**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement procedures to ensure a resident's wishes related to health care treatments and procedures at the end of life were followed and failed to honor an Advance Directive that reflected the decision to withhold Cardiopulmonary resuscitation (CPR) for 1 of 8 residents reviewed for Advanced Directives of a total sample of 8 residents, (#1). These failures contributed to resident #1 receiving CPR in violation of an explicit wish for a natural and dignified death. There was likelihood resident #1 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE] at approximately 11:48 PM, resident #1 was observed unresponsive in his wheelchair at the nurse's station. He was taken to his room where a licensed nurse initiated CPR without first verifying the resident's code status in the medical record. Emergency Medical Services (EMS) arrived at the facility at midnight and continued to provide CPR for another 20 minutes before resident #1 was transported to the hospital where he was intubated and stabilized until his wife requested life support be withdrawn. The facility failed to honor the resident's wishes not to be resuscitated and the physician order for Do Not Resuscitate. The facility's failure to honor the right to choose withholding of lifesaving interventions placed all residents with a Do Not Resuscitate Order (DNRO) Advance Directive at risk for serious psychosocial harm, physical trauma, and a prolonged, undignified death from unwanted resuscitation efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed [DATE] based on verification of the facility's corrective actions. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Cross reference F678. Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including fracture of right femur, senile degeneration of brain, unspecified dementia, dysphagia (trouble swallowing), and chronic kidney disease stage III. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 02/15 which indicated he had severe cognitive impairment. A care plan for Advance Directives was initiated [DATE] which indicated resident #1 had an established Full Code order in place and identified his wife as his proxy and emergency contact. Review of the electronic medical record (EMR) revealed a care plan minutes form from [DATE], scanned into the miscellaneous documents. The form indicated those in attendance included resident #1's wife, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Under resident/family concern was written, change code status to DNR. Review of resident #1's EMR revealed a State of Florida Do Not Resuscitate Order (DNRO) form signed by resident #1's wife on [DATE]. A Nurses Progress Note dated [DATE] at 1:07 AM revealed Certified Nursing Assistant (CNA) A observed resident #1 was unresponsive and notified nurse. Licensed Practical Nurse (LPN) B arrived on the scene, assessed the resident and confirmed he was unresponsive. The note indicated resident #1 was immediately transferred to his room where staff initiated CPR at 11:51 PM, and emergency services were called at 11:54 PM. EMS arrived on the scene at midnight and continued to provide resuscitation efforts. Resident #1 was transferred to a nearby hospital by EMS at 12:20 AM. A Social Services progress note dated [DATE] revealed resident #1's wife was contacted regarding his change in condition. The note indicated the caller was informed by his wife resident #1 had been intubated at the hospital and expired 30 minutes after the he was taken off the ventilator. On [DATE] at 9:55 AM, the DON reported she was in the care plan meeting with resident #1's wife on [DATE]. The DON recalled she had a conversation with resident #1's wife regarding his code status. She explained resident #1 received hospice services at home prior to entering the hospital but he came into the facility as Full Code. The DON stated she explained the difference between Full Code and DNR to the resident's wife who then decided she wanted resident #1 to be a DNR. She then called the Social Service Assistant (SSA) and informed her of the wife's wish to be a DNR. The DON recalled the wife then signed the DNRO form. She stated she told the ADON to contact the doctor and to update resident #1's code status in the EMR. The DON recalled Licensed Practical Nurse (LPN) B called her in the middle of the night to inform her of the code. She explained she questioned LPN B because the wife had signed the DNRO form earlier that day. LPN B informed the DON that resident #1 was listed as Full Code in the EMR. The DON explained she spoke to the ADON later that morning who stated she had forgotten to update the EMR with the change in resident #1's code status. She confirmed LPN B should have checked the EMR and the Code Status Binder to confirm the code status per facility policy. The DON acknowledged resident #1 was a DNR at the time CPR was performed. In a phone interview on [DATE] at 12:32 PM, the ADON confirmed she was in the care plan meeting on [DATE]. She recalled resident #1's wife wanted him to be a DNR and she went with the SSA to sign the DNRO form. She acknowledged the DON told her the wife signed the form and asked her to update the EMR with the new code status. The ADON recalled she was busy with another staff member and had asked the DON to remind her. She explained the DON did not remind her and she forgot to update the EMR. The ADON explained any nurse could have updated the EMR with the new code status. She said she did not know why someone else did not do it. In a phone interview on [DATE] at 10:14 AM, the SSA stated she was called into the care plan meeting and was told resident #1 had a DNRO form at home. The SSA informed resident #1's wife she had a DNRO form in her office that could be signed and would be activated that day. She explained resident #1's wife signed the form. The SSA reported she uploaded a scan of the form to the EMR and placed a copy in the Code Status Binder on the code cart on the unit on the afternoon of [DATE]. She stated the following morning she was told resident #1 was found unresponsive and the nurses provided CPR. Once she got to the facility, the SSA discovered resident #1's code status had not been updated in the EMR. On [DATE] at 8:54 AM, LPN B stated she was assigned to resident #1 on the night of [DATE]. She recalled seeing resident #1 in his wheelchair by the nurse's station. LPN B reported as she was rounding, she heard another staff member announce a Code Blue. She stated resident #1 had been found unresponsive and she assisted with getting him to his room and into the bed. LPN B stated she asked for someone to check his code status and heard someone reply he was a Full Code. She explained she asked again if he was a Full Code, and the person said it again. LPN B reported she then began chest compressions at 11:51 PM. She stated she alternated compressions with other nurses until EMS arrived. LPN B recalled she then went outside the room to verify the resident's code status for herself when she first switched off with another nurse. LPN B stated the code cart was in the resident's room. She acknowledged she did not check the Code Status Binder located on the cart to verify resident #1's code status. She reported EMS arrived at midnight and took over CPR. She stated EMS continued chest compressions through the time they transported resident #1 to the hospital at 12:20 AM. In a phone interview on [DATE] at 3:05 PM, LPN C confirmed she worked the night of [DATE]. She stated she heard another nurse call a Code Blue from the other wing and ran over to assist. LPN C recalled she assisted getting resident #1 into bed. She did not recall who started the chest compressions but stated she did participate in providing CPR to resident #1. She stated she thought LPN B checked resident #1's code status but was not aware of where she got the information. LPN C acknowledged she did not verify resident #1's code status as CPR was already in progress. In a phone interview on [DATE] at 2:32 PM, Registered Nurse (RN) D confirmed she was working the night of [DATE]. She recalled hearing a Code Blue called on the opposite unit and ran to that unit. RN D stated when she arrived at resident #1's room, LPN B and LPN C were already there. She explained she saw LPN B performing chest compressions. RN D reported that she alternated with LPN B and LPN C to perform CPR on resident #1. She stated she thought the code status had been confirmed since CPR was already in progress. RN D recalled she saw resident #1 was identified as Full Code in the EMR but acknowledged she did not check the Code Status Binder on the code cart to verify. In a phone interview on [DATE] at 12:02 PM, resident #1's wife confirmed she signed the DNRO on [DATE] during a care plan meeting at the facility. She explained her husband received hospice care previously at home and had been a DNR. She stated the facility called her sometime during the night after she had signed the new DNRO to inform her of the Code Blue and that her husband was being sent to the hospital. Resident #1's wife stated she did not know why they performed CPR since their wishes were for DNR. She reported the hospital called her on [DATE] at approximately 1:00 AM to update her on her husband's status. She told them she did not want her husband to be intubated. She explained the hospital staff informed her he had already been intubated. Resident #1's wife stated she went to the hospital that morning and talked with a doctor in order to get the tube removed. She recalled two doctors had to sign off and the tubes were removed around 10:00 AM. She explained she sat with her husband, holding his hand until he passed away a short time later at 10:30 AM. Resident #1's wife explained she had signed the DNRO because she did not want to prolong his life and did not want him to suffer. She stated her husband did not want to suffer either. On [DATE] at 11:13 AM, the Administrator stated the DON called her on [DATE] at approximately 12:30-12:45 AM to inform her of CPR being provided to resident #1. She explained an investigation was initiated that morning. The Administrator reported the ADON failed to update the EMR with the correct code status. She acknowledged the nurses should have verified resident #1's code status in the EMR and Code Status Binder on the code cart before initiating CPR. The Administrator verified this resulted in resident #1 being provided life saving measures against his wishes. The Facility's policy and procedure for Advanced Directives and Code Status dated [DATE] read, It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with Stated and Federal Regulations. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On [DATE] a medical record audit was completed for current residents to ensure DNR forms were present in the electronic medical record for residents with DNR orders. *On [DATE] through [DATE] current licensed nurses were educated on resident's rights regarding treatment and Advanced Directives by the Director of Nursing/delegate. * 40 out of 41 total licensed nurses received education; 98% of nurses: On [DATE] 10 out of 41 nurses completed the education, 24% of nurses, On [DATE] an additional 29 of 41 nurses completed their education, 71% of nurses. On [DATE] an additional 1 of 41 nurses completed the education, 2%. 1 remaining licensed nurse to receive education upon return from leave and prior to working next shift. *New hire nurses at the facility will receive the above education during orientation and prior to working an assignment. *On [DATE] through [DATE] current licensed nurses participated in mock code drills: *18 out of 41 total Licensed Nurses participated in mock code drills; 44% of nurses: On [DATE] 11 out of 41 nurses participated in mock code drills, 27% of nurses. On [DATE] 7 out of 41 nurses participated in mock code drills, 17%. 23 remaining licensed nurses to participate in mock code drills upon return from leave and prior to working next shift. *New hire nurses at the facility will participate in a mock code drill during orientation and prior to working an assignment. *On [DATE] through [DATE] residents and/or responsible parties for current residents residing in facility were interviewed by Social Services/Delegate to validate current physician orders for code status reflect resident and/or responsible party's current wishes for code status. Code status updated, if applicable based on interviews conducted. *Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] completed with Medical Director, Administrator, and additional Interdisciplinary team (IDT) members on the adherence to CPR policy and policy and procedure for Resident Rights Regarding Treatment and Advance Directives and a review of the root cause analysis was completed. *As part of the ongoing Quality Assurance Assessment (QAA) process, an ad hoc QAPI was conducted on [DATE] that included the Medical Director, Administrator, Director of Nursing and additional IDT members to review the plan viability on the Advance Directives process, code process and results of audits. No discrepancies or concerns were noted related to Advanced Directive code status standards and guidelines. Interviews conducted on [DATE] with 10 licensed nurses across all shifts indicated they were knowledgeable of Advance Directives and where to verify the code status in the EMR and the code status binder prior to providing CPR. The surveyors validated the education with attendance sheets for Code Blue drills and in-services. Review of QAPI audits revealed daily Code Blue drills were conducted per performance improvement plan. The resident sample was expanded to include four additional residents, three who elected DNR status and one with Full Code status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, and #8 related to Advance Directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, licensed nurses failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of resuscitation or code status in an emergency for 1 of 8 residents reviewed for Advanced Directives, of a total sample of 8 residents, (#1). On [DATE] at approximately 11:48 PM, resident #1 was observed unresponsive in his wheelchair at the nurse's station. He was taken to his room where a licensed nurse initiated CPR without first verifying the resident's code status in the medical record. Emergency Medical Services (EMS) arrived at the facility at midnight and continued to provide CPR for another 20 minutes before resident #1 was transported to the hospital where he was intubated and stabilized. The facility failed to honor the resident's wishes not to be resuscitated and physician's order for Do Not Resuscitate. The facility's failure to ensure staff followed procedures related to honoring an Advanced Directive to withhold CPR contributed to resident #1 suffering unwanted, aggressive resuscitation efforts and placed all residents who had valid DNROs at risk for serious injury/impairment/prolonged death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Cross reference F578. Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including fracture of right femur, senile degeneration of brain, unspecified dementia, dysphagia (difficulty swallowing), and chronic kidney disease stage III. Review of the Minimum Data Set admission assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 02/15 which indicated he had severe cognitive impairment. Review of the electronic medical record (EMR) revealed a care plan minutes form dated [DATE] scanned into the miscellaneous documents. The form indicated those in attendance at the meeting included resident #1's wife, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Under resident/family concern was written, change code status to DNR. Review of resident #1's EMR revealed a State of Florida Do Not Resuscitate Order (DNRO) form dated [DATE] that was signed by the resident's wife and his attending physician. The document showed the resident representative's signature under the statement, Being informed of my right to refuse cardiopulmonary resuscitation (CPR), including artificial ventilation, cardiac compression, endotracheal intubation and defibrillation, direct that CPR be withheld or withdrawn from me. The physician's statement read, I direct the withholding or withdrawal of CPR from the patient in the event of the patient's cardiac or respiratory arrest. Resident #1's EMR contained a physician order dated [DATE] which read, Full Code. The Facility's policy and procedure for Advanced Directives Code Status dated [DATE] read, It is the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal regulations. The form indicated a resident's code status should be verified by the physician's order tab in the EMR and the corresponding form should be visualized in the code status binder. A Nurse's Progress Note dated [DATE] at 1:07 AM, revealed Certified Nursing Assistant (CNA) A observed resident #1 was unresponsive and notified the nurse. Licensed Practical Nurse (LPN) B arrived on the scene, assessed resident #1 and confirmed he was unresponsive. The note indicated resident #1 was immediately transferred to his room and staff initiated CPR at 11:51 PM and emergency services were called 11:54 PM. Emergency Medical Services (EMS) arrived on the scene at midnight and continued to provide resuscitation efforts. Resident #1 was transferred to the hospital by EMS at 12:20 AM. On [DATE] at 9:55 AM, the DON reported she was in the care plan meeting with resident #1's wife on [DATE]. The DON recalled she had a conversation with resident #1's wife regarding his code status. The DON stated she explained the difference between Full Code and DNR to the wife who then decided to sign a DNRO. The DON explained she asked the Social Services Assistant (SSA) to assist the wife with the DNRO and directed the Assistant Director of Nursing (ADON) to contact resident #1's physician and to update the EMR. She recalled Licensed Practical Nurse (LPN) B called her in the middle of the night to inform her of the code. The DON state she questioned LPN B because the wife had signed a DNRO form. LPN B informed her resident #1 was listed as Full Code in the EMR. The DON acknowledged the EMR had not been updated and resident #1 was a DNR at the time CPR was performed. In a phone interview on [DATE] at 12:32 PM, the ADON confirmed she attended the care plan meeting on [DATE]. She recalled resident #1's wife signed a DNRO. She acknowledged the DON told her to contact the doctor and update the EMR with the new code status. The ADON stated she was busy with another staff member and asked the DON to remind her. She explained she forgot to update the EMR. The ADON stated any nurse could have updated the EMR with the new code status. In a phone interview on [DATE] at 10:14 AM, the SSA confirmed she met with resident #1's wife who signed a DNRO form on [DATE]. The SSA reported she uploaded the form to the EMR and placed a copy in the Code Status Binder on the crash cart on the afternoon of [DATE]. She stated the following morning she was told resident #1 coded and the nurses provided CPR. Once she got to the facility, the SSA discovered the code status had not been updated in the EMR. On [DATE] at 4:09 PM, Certified Nursing Assistant (CNA A) confirmed she was the assigned CNA for resident #1 on [DATE]. She recalled resident #1 was in his wheelchair at the nurse station and he was not moving or breathing. She notified a nurse who called a code blue. CNA A reported staff responded to the call, and she assisted in getting resident to his room and into bed. She explained she stepped outside the room and the nurses took over. CNA A stated she did not know who verified resident #1's code status or who started resuscitation efforts. She did recall seeing the crash cart in the room but did not know who brought it. On [DATE] at 8:54 AM, LPN B stated she was assigned to resident #1 on the night of [DATE]. She described the sequence of events on [DATE], the day resident #1 received CPR. She recalled hearing another staff member announce a Code Blue. LPN B stated she observed resident #1 was unresponsive at nurse station and she assisted with getting him to his room and into the bed. LPN B explained she asked for someone to check code status and heard someone say he was a Full Code. She asked again if he was a Full Code, and the person said it again. LPN B reported she then began chest compressions at 11:51 PM. She stated she switched off with other nurses until EMS arrived at midnight. LPN B recalled she went outside the room to verify resident's code status for herself when she first switched off with another nurse. LPN B stated the crash cart was in the resident's room. She acknowledged she only checked the computer and did not check the Code Status Binder to verify resident #1's code status. She reported EMS took over CPR when they arrived. LPN B stated EMS continued chest compressions until 12:20 AM when they transported resident #1 to the hospital. In a phone interview on [DATE] at 3:05 PM, LPN C confirmed she was working the night of [DATE]. She stated she heard another nurse calling a Code Blue from the other wing and ran over to assist. LPN C recalled she assisted getting resident into bed. She did not recall who started chest compressions but stated she did participate in providing CPR to resident #1. She stated she was sure LPN B checked resident #1's code status. She reported LPN B came back to the room and stated he was a Full Code. She did know how LPN B verified the code status. LPN C acknowledged she did not verify resident #1's code status as CPR had already started. In a phone interview on [DATE] at 2:32 PM, Registered Nurse (RN) D confirmed she was working the night of [DATE]. She recalled hearing a code blue called on the opposite unit and ran to that unit. RN D stated when she arrived LPN B and LPN C were already in resident #1's room. She explained she saw LPN B performing chest compressions. RN D reported that she traded off with LPN B and LPN C to perform CPR. She stated she thought code status had been confirmed since CPR had been started. RN D recalled she later saw resident #1 was a full code in the EMR. She acknowledged she did not check before CPR began and did not check the Code Status Binder on the crash cart to verify. In a phone interview on [DATE] at 12:02 PM, resident #1's wife confirmed she signed a DNRO on [DATE] during a care plan meeting. She stated the facility called her sometime during the night and informed her of the code and her husband being transferred to the hospital. Resident #1's wife stated she did know why they did that since he was a DNR. She reported the hospital called her on [DATE] at approximately 1:00 AM to update her on resident #1's status. She told the caller she did not want her husband to be intubated. She explained the caller informed her he had already been intubated. Resident #1's wife stated she went to the hospital that morning and had to talk with a doctor to get the tube removed. She recalled two doctors had to sign off and the tubes were eventually removed around 10:00 AM. She stated she went into the room and sat with her husband holding his hand until he passed away at 10:30 AM. Resident #1's wife explained she had signed the DNRO because she did not want to prolong his life and did not want him to suffer. She stated her husband did not want to suffer either. On [DATE] at 11:13 AM, the Administrator stated the DON called her on [DATE] around 12:30-12:45 AM and informed her of CPR being provided to resident #1. She explained an investigation was initiated that morning. The Administrator reported that resident #1's wife had signed a DNRO and the ADON failed to update the EMR with the correct code status. She acknowledged the nurses should have verified resident #1's code status in the EMR and Code Status Binder on the crash cart per policy. The Administrator verified this resulted in a resident with a DNR being provided CPR. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On [DATE] through [DATE] current licensed nurses were educated on facility's CPR policy and on procedure for performing a code to include confirmation of resident code status prior to initiating CPR. Post test and code procedure competencies completed to validate comprehension. *39 of 41 total licensed nurses received education; 95% of nurses: On 11/1 5/2024 10 out of 41 nurses completed the education, 24% of nurses, On [DATE] an additional 29 of 41 nurses completed their education, 71% of nurses. 2 remaining licensed nurse to receive education upon return from leave and prior to Working next shift. *New hire nurses at the facility will receive the above education during orientation and prior to working an assignment. *On [DATE] through [DATE] current licensed nurses participated in Mock Code Drills: *18 of 41 total licensed nurses participated in mock code drills; 44% of nurses On [DATE] 11 out of 41 nurses participated in mock code drills, 27% of nurses, On [DATE] 7 out of 41 nurses participated in mock code drills, 17%. 23 remaining licensed nurses to participate in mock code drills upon return from leave and prior to working next shift. *New hire nurses at the facility will participate in a mock code drill during orientation and prior to working an assignment. *Ad Hoc QAPI on [DATE] completed with Medical Director, Administrator, Director of Nursing and additional IDT members on the adherence to CPR policy and checking the residents code status prior to initiating CPR. Interviews conducted on [DATE] with 10 licensed nurses across all shifts indicated they were knowledgeable of Advanced directives and where to verify the code status in the EMR and the code status binder prior to providing CPR. The surveyors validated the education with attendance sheets for code blue drills and in-services. Review of QAPI audits revealed daily code blue drills were conducted per performance improvement plan. The resident sample was expanded to include four additional residents, 3 who elected DNR status and 1 with Full Code status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, and #8 related to Advanced directives. Based on the facility's corrective actions, the survey team determined the immediate jeopardy was removed [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from neglect by not assessing and providing immediate and necessary respiratory care and services for an oxygen dependent resident with a tracheostomy to prevent repeated dislodgement and subsequent death for 1 of 1 resident reviewed for tracheostomy status of a total sample of 7 residents, (#1). A tracheostomy (also called a tracheotomy) 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 (retrieved on [DATE] from www.hopkinsmedicine.org). Removal of a trach tube, or decannulation, is a medical emergency and can be fatal as respiratory and cardiac compromise and/or failure can occur quickly. Resident #1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure and at risk for falls. He breathed through a tracheostomy tube and was dependent on continuous oxygen therapy. Within hours of his admission, resident #1 pulled out his tracheostomy tube on [DATE] at approximately 2:00 AM and had to be transferred to the hospital Emergency Department (ED) for replacement of the tube or cannula. He returned to the facility at approximately 5:00 AM, but a couple of hours later at approximately 7:00 AM, resident #1 again removed his tracheostomy tube and had to be transported to the hospital ED for reinsertion of another cannula. He returned to the facility on [DATE] at approximately at 1:30 PM. Despite two trips to the hospital within a 12-hour period for the decannulation emergencies, the facility did not provide increased supervision to mitigate his behavioral symptoms and ensure the safety and well-being of resident #1. Later that evening, on [DATE] at approximately 7:30 PM, Registered Nurse (RN) B passed resident #1's room and observed him face down on the floor. She notified the resident's assigned nurse, RN A, who checked the resident then went to the nurses' station to call 911, leaving the resident face down on the floor with RN B and Certified Nursing Assistant (CNA) C in the room. A police officer arrived at 7:36 PM and entered resident #1's room where he observed CNA C, but there was no licensed nurse present to assess and monitor the resident's status. Emergency Medical Services (EMS) personnel who arrived soon after the police officer, rolled the resident onto his back, discovered he was not connected to an oxygen source, and found him to be without a pulse and respirations. EMS personnel immediately initiated Cardiopulmonary Resuscitation (CPR) but they were unsuccessful in reviving resident #1 and he was pronounced dead at 7:56 PM. The facility's failure to assess and provide immediate care for an oxygen dependent resident with a tracheostomy after a fall contributed to resident #1's demise, and placed all residents dependent on oxygen or had tracheostomy at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F684, F695, F726. Review of the medical record revealed resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute/chronic respiratory failure, tracheostomy status, diabetes, hypertension, and feeding tube. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1's primary diagnosis was chronic respiratory failure. The document indicated he was alert and disoriented but could follow simple instructions. The form noted the resident's trach tube size was 4 and that he received oxygen via a trach collar. The Initial Respiratory Evaluation, Treatment Plan And Recommendations dated [DATE] revealed the resident's treatment diagnosis was respiratory failure (Trach). The document showed the required size of the resident's trach and indicated an extra trach and back-up trach were available, and Respiratory Therapy (RT) would provide trach care three days a week. Resident #1's admission physician orders dated [DATE] included full code or full resuscitation status, oxygen at 5 liters per minute via trach collar, tracheostomy care every day shift. Resident #1 had a baseline care plan initiated on [DATE] for risk for respiratory complications related to shortness of breath and tracheostomy. The care plan approaches included administer medications/treatments per physician orders, administer oxygen via nasal cannula as ordered, observe for signs and symptoms of respiratory complication, and notify the physician of abnormal findings. The BIMS (Brief Interview For Mental Status) Evaluation with effective date of [DATE] at 1:10 PM, revealed a score of 5, that indicated the resident had severe cognitive impact. A progress note documented by RN A dated [DATE] at 11:59 PM, revealed the resident took off trach x 2 and refused oxygen. A progress note dated [DATE] at 1:57 AM, revealed RN D found the resident's oxygen mask on the floor, and his trach was out. The documentation indicated RN D attempted to reinsert the trach, but due to resistance, resident #1 was sent out to the hospital for trach replacement. A progress note dated [DATE] at 4:57 AM, revealed the resident returned to the facility from the hospital at 4:15 AM with a trach in place, and he was connected to oxygen via a trach collar. Nursing documentation on [DATE] revealed that at 7:00 AM the trach was pulled out again, and the resident was sent out to the hospital. A progress note dated [DATE] at 1:36 PM, read, Resident alert and responsive, returned from ED visit this AM post trach cannula removal, increase agitation, restlessness. Returned with new orders for Lorazepam 0.5 mg via G-tube every 8 hours as needed. Lorazepam is a medication used to treat anxiety (retrieved on [DATE] from www.webmd.com). A progress note documented by Registered Nurse (RN) A on [DATE] at 7:35 PM, read, Resident was on the floor face down. On assessment responded to name when called and had a pulse. 911 was called immediately at 7:35 PM and ambulance was in at 7:38 PM . Ambulance was given resident documents and went into the room to transfer resident out to the hospital. Started CPR on resident and resident later died at 7:56 PM. Review of the eInteract Change in Condition Evaluation with effective date [DATE] at 7:35 PM revealed the resident fell from his bed and was observed on the floor face down. The document noted 911 was called and the resident expired at 7:56 PM. An eInteract Transfer Form with effective date of [DATE] at 7:35 PM, revealed the resident's most recent blood pressure, pulse, respiration, and temperature were obtained on [DATE] at 1:30 PM. His most recent oxygen saturation level was checked on [DATE] at 7:50 AM, and his last blood glucose level obtained on [DATE] at 4:47 PM. The medical record contained no documentation of assessment findings or vital signs for the resident after he was discovered on the floor. Review of the resident's clinical record revealed no documentation to indicate resident #1's physician was made aware of his actions related to pulling out his trach and being transferred to the ED on two separate occasions. There was no documentation to show any actions including increased observations were implemented after each decannulation to prevent reoccurrence, and no evidence of communication with the physician regarding the resident's escalating agitation with potentially harmful behavioral symptoms. Review of the resident #1's Medication Administration Record (MAR) revealed nurses did not administer the anti-anxiety drug Lorazepam although he exhibited restless behavior. The medical record showed no documentation to reflect completion of a thorough nursing assessment including verification of the presence and position of the trach, or that he was connected to oxygen. There was no evidence nurses attempted to ensure resident #1 had a patent airway and was not lying on the trach tubing to obstruct his airway after he was found face down on the floor. On [DATE] at 8:10 AM, in a telephone interview, the investigating law enforcement officer assigned to resident #1's case recalled he arrived on scene on [DATE] between 9:30 PM and 10:00 PM and found resident #1's body still on the floor. He stated he interviewed the two nurses involved in the incident and discovered the charge nurse was not initially informed of the resident's fall to the floor. The investigating officer stated his findings were that facility staff called 911 on [DATE] at 7:33 PM, and the first officer arrived at 7:47 PM. He explained when the officer entered the resident's room, his body camera footage showed the resident was on the floor face down, and only one staff, later identified to be Certified Nursing Assistant (CNA) C, who was not trained in CPR, was in the room with the resident. The investigating officer stated when the responding officer asked the CNA if the resident was still breathing, she had a confused look and bent down to look at the resident. The responding officer turned to alert a nurse and observed EMS personnel approaching the room. The investigating officer verbalized the body camera footage showed EMS personnel arrived approximately 30 seconds after the responding officer. He stated the assigned nurse, RN B reported she assessed the resident's condition, respiration, and pulse, noted he was still breathing, and left him on the floor. When he asked why the resident was not moved, the assigned nurse explained she did not move him for fear of causing further injury. RN B reported she left the room to call EMS and the other nurse stayed behind, while the CNA arrived to change the resident who had been incontinent of bowel and bladder and kept eyes on him until EMS arrived. The responding officer was not able to confirm if the resident was breathing when EMS arrived, but during review of the body camera footage, the investigating officer heard the voice of an EMS personnel say, We've got nothing, which suggested the resident had no pulse. He recalled shortly after that announcement, the video footage showed EMS personnel started CPR which included three rounds of chest compressions and use of Epinephrine, a drug used to stimulate the heart during cardiac arrest, but eventually they called the resident's time of death at 7:56 PM. The investigating officer explained RN B informed the responding officer she did not leave the resident's room until the Fire Department came. However, when she was informed video footage of the police officer's body camera was shared, RN B altered her statement to explain she left resident #1's room when she knew EMS was in the building. The interviews and activities at the scene were recorded by the responding officer's body camera. On [DATE] at 7:42 AM, in a telephone interview, RN A confirmed resident #1 was on her assignment on [DATE] during the 3:00 PM to 11:00 PM shift. She recalled the off-going day shift nurse told her the resident went to the hospital overnight because he pulled out his trach and would not allow nurses to replace it. RN A was informed the resident received Lorazepam in the hospital and returned to the facility with a prescription for the drug. She acknowledged she received instruction to administer the Lorazepam if resident #1 became aggressive. RN A recalled resident #1 was calm when she administered his routine medication and checked his blood glucose at about 5:00 PM. She stated the last time she saw him was at 6:45 PM and the tubing that connected the oxygen to the trach mask was around his neck. She stated she removed and rearranged the trach oxygen tubing and observed the resident moving his hands up and down. She explained she continued passing medication until approximately 7:35 PM when RN B informed her a resident was on the floor. She stated they both went in to check and resident #1 was on the floor, face down. RN A said the resident's trach was in place, he was breathing, and his color was good. She recalled he had a bowel movement, so she asked CNA C to change him but advised her to be careful in moving the resident. She stated she then went to the nurses' station, called 911, reported that the resident was on the floor face down, and was told to make him comfortable but not move him, and have his medical record available for EMS. RN A could not recall if she informed the 911 operator the resident had a tracheostomy. RN A confirmed she directed a police officer and the EMS personnel to the resident's room when they arrived, and soon after, she found out they initiated CPR. RN A stated when she found the resident face down on the floor, she did not have time to check his blood pressure and only checked for a pulse and noted he was breathing and comfortable. She could not say if resident #1 was lying on his trach when she evaluated him. On [DATE] at 2:02 PM, in a telephone interview, RN B recalled on [DATE] she saw legs on the floor in resident #1's room when she walked past the doorway. She stated she called RN A, who came into the room, got down on the floor, tapped the resident on his shoulder, and he responded. RN B recalled RN A commented that his response was not at his baseline status, and she did not want to turn him over onto his back as she was afraid he might have suffered a fracture. RN B confirmed she was not able to see the resident's trach and could not see if he was lying on the trach oxygen tubing. RN B added she knew the resident was breathing as she heard him making grunting and moaning noises. She verbalized that RN A left the room to call 911 as CNA C removed the resident's soiled brief and cleaned up the floor while the resident remained face down on the floor. RN B confirmed she was not in the resident's room when paramedics arrived as she left to take care of her assigned residents. On [DATE] at 2:41 PM, in a telephone interview, CNA C stated she was assigned to resident #1 on [DATE], but at the time he fell she was assigned to monitor residents at risk for falls in the day room. CNA C explained during the change of shift report, the off-going CNA told her to monitor resident #1 closely as he already went out to the hospital twice because he pulled out his trach. She said the resident was not placed on one-to-one observation. CNA C stated RN A told her she needed help, and as soon as another staff member relieved her in the day room she went to resident #1's room. She recalled the resident was on the floor face down, and a sheet was on the floor. She explained she removed the sheet and the resident's soiled brief but did not get to clean him up as she had to move a table and chair to accommodate EMS personnel to work. On [DATE] at 10:59 AM, an interview was conducted with the Administrator, the Director of Nursing (DON), and the Regional Consultant Nurse. The DON stated the night shift staff verbalized they rounded on resident #1 on [DATE], and on his return from the hospital on [DATE] at 4:57 AM, CNAs and nurses increased the frequency of rounding. During review of the resident's clinical record, the DON confirmed there was no documentation to indicate staff initiated increased supervision for the resident. The DON explained information regarding increased frequency of rounding was based on statements obtained from the nurse and CNA assigned to the resident on the 11:00 PM to 7:00 AM shift from [DATE] to [DATE]. When asked what interventions were put in place to protect the resident's trach tube after he returned to the facility on [DATE] at 1:36 PM, the DON stated the resident was not agitated and did not need a dose of the newly ordered Lorazepam. He validated the resident was not placed on one-to-one observation to ensure he did not decannulate himself again. The DON explained RN A last saw the resident at 6:45 PM, when she adjusted the trach oxygen tubing that was stuck by his head, and he allowed the nurse to untangle it. He stated the resident was confused but calm when RN A left the room. The Administrator and DON stated the facility conducted an incident investigation and a Root Cause Analysis (RCA) showed Fall due to confusion of the resident, initiated some kind of movement and fell out of bed. The Administrator, DON, and Regional Consultant Nurse stated the facility felt the resident received appropriate care after he fell from his bed; however, the incident investigation and RCA did not identify and address the failure to assess the resident's tracheostomy and lack of an oxygen source as contributing factors to his death. Review of the EMS Patient Care Record-Admin/Hospital form with call date/time of [DATE] at 7:35 PM revealed EMS personnel arrived at the facility and found the resident unresponsive, lying prone on the floor next to his bed, and his hands and arms up to his forearm appeared pale. The document revealed the resident's fall from bed was unwitnessed, and when he was noticed on the ground by another staff member walking past his room, they called 911 and left him in that position. Documentation read, According to the staff, he was transported to [name of hospital] last night at [1:57 AM] for pulling his trach out and returned at [4:15 AM]. He pulled his trach out again and was transported to [name of hospital] at [7:34 AM] this morning and returned around [1:30 PM]. His nurse advised they gave him Ativan at the hospital so when she was assessing him at the beginning of her shift, he was acting loopy and drowsy. The EMS form revealed the resident was rolled onto his back and on assessment, no radial or carotid pulse was present and CPR was initiated. The document indicated the resident was usually on 5 liters of oxygen, and it was noticed that the oxygen tube was not attached to his trach. The form read, After 5 cycles of CPR, [patient] remained in asystole (a condition in which the heart ceases to beat) and was pronounced dead at [7:56 PM]. An essential duty and responsibility listed on the Job description for Registered Nurse with date of [DATE] read, Document in EHR (Electronic Health Record) in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care. The policy Medical Emergency Response implemented on 11/2020, and reviewed/revised on [DATE] read, the employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance . A nurse will: Assess the situation and determine the severity of the emergency. Stay with the resident .If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services. The facility's policy Abuse, Neglect and Exploitation with implementation date of 11/2020 and reviewed/revised date of [DATE] described neglect as a failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: *On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, DON, and the Medical Director. The facility discussed and determined a root cause for the incident. *On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the Administrator and DON on their responsibility to ensure nursing staff receive education and competency to provide quality care to the residents. *On [DATE], an Ad Hoc QAPI committee meeting was held with the Medical Director present to revisit and revise the RCA for the incident. The facility's incident/accident policy was reviewed and revised to include if a serious injury is known or suspected, a nurse remains with the resident and designate a staff member to announce Code Blue, if necessary, notify the physician and call 911 as needed. * On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the facility management on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility's fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. * On [DATE], the Administrator/designee initiated education with facility and contract employees on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. *On [DATE], the Administrator/designee continued education with facility and contract employees on incident/accidents, abuse and neglect, responding to medical emergencies and the facility fall prevention program policy. Post-tests were completed to validate competency of education received. Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. 110 of 129 equaling 86% facility and contract staff were educated with posttests. Remaining facility and contract staff will receive education prior to accepting assignment. * On [DATE], licensed nurses were educated on facility oxygen administration policy with post-tests to validate competency and were provided further education on responding to medical emergencies with a focus on assessing the resident for injuries and respiratory complications and remaining with the resident until emergency medical personnel arrive and assume care of the resident. Return demonstrations were completed to validate nurse competency. * On [DATE], there were no residents with a tracheostomy currently residing in the facility. The facility will schedule an outside Respiratory Therapy vendor to provide in-person training to the nurse managers and additional nurses in the facility. The facility will not accept tracheostomy dependent residents until their Licensed nurses have been trained on providing tracheostomy care with return demonstration to validate competency. Newly hired nurses will receive training and competency evaluation during orientation period. Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. 110 of 129 equaling 86% facility and contract staff were educated with posttests. Remaining facility and Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Incident/Accident, Fall Prevention Program, Medical Emergency Response, and Abuse/Neglect. On [DATE], interviews were conducted with six RNs, two LPN, 6 CNAs, one Central supply personnel, and one Floor tech. All verbalized understanding of the education provided. The facility currently had no other tracheostomy dependent resident. The resident sample was expanded to include additional residents who were at risk for falls, and two residents who were deceased . Observations, interviews, and record reviews revealed no concerns for residents #2, #5, #6, #7, #8 and #9 related to fall prevention interventions, and change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide emergency care and services for an oxygen dependent resident with a tracheostomy to prevent the dislodgement of life saving device after a fall for 1 of 7 sampled residents, (#1). A tracheostomy (also called a tracheotomy) 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 (retrieved on [DATE] from www.hopkinsmedicine.org). Removal of a trach tube, or decannulation, is a medical emergency and can be fatal as respiratory and cardiac compromise and/or failure can occur quickly. Resident #1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure and a risk alert for falls. He breathed through a tracheostomy tube and was dependent on continuous oxygen therapy. Within hours of his admission, resident #1 pulled out his tracheostomy tube on [DATE] at approximately 2:00 AM and had to be transferred to the hospital Emergency Department (ED) for replacement of the tube or cannula. He returned to the facility at approximately 5:00 AM, but a couple of hours later at approximately 7:00 AM, resident #1 again removed his tracheostomy tube and had to be transported to the hospital ED for reinsertion of another cannula. He returned to the facility on [DATE] at approximately at 1:30 PM. Despite two trips to the hospital within a 12-hour period for the decannulation emergencies, the facility did not provide increased supervision to mitigate his behavioral symptoms and ensure the safety and well-being of resident #1. Later that evening, on [DATE] at approximately 7:30 PM, Registered Nurse (RN) B passed resident #1's room and observed him face down on the floor. She notified the resident's assigned nurse, RN A, who checked the resident then went to the nurses' station to call 911, leaving the resident face down on the floor with RN B and Certified Nursing Assistant (CNA) C in the room. A police officer arrived at 7:36 PM and entered resident #1's room where he observed CNA C, but there was no licensed nurse present to assess and monitor the resident's status. Emergency Medical Services (EMS) personnel who arrived soon after the police officer, rolled the resident onto his back, discovered he was not connected to an oxygen source, and found him to be without a pulse and respirations. EMS personnel immediately initiated Cardiopulmonary Resuscitation (CPR) but they were unsuccessful in reviving resident #1 and he was pronounced dead at 7:56 PM. The facility's failure to properly assess and respond to a medical emergency for an oxygen-dependent resident with a tracheostomy contributed to resident #1's death, and placed all residents who had a tracheostomy or depended on continuous oxygen therapy at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F600, F695, F726 Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. His diagnoses included, acute/chronic respiratory failure, non-traumatic ischemic infarction of muscle, tracheostomy dependent and feeding tube. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1's primary diagnosis was chronic respiratory failure. The document indicated he was alert, but disoriented, and could follow simple instructions. His Trach size was 4 and he received oxygen via a trach collar. Resident #1's admission physician orders dated [DATE] included full code or full resuscitation status, oxygen at 5 liters per minute via trach collar, and tracheostomy care every day shift. The BIMS (Brief Interview For Mental Status) Evaluation dated [DATE] at 1:10 PM revealed a score of 5 out of 15 that indicated the resident had severe cognitive impact. The Initial Respiratory Evaluation, Treatment Plan And Recommendations dated [DATE] revealed the resident's treatment diagnosis was respiratory failure (Trach). The document showed the required size of the resident's trach and indicated an extra trach and back-up trach were available, and Respiratory Therapy (RT) would provide trach care three days a week. The Fall Risk Evaluation dated [DATE] revealed resident #1 was considered at risk for falls with a score of 13. A total score of 10 or greater would be considered High risk for potential falls. Resident #1 had a baseline care plan initiated on [DATE] for risk for respiratory complications related to shortness of breath and tracheostomy. The care plan approaches included administer medications/treatments per physician orders, administer oxygen via nasal cannula as ordered, observe for signs and symptoms of respiratory complication, and notify the physician of abnormal findings. Nursing progress notes documented the resident's oxygen mask was on the floor and the resident's trach was out on [DATE] at 1:57 AM. The nurse, RN D attempted to reinsert the trach but was unable to and the resident was transferred to the hospital for trach replacement. The resident returned to the facility at 4:15 AM and at 7:00 AM, his trach was pulled out again. The resident was transferred to the hospital a second time for trach replacement and returned on [DATE] at 1:36 PM. The note read, Resident alert and responsive, returned from ED visit this AM post trach cannula removal, increase agitation, restlessness. A progress note documented by RN A on 2/24/ 23 at 7:35 PM read, Resident was on the floor face down. On assessment responded to name when called and had a pulse. 911 was called immediately at 7:35 PMand ambulance was in at 7:38 PM. With a policeperson walked into the building at 7:36 PM.Ambulance was given resident documents and went into the room to transfer resident out to the hospital. Started CPR on resident and resident later died at 7:56 PM. Review of the eInteract Change in Condition Evaluation with effective date [DATE] at 7:35 PM revealed the resident fell from his bed and was observed on the floor face down. The document noted 911 was called and the resident expired at 7:56 PM. An eInteract Transfer Form with effective date of [DATE] at 7:35 PM revealed that the resident's most recent blood pressure, pulse, respiration, and temperature were obtained on [DATE] at 1:30 PM. His most recent oxygen saturation level was checked on [DATE] at 7:50 AM, and his last blood glucose level obtained on [DATE] at 4:47 PM. The medical record contained no documentation of assessment findings or vital signs for the resident after he was discovered on the floor. The resident's clincial record showed no documentation to reflect completion of a thorough nursing assessment including verification of the presence and position of the trach, or that he was connected to oxygen. There was no evidence nurses attempted to ensure resident #1 had a patent airway and was not lying on the trach tubing to obstruct his airway after he was found face down on the floor. On [DATE] at 8:10 AM, in a telephone interview, the investigating law enforcement officer assigned to resident #1's case recalled he arrived on scene on [DATE] between 9:30 PM and 10:00 PM and found resident #1's body still on the floor, face up. He stated he interviewed the two nurses involved in the incident and discovered the charge nurse was not initially informed of the resident's fall to the floor. The investigating officer stated his findings were that facility staff called 911 on [DATE] at 7:33 PM and the first officer arrived at 7:47 PM. He explained when the officer entered the resident's room, his body camera footage showed the resident was on the floor face down, and only one staff, later identified to be Certified Nursing Assistant (CNA) C, who was not trained in CPR, was in the room with the resident. The investigating officer stated when the responding officer asked the CNA if the resident was still breathing, she had a confused look and bent down to look at the resident. The responding officer turned to alert a nurse and observed EMS personnel approaching the room. The investigating officer verbalized the body camera footage showed EMS personnel arrived approximately 30 seconds after the responding officer. He stated the assigned nurse, RN B reported she assessed the resident's condition, respiration, and pulse, noted he was still breathing, and left him on the floor. When he asked why the resident was not moved, the assigned nurse explained she did not move him for fear of causing further injury. RN B reported she left the room to call EMS and the other nurse stayed behind, while the CNA arrived to change the resident who had been incontinent of bowel and bladder. urine, and the kept eyes on him until EMS arrived. The responding officer was not able to confirm if the resident was breathing when EMS arrived, but during review of the body camera footage, the investigating officer heard the voice of an EMS personnel say, We've got nothing, which suggested the resident had no pulse. He recalled shortly after that announcement, the video footage showed EMS personnel started CPR which included three rounds of chest compressions and use of epinephrine, a drug used to stimulate the heart during cardiac arrest, but eventually they called the resident's time of death at 7:56 PM. The investigating officer explained RN B informed the responding officer she did not leave the resident's room until the Fire Department came. However, when she was informed video footage of the police officer's body camera was shared, RN B altered her stated to explain she left resident #1's room when she knew EMS was in the building. The interviews and activities at the scene were recorded by the responding officer's body camera. On [DATE] at 7:42 AM, in a telephone interview, RN A confirmed resident #1 was on her assignment on [DATE] during the 3:00 PM to 11:00 PM shift. She recalled the off-going day shift nurse told her the resident went to the hospital overnight because he pulled out his trach and would not allow nurses to replace it. RN A recalled resident #1 was calm when she administered his routine medication and checked his blood glucose at about 5:00 PM. She stated the last time she saw him was at 6:45 PM and the tubing that connected the oxygen to the trach mask was around his neck. She stated she removed and rearranged the trach oxygen tubing and observed the resident moving his hands up and down. She explained she continued passing medication until approximately 7:35 PM when RN B informed her a resident was on the floor. She stated they both went in to check and resident #1 was on the floor, face down. RN A said the resident was breathing, and his color was good. She explained she did not have time to check his blood pressure, and verbalized that all she checked was his pulse, and she left him lying on the floor face down. RN A stated she has worked with residents with a trach before, however she could not say if resident #1 was lying on his trach when he was found on the floor face down. RN A stated that when she called the resident's son to notify him of the resident's fall, and that she was going to send him to the hospital, the son asked why no one was watching him. She did not have an answer for him, telling him she had to prepare the documents for transfer. She recalled he had a bowel movement, so she asked CNA C to change him but advised her to be careful in moving the resident. She stated she then went to the nurses' station, called 911, reported that the resident was on the floor face down, and was told to make him comfortable but not move him, and have his medical record available for EMS. RN A could not recall if she informed the 911 operator the resident had a tracheostomy. RN A confirmed she directed a police officer and the EMS personnel to the resident's room when they arrived, and soon after, she found out they initiated CPR. RN A stated when she found the resident face down on the floor, she did not have time to check his blood pressure and only checked for a pulse and noted he was breathing and comfortable. She confirmed she had worked with residents with tracheostomies before; however, she could not say if resident #1 was lying on his trach when she evaluated him. On [DATE] at 10:59 AM, an interview was conducted with the Administrator, the Director of Nursing (DON), and the Regional Consultant Nurse. The DON stated the night shift staff verbalized they rounded on resident #1 on [DATE], and on his return from the hospital on [DATE] at 4:57 AM, CNAs and nurses increased the frequency of rounding. During review of the resident's clinical record, the DON confirmed there was no documentation to indicate staff initiated increased supervision for the resident. The DON explained information regarding increased frequency of rounding was based on statements obtained from the nurse and CNA assigned to the resident on the 11:00 PM to 7:00 AM shift from [DATE] to [DATE]. When asked what interventions were put in place to protect the resident's trach tube after he returned to the facility on [DATE] at 1:36 PM, the DON stated the resident was not agitated and he validated the resident was not placed on one-to-one observation to ensure he did not decannulate himself again. The DON explained RN A last saw the resident at 6:45 PM, when she adjusted the trach oxygen tubing that was stuck by his head, and he allowed the nurse to untangle it. He stated the resident was confused but calm when RN A left the room. The Administrator and DON stated the facility conducted an incident investigation and a Root Cause Analysis (RCA) showed Fall due to confusion of the resident, initiated some kind of movement and fell out of bed. The Administrator, DON, and Regional Consultant Nurse stated the facility felt the resident received emergency care; however, the incident investigation and RCA did not identify and address the failure to assess the resident's tracheostomy and lack of an oxygen source as contributing factors to his death. On [DATE] at 2:02 PM, in a telephone interview, RN B recalled on [DATE] she saw legs on the floor in resident #1's room when she walked past the doorway. She stated she called RN A, who came into the room, got down on the floor, tapped the resident on his shoulder, and he responded. RN B recalled RN A commented that his response was not at his baseline status, and she did not want to turn him over onto his back as she was afraid he might have suffered a fracture. RN B confirmed she was not able to see the resident's trach and could not see if he was lying on the trach oxygen tubing. RN B added she knew the resident was breathing as she heard him making grunting and moaning noises. She verbalized that RN A left the room to call 911 as CNA C removed the resident's soiled brief and cleaned up the floor while the resident remained face down on the floor. RN B confirmed she was not in the resident's room when paramedics arrived as she left to take care of her assigned residents. On [DATE] at 2:41 PM, in a telephone interview, CNA C stated she was assigned to resident #1 on [DATE], but at the time he fell she was assigned to monitor residents at risk for falls in the day room. CNA C explained during the change of shift report, the off-going CNA told her to monitor resident #1 closely as he already went out to the hospital twice because he pulled out his trach. She said the resident was not placed on one-to-one observation. CNA C stated RN A told her she needed help, and as soon as another staff member relieved her in the day room she went to resident #1's room. She recalled the resident was on the floor face down, and a sheet was on the floor. She explained she removed the sheet and the resident's soiled brief but did not get to clean him up as she had to move a table and chair to accommodate EMS personnel to work. Review of the EMS Patient Care Record-Admin/Hospital form with call date/time of [DATE] at 7:35 PM revealed EMS personnel arrived at the facility and found the resident unresponsive, lying prone on the floor next to his bed, and his hands and arms up to his forearm appeared pale. The document revealed the resident's fall from bed was unwitnessed, and when he was noticed on the ground by another staff member walking past his room, they called 911 and left him in that position. Documentation read, According to the staff, he was transported to [name of hospital] last night at [1:57 AM] for pulling his trach out and returned at [4:15 AM]. He pulled his trach out again and was transported to [name of hospital] at [7:34 AM] this morning and returned around [1:30 PM]. His nurse advised they gave him Ativan at the hospital so when she was assessing him at the beginning of her shift, he was acting loopy and drowsy. The EMS form revealed the resident was rolled onto his back and on assessment, no radial or carotid pulse was present and CPR was initiated. The document indicated the resident was usually on 5 liters of oxygen, and it was noticed that the oxygen tube was not attached to his trach. The form read, After 5 cycles of CPR, [patient] remained in asystole (a condition in which the heart ceases to beat) and was pronounced dead at [7:56 PM]. The facility's policy Medical Emergency Response implemented on 11/2020, and reviewed/revised on [DATE] read, the employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance . A nurse will: Assess the situation and determine the severity of the emergency. Stay with the resident .If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: * On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, DON, and the Medical Director. The facility discussed and determined a root cause for the incident. * On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the Administrator and DON on their responsibility to ensure nursing staff receive education and competency to provide quality care to the residents. * On [DATE], an Ad Hoc QAPI committee meeting was held with the Medical Director present to revisit and revise the RCA for the incident. The facility's incident/accident policy was reviewed and revised to include if a serious injury is known or suspected, a nurse remains with the resident and designate a staff member to announce Code Blue, if necessary, notify the physician and call 911 as needed. * On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the facility management on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility's fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. * On [DATE], the Administrator/designee initiated education with facility and contract employees on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. * On [DATE], the Administrator/designee continued education with facility and contract employees on incident/accidents, abuse and neglect, responding to medical emergencies and the facility fall prevention program policy. Post-tests were completed to validate competency of education received. Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. 110 of 129 equaling 86% facility and contract staff were educated with posttests. Remaining facility and contract staff will receive education prior to accepting assignment. * On [DATE], licensed nurses were educated on facility oxygen administration policy with post-tests to validate competency and were provided further education on responding to medical emergencies with a focus on assessing the resident for injuries and respiratory complications and remaining with the resident until emergency medical personnel arrive and assume care of the resident. Return demonstrations were completed to validate nurse competency. * On [DATE], there were no residents with a tracheostomy currently residing in the facility. The facility will schedule an outside Respiratory Therapy vendor to provide in-person training to the nurse managers and additional nurses in the facility. The facility will not accept tracheostomy dependent residents until their Licensed nurses have been trained on providing tracheostomy care with return demonstration to validate competency. Newly hired nurses will receive training and competency evaluation during orientation period. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Incident/Accident, Fall Prevention Program, Medical Emergency Response, and Abuse/Neglect. On [DATE], interviews were conducted with six RNs, two LPN, six CNAs, one Central supply personnel, and one Floor tech. All verbalized understanding of the education provided. The facility currently had no other oxygen-dependent residents with tracheostomies. The resident sample was expanded to include additional residents who were at risk for falls, utilized oxygen and two residents who were deceased . Observations, interviews, and record reviews revealed no concerns for residents #2, #5, #6, #7, #8 and #9 related to fall prevention interventions, and change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary respiratory care and services for an oxygen-dependent resident with a tracheostomy to prevent repeated dislodgements of the life-saving device for 1 of 1 resident reviewed for tracheostomy status, (#1), and failed to ensure oxygen therapy was administered as ordered by the physician for 1 of 2 residents reviewed for oxygen use, (#2), of a total sample of 7 residents. A tracheostomy (also called a tracheotomy) 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 (retrieved on [DATE] from www.hopkinsmedicine.org). Removal of a trach tube, or decannulation, is a medical emergency and can be fatal as respiratory and cardiac compromise and/or failure can occur quickly. Resident #1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure and a risk alert for falls. He breathed through a tracheostomy tube and was dependent on continuous oxygen therapy. Within hours of his admission, resident #1 pulled out his tracheostomy tube on [DATE] at approximately 2:00 AM and had to be transferred to the hospital Emergency Department (ED) for replacement of the tube or cannula. He returned to the facility at approximately 5:00 AM, but a couple of hours later at approximately 7:00 AM, resident #1 again removed his tracheostomy tube and had to be transported to the hospital ED for reinsertion of another cannula. He returned to the facility on [DATE] at approximately at 1:30 PM. Despite two trips to the hospital within a 12-hour period for the decannulation emergencies, the facility did not provide increased supervision to mitigate his behavioral symptoms and ensure the safety and well-being of resident #1. Later that evening, on [DATE] at approximately 7:30 PM, Registered Nurse (RN) B passed resident #1's room and observed him face down on the floor. She notified the resident's assigned nurse, RN A, who checked the resident then went to the nurses' station to call 911, leaving the resident face down on the floor with RN B and Certified Nursing Assistant (CNA) C in the room. A police officer arrived at 7:36 PM, and entered resident #1's room where he observed CNA C, but there was no licensed nurse present to assess and monitor the resident's status. Emergency Medical Services (EMS) personnel who arrived soon after the police officer, rolled the resident onto his back, discovered he was not connected to an oxygen source, and found him to be without a pulse and respirations. EMS personnel immediately initiated Cardiopulmonary Resuscitation (CPR) but they were unsuccessful in reviving resident #1 and he was pronounced dead at 7:56 PM. The facility's failure to develop and implement appropriate approaches to maintain optimal respiratory status, and failure to properly assess and respond to a medical emergency for an oxygen-dependent resident with a tracheostomy contributed to resident #1's death, and placed all residents who had a tracheostomy or depended on continuous oxygen therapy at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F600, F684, and F726. 1. Review of the medical record revealed resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acute/chronic respiratory failure, tracheostomy status, diabetes, hypertension, and gastrostomy tube or feeding tube. He was transferred back to the hospital soon after he arrived at the facility. A Hospital Internal Medicine History and Physical note dated [DATE] explained resident #1 was just discharged from [name of the hospital] last night to SNF (Skilled Nursing Facility). Upon arrival at the SNF, they rerouted him to [name of the hospital] stating that their facility did not have the capability of taking care of patients with trach. They said that they were unaware that he had a trach when they accepted him. A hospital Internal Medicine progress note with a date of service of [DATE] at 1:57 PM, revealed while in the hospital, resident #1 required wrist restraints. The note indicated the hospital was in process of weaning use of the restraints and the resident was down to mittens only. His principal problem was noted as chronic respiratory failure, and his active problem was listed as Tracheostomy dependent. Resident #1's medical record showed the facility readmitted him eight days later, on [DATE]. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1's primary diagnosis was chronic respiratory failure. The document indicated he was alert and disoriented but could follow simple instructions. The form noted the resident's trach tube size was 4 and that he received oxygen via a trach collar. Resident #1's admission physician orders dated [DATE] included full code or full resuscitation status, oxygen at 5 liters per minute via trach collar, tracheostomy care every day shift, and Eliquis 5 milligram (mg) daily for blood clot prevention. The BIMS (Brief Interview For Mental Status) Evaluation with effective date of [DATE] at 1:10 PM, revealed a score of 5, that indicated the resident had severe cognitive impairment. The Initial Respiratory Evaluation, Treatment Plan And Recommendations dated [DATE] revealed the resident's treatment diagnosis was respiratory failure (Trach). The document showed the required size of the resident's trach and indicated an extra trach and back-up trach were available, and Respiratory Therapy (RT) would provide trach care three days a week. The Tracheostomy Flow Sheet revealed assessments conducted on [DATE] at 1:10 PM, and on [DATE] at 3:20 PM, noted the resident was on oxygen at 5 liters per minute, tracheostomy care was provided, and a spare trach and a handheld manual resuscitation bag valve mask were available. The Fall Risk Evaluation dated [DATE] revealed resident #1 was considered at risk for falls with a score of 13. A total score of 10 or greater was considered High risk for potential falls. The Skilled Evaluation with effective date of [DATE] revealed the resident's initial admission was on [DATE] and showed the resident was alert with some forgetfulness, oxygen device/delivery was by trach, and nutrition was via tube feed. The Respiratory Therapy Treatment Note with Clinical Assessment date of [DATE] revealed the resident arrived at the facility with a trach and was alert and stable. Resident #1 had a baseline care plan initiated on [DATE] for risk for respiratory complications related to shortness of breath and tracheostomy. The care plan approaches included administer medications/treatments per physician orders, administer oxygen via nasal cannula as ordered, observe for signs and symptoms of respiratory complications, and notify the physician of abnormal findings. A progress note documented by RN A dated [DATE] at 11:59 PM, revealed the resident took off his trach two times and refused oxygen. A progress note dated [DATE] at 1:57 AM, revealed RN D found the resident's oxygen mask on the floor, and his trach was out. The documentation indicated RN D attempted to reinsert the trach, but due to resistance, resident #1 was sent out to the hospital for trach replacement. A progress note dated [DATE] at 4:57 AM, revealed the resident returned to the facility from the hospital at 4:15 AM with a trach in place, and he was connected to oxygen via a trach collar. Nursing documentation on [DATE] revealed that at 7:00 AM the trach was pulled out again, and the resident was sent out to the hospital. A progress note dated [DATE] at 1:36 PM, read, Resident alert and responsive, returned from ED visit this AM post trach cannula removal, increase agitation, restlessness. Returned with new orders for Lorazepam 0.5 mg via G-tube every 8 hours as needed. Lorazepam is a medication used to treat anxiety (retrieved on [DATE] from www.webmd.com). A progress note documented by RN A on 2/24/ 23 at 7:35 PM, read, Resident was on the floor face down. On assessment responded to name when called and had a pulse. 911 was called immediately at 7:35 PM and ambulance was in at 7:38 PM. With a policeperson walked into the building at 7:36 PM.Ambulance was given resident documents and went into the room to transfer resident out to the hospital. Started CPR on resident and resident later died at 7:56 PM. Review of the eInteract Change in Condition Evaluation with effective date [DATE] at 7:35 PM, revealed the resident fell from his bed and was observed on the floor face down. The document noted 911 was called and the resident expired at 7:56 PM. An eInteract Transfer Form with effective date of [DATE] at 7:35 PM, revealed the resident's most recent blood pressure, pulse, respiration, and temperature were obtained on [DATE] at 1:30 PM. His most recent oxygen saturation level was checked on [DATE] at 7:50 AM, and his last blood glucose level was obtained on [DATE] at 4:47 PM. The medical record contained no documentation of assessment findings or vital signs for the resident after he was discovered on the floor. Clinical record review revealed no documentation to indicate resident #1's physician was made aware of his actions related to pulling out his trach and being transferred to the ED on two separate occasions. There was no documentation to show any actions were taken after each decannulation to prevent reoccurrence, and no evidence of communication with the physician regarding the resident's escalating agitation with potentially harmful behavioral symptoms. Review of resident #1's Medication Administration Record (MAR) revealed nurses did not administer the anti-anxiety drug Lorazepam although he exhibited restless behavior. The medical record showed no documentation to reflect completion of a thorough nursing assessment including verification of the presence and position of the trach, or that he was connected to oxygen. There was no evidence that nurses attempted to ensure resident #1 had a patent airway and was not lying on the trach tubing to obstruct his airway after he was found face down on the floor. On [DATE] at 8:10 AM, in a telephone interview, the investigating law enforcement officer assigned to resident #1's case recalled he arrived on scene on [DATE] between 9:30 PM and 10:00 PM, and found resident #1's body still on the floor, face up. He stated he interviewed the two nurses involved in the incident and discovered the charge nurse was not initially informed of the resident's fall to the floor. The investigating officer stated his findings were that facility staff called 911 on [DATE] at 7:33 PM, and the first officer arrived at 7:47 PM. He explained when the officer entered the resident's room, his body camera footage showed the resident was on the floor face down, and only one staff, later identified to be Certified Nursing Assistant (CNA) C, who was not trained in CPR, was in the room with the resident. The investigating officer stated when the responding officer asked the CNA if the resident was still breathing, she had a confused look and bent down to look at the resident. The responding officer turned to alert a nurse and observed EMS personnel approaching the room. The investigating officer verbalized the body camera footage showed EMS personnel arrived approximately 30 seconds after the responding officer. He stated the assigned nurse, RN B reported she assessed the resident's condition, respiration, and pulse, noted he was still breathing, and left him on the floor. When he asked why the resident was not moved, the assigned nurse explained she did not move him for fear of causing further injury. RN B reported she left the room to call EMS and the other nurse stayed behind, while the CNA arrived to change the resident who had been incontinent of bowel and bladder and kept eyes on him until EMS arrived. The responding officer was not able to confirm if the resident was breathing when EMS arrived, but during review of the body camera footage, the investigating officer heard the voice of an EMS personnel say, We've got nothing, which suggested the resident had no pulse. He recalled shortly after that announcement, the video footage showed EMS personnel started CPR which included three rounds of chest compressions and use of Epinephrine, a drug used to stimulate the heart during cardiac arrest, but eventually they called the resident's time of death at 7:56 PM. The investigating officer explained RN B informed the responding officer she did not leave the resident's room until the Fire Department came. However, when she was informed video footage of the police officer's body camera was shared, RN B altered her statement to explain she left resident #1's room when she knew EMS was in the building. The interviews and activities at the scene were recorded by the responding officer's body camera. On [DATE] at 11:47 AM, the B Wing Licensed Practical Nurse (LPN) Unit Manager (UM) stated resident #1 was admitted to the B Wing on [DATE] between 1:00 PM and 2:00 PM. She recalled the Respiratory Therapist (RT) was at the facility to ensure all the required equipment and devices were set up correctly. She stated the resident's trach was in place and intact and he was calm. The UM verbalized that on Friday [DATE] at 2:31 AM, she received a notification via email that the resident was sent to the hospital via 911. She recalled when she came to work later that morning, she was made aware the resident decannulated himself and although staff attempted to reinsert the trach, resident #1 was resisting and 911 had to be called. She stated the resident returned to the facility with a new trach but a short time after his return, at about 7:00 AM, he was sent out to the hospital again for the same reason. The UM stated he returned to the facility at about 12:30 PM or 1:00 PM, with a newly inserted trach and a prescription for Lorazepam 0.5 mg via his G-tube. She stated resident #1 received the antianxiety medication in the hospital prior to returning to the facility. The UM stated that on [DATE] at 7:33 PM, she received another email indicating 911 was again called from the B Wing nurses' station for resident #1. She said she was notified the following day, on [DATE], that the resident had fallen out of bed and passed away. She was told the family was called, the Medical Examiner was involved, and the police and EMS came. On [DATE] at 12:40 PM, an interview was conducted with the Administrator and the Director of Nursing (DON). They confirmed they were knowledgeable of the sequence of events related to resident #1's admission and two transfers to the hospital for emergency services after self-decannulation. The DON stated on [DATE] at about 7:30 PM, he was informed the resident coded or stopped breathing, when EMS personnel were in the facility. The Administrator stated the Weekend Supervisor notified him of the incident. He verbalized after interviewing the Weekend Supervisor and reviewing the resident's medical chart, it appeared the resident coded after EMS personnel entered the facility. On [DATE] at 7:42 AM, in a telephone interview, RN A confirmed resident #1 was on her assignment on [DATE] during the 3:00 PM to 11:00 PM shift. She recalled the off-going day shift nurse told her the resident went to the hospital overnight because he pulled out his trach and would not allow nurses to replace it. RN A was informed the resident received Lorazepam in the hospital and returned to the facility with a prescription for the drug. She acknowledged she received instruction to administer the Lorazepam if resident #1 became aggressive. RN A recalled resident #1 was calm when she administered his routine medication and checked his blood glucose at about 5:00 PM. She stated the last time she saw him was at 6:45 PM and the tubing that connected the oxygen to the trach mask was around his neck. She stated she removed and rearranged the trach oxygen tubing and observed the resident moving his hands up and down. She explained she continued passing medication until approximately 7:35 PM when RN B informed her a resident was on the floor. She stated they both went in to check and resident #1 was on the floor, face down. RN A said the resident's trach was in place, he was breathing, and his color was good. She recalled he had a bowel movement, so she asked CNA C to change him but advised her to be careful in moving the resident. She stated she then went to the nurses' station, called 911, reported the resident was on the floor face down, and was told to make him comfortable but not move him, and have his medical record available for EMS. RN A could not recall if she informed the 911 operator the resident had a tracheostomy. RN A confirmed she directed a police officer and the EMS personnel to the resident's room when they arrived, and soon after, she found out they initiated CPR. RN A stated when she found the resident face down on the floor, she did not have time to check his blood pressure and only checked for a pulse and noted he was breathing and comfortable. She confirmed she had worked with residents with tracheostomies before; however, she could not say if resident #1 was lying on his trach when she evaluated him. On [DATE] at 10:59 AM, an interview was conducted with the Administrator, the DON, and the Regional Consultant Nurse. The DON stated the night shift staff verbalized they rounded on resident #1 on [DATE], and on his return from the hospital on [DATE] at 4:57 AM, CNAs and nurses increased the frequency of rounding. During review of the resident's clinical record, the DON confirmed there was no documentation to indicate staff initiated increased supervision for the resident. The DON explained information regarding increased frequency of rounding was based on statements obtained from the nurse and CNA assigned to the resident on the 11:00 PM to 7:00 AM shift from [DATE] to [DATE]. When asked what interventions were put in place to protect the resident's trach tube after he returned to the facility on [DATE] at 1:36 PM, the DON stated the resident was not agitated and did not need a dose of the newly ordered Lorazepam. He validated the resident was not placed on one-to-one observation to ensure he did not decannulate himself again. The DON explained RN A last saw the resident at 6:45 PM, when she adjusted the trach oxygen tubing that was stuck by his head, and he allowed the nurse to untangle it. He stated the resident was confused but calm when RN A left the room. The Administrator and DON stated the facility conducted an incident investigation and a Root Cause Analysis (RCA) showed Fall due to confusion of the resident, initiated some kind of movement and fell out of bed. They explained residents were re-evaluated for fall risk and the Regional Consultant Nurse conducted audits of skin assessment for newly admitted residents and reviewed wound treatment orders for the month of February 2023. The Administrator, DON, and Regional Consultant Nurse stated the facility felt the resident received emergency care; however, the incident investigation and RCA did not identify and address the failure to assess the resident's tracheostomy and lack of an oxygen source as contributing factors to his death. On [DATE] at 2:02 PM, in a telephone interview, RN B recalled on [DATE] she saw legs on the floor in resident #1's room when she walked past the doorway. She stated she called RN A, who came into the room, got down on the floor, tapped the resident on his shoulder, and he responded. RN B recalled RN A commented that his response was not at his baseline status, and she did not want to turn him over onto his back as she was afraid he might have suffered a fracture. RN B confirmed she was not able to see the resident's trach and could not see if he was lying on the trach oxygen tubing. RN B added she knew the resident was breathing as she heard him making grunting and moaning noises. She verbalized that RN A left the room to call 911 as CNA C removed the resident's soiled brief and cleaned up the floor while the resident remained face down on the floor. RN B confirmed she was not in the resident's room when paramedics arrived as she left to take care of her assigned residents. On [DATE] at 2:32 PM, in a telephone interview, the RN Weekend Supervisor stated that on [DATE], he was not aware resident #1 fell until he saw the EMS crew entering the building. He stated he followed them to the B Wing, where additional EMS personnel were already in the resident's room. The Weekend Supervisor recalled one of the nurses told him the resident fell from his bed, was still breathing, and 911 was called. The Weekend Supervisor stated when EMS personnel left the facility he attempted to enter resident #1's room, but a police officer told him he could not go in as it was the scene of an active investigation. The Weekend Supervisor explained the facility's usual post-fall process was for a staff member to locate him and he would assess the resident. The Weekend Supervisor stated he was informed the resident had a trach, used supplemental oxygen, and had anxiety. He acknowledged he was not sure if the resident got any anti-anxiety medication, and he was not aware that increased observation was initiated for the resident, except that the assigned nurse and CNA continued to round and check on the resident. On [DATE] at 2:41 PM, in a telephone interview, CNA C stated she was assigned to resident #1 on [DATE], but at the time he fell she was assigned to monitor residents at risk for falls in the day room. CNA C explained during the change of shift report, the off-going CNA told her to monitor resident #1 closely as he already went out to the hospital twice because he pulled out his trach. She said the resident was not placed on one-to-one observation. CNA C stated RN A told her she needed help, and as soon as another staff member relieved her in the day room she went to resident #1's room. She recalled the resident was on the floor face down, and a sheet was on the floor. She explained she removed the sheet and the resident's soiled brief but did not get to clean him up as she had to move a table and chair to accommodate EMS personnel to work. On [DATE] at 3:29 PM, in a telephone interview, the Medical Director stated he was notified of the incident with resident #1 after the fact. He was aware the resident was sent to the hospital a couple times, and recalled he was told the resident had stable vital signs when he was on the floor. The Medical Director verbalized that when the resident was lying face down, his airway would not necessarily be compromised. He explained the resident could have been compromised for several reasons. The Medical Director acknowledged he had lots of questions but thought everything was done to the scope of the ability and training of staff. He stated staff had basic competencies. Review of the EMS Patient Care Record-Admin/Hospital form with call date/time of [DATE] at 7:35 PM, revealed EMS personnel arrived at the facility and found the resident unresponsive, lying prone on the floor next to his bed, and his hands and arms up to his forearm appeared pale. The document revealed the resident's fall from bed was unwitnessed, and when he was noticed on the ground by another staff member walking past his room, they called 911 and left him in that position. Documentation read, According to the staff, he was transported to [name of hospital] last night at [1:57 AM] for pulling his trach out and returned at [4:15 AM]. He pulled his trach out again and was transported to [name of hospital] at [7:34 AM] this morning and returned around [1:30 PM]. His nurse advised they gave him Ativan at the hospital so when she was assessing him at the beginning of her shift, he was acting loopy and drowsy. The EMS form revealed the resident was rolled onto his back and on assessment, no radial or carotid pulse was present and CPR was initiated. The document indicated the resident was usually on 5 liters of oxygen, and it was noticed that the oxygen tube was not attached to his trach. The form read, After 5 cycles of CPR, [patient] remained in asystole (a condition in which the heart ceases to beat) and was pronounced dead at [7:56 PM]. The facility's policy for Tracheostomy Care implemented in [DATE] and reviewed/revised on [DATE] read, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice.The facility will ensure staff responsible for providing tracheostomy care.are trained and competent according to professional standards of practice. The facility's policy for Medical Emergency Response implemented in [DATE], and reviewed/revised on [DATE] read, The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance.A nurse will: Assess the situation and determine the severity of the emergency. Stay with the resident.If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services. Review of the Facility Assessment dated [DATE], indicated services and care offered was based on the residents' needs and special care needs included tracheostomy care. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: * On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, DON, and the Medical Director. The facility discussed and determined a root cause for the incident. * On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the Administrator and DON on their responsibility to ensure nursing staff receive education and competency to provide quality care to the residents. * On [DATE], an Ad Hoc QAPI committee meeting was held with the Medical Director present to revisit and revise the RCA for the incident. The facility's incident/accident policy was reviewed and revised to include if a serious injury is known or suspected, a nurse remains with the resident and designate a staff member to announce Code Blue, if necessary, notify the physician and call 911 as needed. * On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the facility management on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility's fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. * On [DATE], the Administrator/designee initiated education with facility and contract employees on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. * On [DATE], the Administrator/designee continued education with facility and contract employees on incident/accidents, abuse and neglect, responding to medical emergencies and the facility fall prevention program policy. Post-tests were completed to validate competency of education received. Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. 110 of 129 equaling 86% facility and contract staff were educated with posttests. Remaining facility and contract staff will receive education prior to accepting assignment. * On [DATE], licensed nurses were educated on facility oxygen administration policy with post-tests to validate competency and were provided further education on responding to medical emergencies with a focus on assessing the resident for injuries and respiratory complications and remaining with the resident until emergency medical personnel arrive and assume care of the resident. Return demonstrations were completed to validate nurse competency. * On [DATE], there were no residents with a tracheostomy currently residing in the facility. The facility will schedule an outside Respiratory Therapy vendor to provide in-person training to the nurse managers and additional nurses in the facility. The facility will not accept tracheostomy dependent residents until their Licensed nurses have been trained on providing tracheostomy care with return demonstration to validate competency. Newly hired nurses will receive training and competency evaluation during orientation period. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Incident/Accident, Fall Prevention Program, Medical Emergency Response, and Abuse/Neglect. On [DATE], interviews were conducted with six RNs, two LPN, six CNAs, one Central supply personnel, and one Floor tech. All verbalized understanding of the education provided. The facility currently had no other oxygen-dependent residents with tracheostomies. The resident sample was expanded to include additional residents who were at risk for falls, utilized oxygen and two residents who were deceased . Observations, interviews, and record reviews revealed no concerns for residents #2, #5, #6, #7, #8 and #9 related to fall prevention interventions, and change in condition. A concern was identified related to oxygen use for resident #2 that resulted in noncompliance that was not Immediate Jeopardy. 2. Review of the medical record revealed resident #2 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including encephalopathy, acute respiratory failure, and traumatic subdural hemorrhage. The resident had a physician order dated [DATE] for oxygen therapy at 2 Liters per minute (LPM) continuously via nasal cannula. On [DATE] at 9:50 AM and 11:30 AM, resident #2 was seated in his wheelchair close to the nurses' station. He wore oxygen that infused at 3 LPM via nasal cannula that was connected to an oxygen concentrator. On [DATE] at 11:37 AM, the resident's oxygen flow rate was observed with the A Wing LPN UM. She confirmed the Oxygen flow rate was set at 3 LPM, and she confirmed it should be set at 2 LPM. The resident's physician orders were reviewed with the UM, and she validated the resident was admitted on [DATE], and his physician ordered oxygen at 2 LPM. The A Wing LPN UM stated the resident's assigned nurses should check his oxygen settings every shift to ensure oxygen therapy was administered as ordered. On [DATE] at 3:24 PM, the DON stated oxygen therapy required a physician order and she

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to adequately conduct assessments, and develop and implement interventions to provide routine care and emergency services for an oxygen-dependent resident with a tracheostomy for 1 of 1 resident reviewed for tracheostomy status, of a total sample of 7 residents, (#1). A tracheostomy (also called a tracheotomy) 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 (retrieved on [DATE] from www.hopkinsmedicine.org). Removal of a trach tube, or decannulation, is a medical emergency and can be fatal as respiratory and cardiac compromise and/or failure can occur quickly. Resident #1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure and a risk alert for falls. He breathed through a tracheostomy tube and was dependent on continuous oxygen therapy. Within hours of his admission, resident #1 pulled out his tracheostomy tube on [DATE] at approximately 2:00 AM and had to be transferred to the hospital Emergency Department (ED) for replacement of the tube or cannula. He returned to the facility at approximately 5:00 AM, but a couple of hours later at approximately 7:00 AM, resident #1 again removed his tracheostomy tube and had to be transported to the hospital ED for reinsertion of another cannula. He returned to the facility on [DATE] at approximately at 1:30 PM. Despite two trips to the hospital within a 12-hour period for the decannulation emergencies, the facility did not provide increased supervision to mitigate his behavioral symptoms and ensure the safety and well-being of resident #1. Later that evening, on [DATE] at approximately 7:30 PM, Registered Nurse (RN) B passed resident #1's room and observed him face down on the floor. She notified the resident's assigned nurse, RN A, who checked the resident then went to the nurses' station to call 911, leaving the resident face down on the floor with RN B and Certified Nursing Assistant (CNA) C in the room. A police officer arrived at 7:36 PM and entered resident #1's room where he observed CNA C, but there was no licensed nurse present to assess and monitor the resident's status. Emergency Medical Services (EMS) personnel who arrived soon after the police officer, rolled the resident onto his back, discovered he was not connected to an oxygen source, and found him without a pulse and respirations. EMS personnel immediately initiated Cardiopulmonary Resuscitation (CPR) but they were unsuccessful in reviving resident #1 and he was pronounced dead at 7:56 PM. The facility's failure to develop and implement an appropriate plan of care to prevent decannulation, and failure to conduct a thorough assessment with proper response to a medical emergency contributed to resident #1's death and placed all residents with tracheostomies at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Cross Reference F600, F684, and F695. Review of the medical record revealed resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute/chronic respiratory failure, tracheostomy status, diabetes, hypertension, and gastrostomy tube or feeding tube. A progress note documented by RN A dated [DATE] at 11:59 PM revealed the resident took off trach two times and refused oxygen. A progress note dated [DATE] at 1:57 AM, revealed RN D found the resident's oxygen mask on the floor, and his trach was out. The documentation indicated RN D attempted to reinsert the trach, but due to resistance, resident #1 was sent out to the hospital for trach replacement. A progress note dated [DATE] at 4:57 AM, revealed the resident returned to the facility from the hospital at 4:15 AM with a trach in place, and he was connected to oxygen via a trach collar. Nursing documentation on [DATE] revealed that at 7:00 AM the trach was pulled out again, and the resident was sent out to the hospital. A progress note dated [DATE] at 1:36 PM, read, Resident alert and responsive, returned from ED visit this AM post trach cannula removal, increase agitation, restlessness. Returned with new orders for Lorazepam 0.5 mg via G-tube every 8 hours as needed. Lorazepam is a medication used to treat anxiety (retrieved on [DATE] from www.webmd.com). A progress note documented by RN A on 2/24/ 23 at 7:35 PM, read, Resident was on the floor face down. On assessment responded to name when called and had a pulse. 911 was called immediately at 7:35 PM and ambulance was in at 7:38 PM. With a policeperson walked into the building at 7:36 PM.Ambulance was given resident documents and went into the room to transfer resident out to the hospital. Started CPR on resident and resident later died at 7:56 PM. On [DATE] at 7:42 AM, in a telephone interview, RN A confirmed resident #1 was on her assignment on [DATE] during the 3:00 PM to 11:00 PM shift. She recalled the off-going day shift nurse told her the resident went to the hospital overnight because he pulled out his trach and would not allow nurses to replace it. RN A was informed the resident received Lorazepam in the hospital and returned to the facility with a prescription for the drug. She acknowledged she received instruction to administer the Lorazepam if resident #1 became aggressive. RN A recalled resident #1 was calm when she administered his routine medication and checked his blood glucose at about 5:00 PM. She stated the last time she saw him was at 6:45 PM and the tubing that connected the oxygen to the trach mask was around his neck. She stated she removed and rearranged the trach oxygen tubing and observed the resident moving his hands up and down. She explained she continued passing medication until approximately 7:35 PM when RN B informed her a resident was on the floor. She stated they both went in to check and resident #1 was on the floor, face down. RN A said the resident's trach was in place, he was breathing, and his color was good. She recalled he had a bowel movement, so she asked CNA C to change him but advised her to be careful in moving the resident. She stated she then went to the nurses' station, called 911, reported that the resident was on the floor face down, and was told to make him comfortable but not move him, and have his medical record available for EMS. RN A could not recall if she informed the 911 operator the resident had a tracheostomy. RN A confirmed she directed a police officer and the EMS personnel to the resident's room when they arrived, and soon after, she found out they initiated CPR. RN A stated when she found the resident face down on the floor, she did not have time to check his blood pressure and only checked for a pulse and noted he was breathing and comfortable. She confirmed she had worked with residents with tracheostomies before; however, she could not say if resident #1 was lying on his trach when she evaluated him. On [DATE] at 2:02 PM, in a telephone interview, RN B stated she saw resident #1 on the floor and alerted his assigned nurse, RN A. She recalled RN A entered the room, got down on the floor, tapped the resident on his shoulder, and he responded. RN B recalled RN A commented that his response was not at his baseline status, and she did not want to turn him over onto his back as she was afraid he might have suffered a fracture. RN B confirmed she was not able to see the resident's trach and could not see if he was lying on the trach oxygen tubing. RN B added she knew the resident was breathing as she heard him making grunting and moaning noises. She stated RN A left the room to call 911, and when CNA C arrived she left the CNA with the resident, who was still face down on the floor. RN B acknowledged she did not remain in the room to monitor the resident's respiratory, cardiac, or neurological status while RN A called for assistance. She confirmed she did not wait with the resident until EMS personnel arrived, instead she left to take care of her assigned residents. On [DATE] at 3:05 PM, RN D stated she was assigned to resident #1 on the 11:00 PM to 7:00 AM shift on [DATE], his first night in the facility. RN D recalled the resident pulled out his trach and she attempted to reinsert the device. She explained resident #1 was resistant to her efforts and she had to arrange for him to be transferred to the hospital for replacement of the trach. RN D stated she rarely took care of residents with tracheostomies and felt she needed more training in that area. RN D did not recall receiving education, attending in-services, or completing a post-test regarding tracheostomy care on [DATE]. On [DATE] at 4:43 PM, and on [DATE] at 2:50 PM, the DON stated verbal education on tracheostomy care was provided to nurses on [DATE] during the 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM shifts. When informed RN D could not recall participating in any such in-service even though her name was on the attendance sheet, the DON declined to comment. When asked about staff competency, the DON verbalized the facility's last competency exercises for tracheostomy care were done in [DATE]. He stated licensed nurses had their competency assessed by return demonstration method and/or pre-tests and post-tests. The DON stated he contacted the Respiratory Therapist regarding documentation of the training and competencies done in [DATE] but none were found. He explained there was no evidence of competencies for tracheostomy care in the education folders he reviewed. The DON stated he had been on staff since [DATE], and resident #1 was the first resident admitted to the facility with a tracheostomy since [DATE]. Review of the resident's clinical record revealed no documentation to indicate resident #1's physician was made aware of his actions related to pulling out his trach and being transferred to the ED on two separate occasions. There was no documentation to show any actions were taken after each decannulation to prevent reoccurrence, and no evidence of communication with the physician regarding the resident's escalating agitation with potentially harmful behavioral symptoms. Nursing progress notes showed assigned nurses did not collaborate with the Weekend Nursing Supervisor or other members of nursing management to adjust staffing to meet resident #1's need for increased supervision. Review of resident #1's Medication Administration Record (MAR) revealed nurses did not administer the anti-anxiety drug Lorazepam although he exhibited restless behavior. The medical record showed no documentation to reflect completion of a thorough nursing assessment including verification of the presence and position of the trach, or that he was connected to oxygen. There was no evidence nurses attempted to ensure resident #1 had a patent airway and was not lying on the trach tubing to obstruct his airway after he was found face down on the floor. The job description for the Director of Nursing dated [DATE] revealed the DON was to manage the overall operations of the Nursing Department in accordance with.standards of nursing practices.to maintain excellent care of all residents' needs. The policy for Tracheostomy Care implemented in [DATE], and reviewed/revised on [DATE] read, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice.The facility will ensure staff responsible for providing tracheostomy care.are trained and competent according to professional standards of practice. Review of the Facility Assessment dated [DATE], revealed the assessment was completed to determine the resources necessary to care for the residents competently during the day-to- day operations of the facility and during emergencies. The assessment addressed staff competencies necessary to provide the level and types of care needed for the resident population, and indicated the facility considered the clinical characteristics of the resident population to determine the skills and competencies required to meet the resident needs. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: *On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, DON, and the Medical Director. The facility discussed and determined a root cause for the incident. *On [DATE], an Ad Hoc QAPI committee meeting was held with the Medical Director present to revisit and revise the RCA for the incident. The facility's incident/accident policy was reviewed and revised to include if a serious injury is known or suspected, a nurse remains with the resident and designate a staff member to announce Code Blue, if necessary, notify the physician and call 911 as needed. *On [DATE], the Regional Nurse Consultant and Regional Director of Operations educated the facility management on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility's fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. *On [DATE], the Administrator/designee initiated education with facility and contract employees on Incident/Accidents, Abuse and Neglect, responding to medical emergencies and the facility fall prevention program policy. Education included that in a medical emergency a nurse will assess the resident, stay with the resident, and designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. Post-tests were completed to validate competency of education received. *On [DATE], the Administrator/designee continued education with facility and contract employees on incident/accidents, abuse, and neglect, responding to medical emergencies and the facility fall prevention program policy. Post tests were completed to validate competency of education received. Newly hired staff will be educated during orientation and agency nurses will be educated prior to accepting nursing assignments. 110 of 129 equaling 86% facility and contract staff were educated with post-tests. Remaining facility and newly hired staff will be educated during orientation, and agency nurses will be educated prior to accepting nursing assignments. *On [DATE], licensed nurses were educated on the facility oxygen administration policy with post-test to validate competency and were provided further education on responding to medical emergencies with a focus on assessing the resident for injuries and respiratory complications and remaining with the resident until emergency medical personnel arrive and assume care of the resident. Return demonstration completed to validate nurse competency. *On [DATE], there were no residents currently residing in the facility with a tracheostomy. The facility will schedule an outside Respiratory Therapy vendor to provide in-person training to the nurse managers and additional nurses in the facility. The facility will not accept tracheostomy dependent residents until their Licensed nurses have been trained on providing tracheostomy care with return demonstration to validate competency. Newly hired nurses will receive training and competency evaluation during orientation period. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Medical Emergency Response, Abuse/Neglect, and Fall Prevention Program with evidence of post-tests. On [DATE], interviews were conducted with six RNs and two LPN. They verbalized understanding of the education provided.