal size and one size down maintained at bedside. Date [DATE]. -Tracheostomy type: Shiley size 6. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Every shift. Date [DATE]. Review of Resident #15's [DATE] Treatment Administration Record (TAR) showed no documentation that the resident was suctioned on [DATE] evening shift and [DATE] day shift. It showed there was no documentation that the ambu bag and replacement trach was at the bedside or suction was set up at the bedside on [DATE] evening shift and [DATE] day shift. Review of Resident #15's hospital History and Physical, showed he had his tracheostomy procedure on [DATE] and he was decannulated (trach was removed) on [DATE]. The resident's chief complaint was respiratory failure and he had to have a repeat tracheostomy on [DATE]. Review of Resident #15's Respiratory Notes, dated [DATE], showed the resident was tolerating a speaking valve on his trach and was in no respiratory distress. It showed the resident had yellow drainage and nursing was made aware. The Respiratory Note, dated [DATE], showed the resident was alert and pleasant, sitting in his wheelchair. He had no signs or symptoms and denied any distress. He had a moderate amount of thick white/pale yellow secretions. Trach care was done with inner cannula and tie changed. An interview was conducted on [DATE] at 9:44 a.m. with Staff A, CNA. She said she took care of Resident #15 starting at 11:00 p.m. on [DATE]. She said right around change of shift she was walking down the hall checking on each resident like she did every shift change. Staff A said she saw Resident #15 had his light on, so she went to check on him. She said the resident told her he needed his trach suctioned. She said he didn't seem distressed. She said she did notice his feet looked different, they were uncovered and were very pale. She told the resident it was the middle of shift change but she would let the nurse know and the resident told her thank you. Staff A said when she left Resident #15's room the nurse, Staff B, Licensed Practical Nurse (LPN) was in the hall. She said Staff B was checking her resident rooms also since the shift just started. Staff A, CNA told Staff B, LPN the resident needed to be suctioned and Staff B went to the room and came right back out. Staff A said Staff B went to the nurses' station and Staff A assumed the nurse was getting supplies. Staff A said it was about 10 minutes later when Staff B, LPN went back to Resident #15's room and found him unresponsive, and a code blue was called. An interview was conducted on [DATE] at 3:46 p.m. with Staff B, LPN. She said she worked from 11:00 p.m. on [DATE] to 7:00 a.m. on [DATE] and was assigned to care for Resident #15. She said she got report from the nurse who was leaving then did her rounds. Staff B said she went to check on another resident and was suctioning that resident when Staff A, CNA came and told her Resident #15 needed suctioning. She said she finished up with the other resident and went to Resident #15's room. She said it was only 1-2 minutes. She said she went to Resident #15's room around 11:30 p.m. Staff B said when she got to his room, called his name, and rubbed his chest when he didn't respond. She said Resident #15 was not breathing and she yelled for another nurse to call a code blue. Staff B said she took out the inner cannula of his trach and everyone else arrived and they attached the bag to his trach. She said the resident was not suctioned prior to or during CPR. Staff B said she had cared for Resident #15 previously and was familiar with him. She said when he asked to be suctioned, she would go do it. She said he would let staff know if he needed suctioning. Staff B said sometimes he would want to be suctioned before he went to bed around midnight and sometimes he didn't get suctioned at all during her 11:00 p.m. to 7:00 a.m. shift. She said when she suctioned him on previous shifts he was mucousy and wanted to clear his throat. She said sometimes his secretions were a little thick. Staff B said Resident #15 couldn't really cough. A follow-up interview was conducted on [DATE] at 4:56 p.m. with Staff A, CNA. She confirmed when she checked on Resident #15 and came out of his room and Staff B, LPN was in the hall walking behind me going to rooms and stuff. She said Staff B was not in another resident room. She said Staff B walked in the room, talked to the resident for a minute then came back out and went to nurses' station. Staff A said she continued to check on her residents, finishing her last rooms. She said she then came out and started fixing ice water cups for residents that may want them. Staff A said she had fixed a few cups when Staff B went into Resident #15's room, and the code was called. She said it was about 10 minutes after she told the nurse the resident needed suctioning. An interview was conducted on [DATE] at 10:56 a.m. with the facility's Respiratory Therapist (RT). She said she comes to the facility once a month to do full trach changes on the residents with tracheostomies. She said each trach resident had a supply bag at their bedside for emergencies that contained a suction catheter, inner cannula, lubricant, trach cleaning kit and trach ties. The RT said if a resident asked to be suctioned, they should be suctioned right then. She said no resident wants to be suctioned, it is not comfortable, so if they are asking for it, they need it. She said the suctioning should be done right when the resident asks. The RT said Resident #15 had been doing really good. She said when she came in, the resident always needed a deep suctioning, and he needed continuous oxygen. She said he needed to be checked because even when his oxygen saturation was in the 80's he did not report shortness of breath. She said he did not have a good cough and couldn't get anything up, even part of the way. She said for him it would not have been okay to wait 10 minutes if he said he needed suctioning. The RT said if Resident #15 was not suctioned quickly, it would cause distress for him. She said she practiced coughing with him, and he just did not have a good cough. She said the resident had thick secretions. The RT said if he asked for suctioning and it took 10 minutes for someone to do it, it could have caused respiratory arrest. The RT said in her training with the nurses she taught them if the inner cannula is not open that is the easiest way to code a patient. On [DATE] at 4:03 p.m. an interview was conducted with the Director of Nursing (DON) regarding Resident #15. The DON stated Resident #15 was a trach patient. She stated she was notified the resident had notified a CNA he needed to be suctioned and by the time the nurse got to him, he had coded. The DON stated she was shocked. She said, I had seen him earlier. He was just fine. The only question I had in my mind was how long he had been waiting to be suctioned and how soon did our staff respond. She stated she had not had a chance to review the record or interview the CNA and nurse on their timeline. She stated it was something in the back of her mind. She said, It is hard to tell what really happened. A follow-up interview was conducted on [DATE] at 11:54 a.m. with the DON. She said when she called the hospital, she found out Resident #15 had passed away. She said she hadn't talked to the nurse or CNA about the situation or what happened. She said there are emergency supplies in each trach resident's room, but routine suctioning supplies are not necessarily in the room. She said some nurses keep supplies in the drawer of the room, but they are in the supply closet that isn't far away. She said, I feel like when a resident needs suctioning that needs to be done right away. Suctioning should be immediate you don't know if it is stopped their airway. It is very important they are suctioned right away. Within 2 minutes. If right outside door, less than a sec[second]. When asked if she felt like nurses responded to the resident's need for trach suctioning timely, she responded, I am going to plead the fifth on that one. It is a work in progress. The DON said the process needs structure and No, they don't respond. They don't respond quick enough for me. The DON said, I think it is more they need more training and more confidence. Some nurses have just graduated out of school. She said that is why she had the RT do training last week. The DON said during training the nurses didn't do return demonstration or competencies. They just went over the information on trach care. The DON said management, or the Respiratory Therapist had not watched nurses do trach care to ensure they knew what they were doing. She said she is going to start that. She said not 100% of their nurses were comfortable doing trach care and some of the newer nurses needed more training. The DON agreed a resident was placed at risk if their trach was clogged and said if a resident asked to be suctioned a nurse should respond immediately. She added, That patient is in danger. They could be where they can't breathe. The DON read the grievance filed on [DATE]. She said she was not made aware of the grievance and had not addressed it. She said if a person did not receive trach care and suctioning, it was a lack of care and services, and I think that is neglect. The DON said Monday, [DATE] at approximately 10:00 a.m., management had a morning clinical meeting where they looked back at what happened the past 72 hours. She said she saw the note about Resident #15 and her first question was why. She said her thought when she read the progress note was how long did it take that nurse to get in that room. Where was the nurse? The DON said, I was shocked. I literally was shocked. I talked to him on Friday. He was sitting in the dining room. An interview was conducted on [DATE] at 2:38 p.m. with Staff C, Registered Nurse (RN). He said he knew Resident #15 and was surprised when he heard he passed away. Staff C stated Resident #15 was pleasant and sometimes asked to be suctioned or have his trach inner cannula changed. Staff C said Resident #15 was not the type that asked all the time. So, if he asked for suctioning, then he really needed it. A review of the admission Record showed Resident #19 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include cerebral palsy, other specified diseases of the jaw, chronic obstructive pulmonary disease (COPD), epilepsy, dementia, respiratory failure, tracheostomy, and gastrostomy. Review of Resident #19's Discharge MDS, dated [DATE], showed his BIMS was unable to be conducted. Review of Resident #19's physician orders showed the following: -Change small tubing between canister and suction machine monthly starting on the 15th. Date [DATE]. -Tracheostomy Type: Shiley Size 4. Trach care daily and as needed. Clean inner cannula and replace. Cleanse tracheostomy site with normal saline, pat dry. Cover with drain sponge daily and as needed. Date: [DATE]. -Trach: Suction trach post. Record amount of secretions, characteristics of secretions (color, odor, viscosity), lung sounds, heart rate, respirations, and tolerance. Every shift for preventative measure. Date [DATE]. -Maintain suction set up at bedside, every shift and as needed. Date [DATE]. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date [DATE]. -Change trach collar, mask, and oxygen weekly as well as PRN. Every Sunday for preventative. Date [DATE]. -Humidified oxygen per trach continuously 28 L every shift for Shortness of Breath. Date [DATE]. Review of Resident #19's [DATE] TAR showed no documentation for trach care on 3/5, 3/6, and [DATE]. It also showed no documentation for continuous humidified oxygen at 28 L or trach suctioning on [DATE] evening shift, [DATE] day shift, [DATE] day and evening shift, [DATE] day and evening shift, [DATE] night shift, and [DATE] evening shift. Review of Resident #19's [DATE] Medication Administration Record (MAR) showed the resident was taking the antibiotic, Ciprofloxacin 500 milligram (mg) for a trach site infection from [DATE] to [DATE]. Review of Resident #19's Change in Condition Evaluation, dated [DATE], showed the resident was observed bleeding from his mouth and trach. He was transferred to a higher level of care. Review of Resident #19's Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form (3008), dated [DATE], showed the resident's primary diagnosis was tracheostomy issue. Review of Resident #19's Respiratory Notes, dated [DATE], showed the resident was slightly tachypneic (rapid shallow breathing) with oxygen saturation at 88% on room air. Resident was placed on oxygen via trach mask at 2 L with oxygen saturation increasing to 95%. The Respiratory Therapist's recommendations were monitor symptoms (tachypnea and low sats [oxygen saturation.] A Respiratory Note, dated [DATE], showed his breath sounds were course with mild expiratory wheeze, sputum sample obtained related to a moderate amount of yellowish green sputum with a foul odor. Review of Resident #19's Weights and Vitals showed the resident's oxygen saturation was not documented on 2/10, 2/11, [DATE] and only once on [DATE] at 2:03 p.m. During the interview with the RT on [DATE] at 10:56 a.m. the RT said Resident #19 was currently on antibiotics due to a trach site infection. She said the resident also had pneumonia, but she felt like it started as a trach site infection then progressed to his lungs. When asked how the staff were with the resident's trach care she said she was not in the facility on a consistent basis, but sometimes when she came It may not be like I would like it. The RT said, I am not sure how good they do. With the newer staff I am not sure how comfortable with trach stuff they are. Review of the facility's Grievance Log for March of 2024 revealed a grievance filed on [DATE] by the family of Resident #16. They wrote that on many occasions the resident's equipment and trach were not working and his tracheostomy tube was clogged on [DATE] when they came to visit. The family wrote the evening nurse got an attitude when they mentioned the tracheostomy tube being clogged. The grievance showed the Nursing Home Administrator (NHA) and Unit Manager (UM) were designated to take action for this grievance. It was assigned on [DATE] showing the action to resolve the grievance was Nursing will educate staff. During a facility tour on [DATE] at 9:49 a.m., an observation was made of Resident #16 in bed, he summoned this surveyor pointing to his suction equipment. The suctioning hose and mask were observed on the floor. The resident's suctioning piece was in his hand. The resident only spoke Spanish. He pointed to the cup on his bedside table. He nodded yes to needing water. This Surveyor exited the room and could not locate the CNA assigned to this hall. When the nurse had finished administering meds in the room adjacent to Resident #16, surveyor notified the nurse (Staff G, LPN) that Resident #16 needed water. The nurse said, Hang on. I'll get with him. After approximately 5 minutes, she entered the room to respond to the resident. Review of the admission Record showed Resident #16 was admitted on [DATE] with diagnoses to include respiratory failure, unspecified with hypoxia, shortness of breath, Parkinson's disease without dyskinesia, without mention of fluctuations, tracheostomy status, gastrostomy status, personal history of pneumonia (Recurrent), iron deficiency anemia, unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, essential (Primary) hypertension, hyperglycemia, unspecified, elevated white blood cell count, Unspecified, and paralysis of vocal cords and larynx, unspecified. Review of Resident #16's MDS admission assessment, dated [DATE], revealed a BIMS in Section C - Cognitive Patterns: he was not assessed due to his diagnosis of paralysis of vocal cords and larynx. Review of Resident #16's physician orders showed the following: -Tracheostomy Type: Cuffless Size: 6XL Tracheostomy change or replace as needed if displaced or dislodged. every 24 hours as needed. Date [DATE]. -Tracheostomy Type: Cuffless Size: 6XL Trach care daily and as needed. Cleanse tracheostomy site with normal saline, pat dry. Change inner cannula. Cover with drain sponge daily and as needed. every day shift AND as needed. Date [DATE]. -Maintain suction set up at bedside, every shift and as needed. Date [DATE]. -Change suction canister every 72 hours and/or when 3/4 full. Every 72 hours and as needed. Date [DATE]. Resident #16 did not have any tracheostomy cleaning or change orders prior to the start of the survey on [DATE]. Review of Resident #16's [DATE] TAR revealed missing documentation showing suction was set up at the bedside and an ambu bag and replacement trach was at the bedside on 3/18, 3/21, 3/25, and [DATE]. During a tour of hall 200 on [DATE] at 9:54 a.m., an observation was made of Resident #14. The resident was non-verbal and pointed to her trach site. The resident was asked if she needed to be suctioned. She nodded her head up and down indicating, yes. A nurse or CNA could not be located in the hall, the NHA was notified the resident needed care. The NHA went to the resident's room and notified Resident #14 that she would let the nurse know. An observation was conducted on [DATE] at 12:45 p.m. Two call lights were observed on. Staff C, RN was observed sitting at the nurses' station on the phone. Staff C was asked what the beeping noise was, and he stated it was because a resident had turned on a call light. Staff H, CNA was observed responding to the call light in Resident #14's room. Staff H stepped out of the room and stated Resident #14 needed something to do with her trach and she was letting the nurse know. Staff C, RN overheard the CNA speaking to surveyor. He said to the surveyor, I'm on break, am I not entitled to my break? The nurse was observed remaining seated at the nurse's desk. A tour with the DON was conducted on [DATE] at 3:46 p.m. of Resident #14's room. The resident was again observed pointing to her trach site. The DON asked the resident if she needed to be suctioned. The resident nodded yes. The DON notified Staff G, LPN. An observation was made with the DON on [DATE] at 3:54 p.m. Resident #16 was observed in his room. The resident's Yankauer (a ridged oral suctioning tool) was observed on the resident's bedside table, exposed to the elements. The hose was observed to have some dust and crusted matter on it from being on the floor earlier in the day. The resident spoke Spanish. The DON stated the equipment should be maintained in a sanitary manner. She stated anything that goes into a resident should be bagged and dated. She stated she had noted there was need for training related to trach care. A follow-up interview was conducted on [DATE] at 5:03 p.m. with the DON. She stated the nurse told her Resident #14's trach was cleaned and changed by the Staff F, RN/UM at approximately 4:45 p.m. The DON stated there was no documentation that the resident had received trach care. The DON stated if it was not documented it did not happen. An interview was conducted on [DATE] at 5:18 p.m. with Staff E, RN, who was the 7:00 a.m. to 3:00 p.m. Unit Manager (UM) on the 300/400 hall. She stated she went to Resident #16's room with Staff D, LPN about an hour earlier. She stated they replaced the hose and the suction catheter. She said, Sometime after 4 p.m. [Staff D] came to me. She was looking for the right hose, suction catheter, and connecting hose. She was not sure what size he needed. She asked me for help. I went in, made sure we changed the hose, told the resident to make sure he is not setting it on the table, and told him to keep it clean. Staff E said she wasn't sure what staff were doing previously for him to keep the suction catheter clean, but they are now giving him the bag the suction catheter comes in and encouraging him to place it in the bag when he isn't using it. An observation was conducted on [DATE] at 5:22 p.m. of Resident #14 with mucous coming out of her trach site. The resident had her call light on and was observed pointing to her trach site. The nurse and the CNA assigned to this hall could not immediately be found. The surveyor notified the NHA Resident #14 had a call light on, and she was pointing to her trach site. On [DATE] at 5.24 p.m. the DON confirmed there was no documentation in Resident #14's medical record to show she was suctioned at 4:45 p.m. The DON was notified of the observation of Resident #14's trach site at 5:22 p.m. She had the nurse and the unit manager suction the resident at that time and said she would make sure they documented. An interview was conducted on [DATE] at 2:38 p.m. with Staff F, RN/UM, Staff C, RN and Staff G, LPN. Staff F said there were concerns about getting sterile gloves, need for the trach suctioning procedure, for both himself, Staff C, and three other male nurses. He said they did not have access to XL (extra-large) sterile gloves. Staff C said he did not provide trach care with the inner cannula of the trach because he didn't have gloves. He said he will get another nurse to do the care that fits in the sterile gloves. He said he documented the care because he is in the room when it is done. Staff C said on [DATE] he worked from 7:00 a.m. to around 2: 45 p.m. He said he did not provide trach care to Resident #14. He said he had a problem with supplies and couldn't find stuff. He said he is new here and sometimes provides his own supplies. Staff F, RN/UM stated the expectations is for the facility to provide the supplies needed to care for residents. He said to ensure the product was sanitary, staff needed to use only facility provided supplies. Staff C, RN said, You need the sterile gloves when you do the deep suctioning. We don't have them. I have never received sterile gloves from the facility. It makes it hard to do my job. Staff F said on [DATE] around 2:25 p.m. he suctioned and cleaned Resident #14. He said she was not junky and didn't cough anything out. He confirmed he did not document anything related to this care stating, It is not documented it did not happen. Staff F said prior to this time, he was not aware Resident #14 needed trach care or suctioning. Staff G said she was assigned to Resident #14 on [DATE]. Staff G said Staff F suctioned Resident #14 before he left and a couple hours later the resident kept pointing to her trach site. Staff G said she suctioned her and applied new gauze. She said Resident #14 is always asking to be suctioned because she felt like something was stuck in her throat. Staff G, LPN and Staff C, RN both said they attended a class with the RT the previous week and Staff F, RN/UM said he attended two weeks ago. They said the RT went over the specific cannula sizes for each resident and where the emergency replacements are located. They said other than that, the RT did general trach teaching and did not give specifics that pertain to the residents at the facility. All three staff members said they were not sure about the RT's documentation and had never seen any notes or documentation from respiratory about the trach residents. Staff F, RN/UM reviewed the missing documentation from the residents with trachs and said it looks like it was not done. He said if care was completed, it should be documented. If it is not documented, it did not happen. Staff F said, I don't know if anyone audits documentation. I am not aware of who is in charge of reviewing files for completeness or accuracy. An interview was conducted on [DATE] at 9:11 a.m. with Staff F, RN/UM. He stated he had been notified by the nurse Resident #16's trach equipment was not working. He stated that was why he came in the room with the canister. He said he needed to figure out what happened. Staff F said the nurse assigned to the resident had not worked with trach patients before and was still learning. Staff F was observed trying to communicate with Resident #16 but there was a language barrier. The surveyor asked the Staff F, RN/UM if there was an interpreter, and he said the Business Office Manager (BOM) could interpret. The BOM came to the room and the resident stated he could not eliminate the phlegm in his throat. Staff F stated he had just figured out the equipment was turned off and he did not know how long it had been off. He stated if the machine was off the resident could not suction himself. Staff F then exited the room. During the continued interview the resident stated through an interpreter there was a nurse that does not respond to him when he calls. He stated the 3:00 p.m.-11:00 p.m. nurse (Staff D, LPN) does not care for him and does not understand him. The resident said, through an interpreter, When I ask her for help, she gives me an attitude. She does not want to help me. Resident #16 reported he was currently having shortness of breath and was observed trying to clear his throat. He said to the interpreter, I am not okay. The interpreter left the room to get a nurse. At 9:23 a.m. Staff F, RN/UM responded with a pulse oximeter to check the resident's oxygen saturation. The resident's oxygen saturation was 96% and 98% upon recheck. The resident stated, through an interpreter, he was having anxiety and he needed to be repositioned to clear his air way. A follow-up interview was conducted on [DATE] at 1:05 p.m. with Staff F, RN/UM. He said if Resident #16 is trying to disrupt equipment and his own care, it should be care planned. He said that morning, [DATE], when he went to the resident's room there was a bag over the motor part of the suction machine and the resident could not remove it from where he was sitting due to it being behind him. He said the resident could not see the switch to turn it on/off. He said Resident #16 shuts the suction machine off, but it can shut off if the canister is full. He said the nurses should know that. Staff F said Resident #16 is not care planned for that behavior and if he had behaviors, it should be in the care plan. An interview was conducted on [DATE] at 9:35 a.m. with Staff G, LPN. She stated she had last seen Resident #16 shortly before 8:00 a.m., during medication administration. She stated she had cleaned his equipment and covered it after she was done. She said, I did not check if it was working. I did not notice anything. He did not say anything at that time. He was not using it at the time. An interview was conducted on [DATE] at 11:21 a.m. with the RT. She stated Resident #14 should not have waited all day on [DATE] to receive the care she needed. The RT confirmed Resident #14 can clearly articulate her needs by yes/no by nodding. She said if the resident said she needed suctioning it should have been done and there was no excuse for it not to be. The RT said Resident #14 was assigned to the male nurse, Staff C, RN, who did not have access to sterile gloves. She said he is not able to provide the care he needs because he needs sterile gloves that fit him, and the facility doesn't have any. The RT said she notified the previous administration and just notified the current administration. She said the trach care kits only come with very small sterile gloves that do not fit larger hands.[TRUNCATED]