**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and policy review titled Comprehensive Care Plans, the facility failed to develop and implement person-centered comprehensive care plans for three of 34 sampled residents (R). Specifically, facility failed to maintain emergency trach supplies in the facility and at the bedside for R69; failed to develop a care plan for the use of Continuous Positive Airway Pressure (CPAP) and failed to indicate the accurate code status for Advanced Directive (AD) for R19. On September 29, 2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Regional Nurse Consultant (RNC), and Assistant Regional Nurse Consultant (ARNC) were informed of the Immediate Jeopardy (IJ) on September 29, 2023, at 9:32 am The noncompliance related to the Immediate Jeopardy was identified to have existed on August 5, 2023, when R69 tracheostomy tube attempted to become dislodged and the nurse held the tube in place until emergency medical services arrived, due to facility not having emergency tracheostomy supplies at bedside or in the facility. An Acceptable Removal Plan was received on October 3, 2023. The removal plan included reassessing R69, placing tracheostomy supplies at the bedside in the resident's room and extra tracheostomy supplies on the crash cart, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, re-education of administration staff, and review/revision of policies and procedures for tracheostomy care. Through interviews with facility staff, observation of tracheostomy supplies, observations of R69, clinical record review of revised care plan, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on October 1, 2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies. Findings include: Review of the policy titled Comprehensive Care Plans dated 2/1/2022, indicated the policy is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights with measurable objects and timeframes to meet a residents medical, nursing, and mental and psychosocial needs identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: Number 3: revealed the care plan will describe: a. services to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial wellbeing. c. specialized services. d. goals for admission, desired outcomes, and preferences for future discharge. Number 5: the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. Number 8: qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions initially and when changes are made. 1. Review of the clinical record for R69 revealed he was admitted to the facility on [DATE] with multiple diagnoses including tracheostomy status (surgical procedure to open a direct airway through an incision in the trachea [windpipe]), acute respiratory failure, and dysphasia (language disorder which affect the ability to produce and understand spoken language). Review of the quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not recorded with documentation that resident is rarely/never understood. Section O revealed the resident received oxygen therapy and had a tracheostomy. Review of the care plan revised on 6/23/2023 revealed the focus of tracheostomy related to impaired breathing with respiratory failure-requires continuous oxygen. Interventions to care include observe/document for restlessness, agitation, confusion, increased heart rate, and bradycardia, observe/document respiratory rate, depth, and quality every shift and document, provide good oral care daily and as needed, suction as necessary, use universal precautions, and assist with coughing as needed. Additional intervention Tube Out Procedure keep extra trach tube and obturator at bedside, if tube is coughed out, open stoma with hemostat, if tube cannot be reinserted, monitor/document for signs of respiratory distress. If unable to breathe spontaneously elevate the head of bed 45 degrees and stay with resident. Obtain medical help immediately. Interview on 10/3/2023 at 9:00 am Certified Nursing Assistant (CNA) CCC stated the resident care plan identifies the tasks for the staff to take care of the residents. She stated if residents have problems with respiratory status, she notifies the nurse immediately. Interview on 10/3/2023 at 9:05 am Licensed Practical Nurse (LPN) UU stated the care plan drives the nursing process. She stated the nurse should consult the care plan as it relates to the care needed for all residents. Interview on 10/3/2023 at 9:25 am LPN YY stated the care plan is important in directing the care of each resident. She stated the care plan will trigger assessments the nurse must complete on the medication administration record (MAR) and task for personal care and restorative care for the CNAs to complete. She stated it is the nurse's responsibility to become familiar with the care plan of each resident they are caring for. Interview on 10/3/2023 at 12:13 pm Director of Nursing (DON) and Regional Nurse Consultant (RNC) revealed care plans are updated by the MDS coordinator when assessments are completed. The MDS coordinator attends clinical meetings and when information is shared related to a change in condition or concerns that should be added to the care plan, the MDS coordinator will update the care plan focus, goal, or interventions as needed. The DON stated the MDS coordinator is the person who initiates and updates the comprehensive care plans. During further interview, the DON stated when the MDS Coordinator is not available to update the care plans, he can update the care plans. He stated his expectation is that the care plan be developed within seven days after the comprehensive assessment is completed and after each quarterly MDS assessment is completed. He stated he expected the care plan to be updated in real time as changes are identified and as needed to meet the residents' needs. The MDS Coordinator was not available for interview. 2. Review of the clinical record for R19 revealed she was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder, chronic respiratory failure, cerebral infarction, bipolar disorder, and hyperlipidemia. Review of the quarterly MDS dated [DATE], revealed BIMS was coded as 13, indicating no cognitive impairment. Section O revealed the resident used a C-PAP machine. Review of the care plan revised 8/3/2023 revealed resident is at risk for altered respiratory status related to diagnoses of pneumonia and acute/chronic respiratory failure. Interventions to care include nebulizer treatments and oxygen therapy as ordered. There was no evidence of a focus area for diagnosis of sleep apnea with the use of CPAP machine nightly. During further review of the care plan revealed Advanced Directive was indicated as a Full code. Interventions to care include complete necessary paperwork and document in medical record. Review of Order Summary Report dated 9/27/2023, revealed an order to apply C-PAP machine on night shift - resident will keep on throughout the night every night related to sleep apnea. The order date is 6/22/2023. Further review revealed an order for 'Do Not Resuscitate (DNR)' dated 3/24/2023. Review of Physician Orders for Life Sustaining Treatment (POLST) revealed the document was signed by resident and physician on 3/20/2023. The POLST indicated resident's wishes to allow natural death - Do Not Attempt Resuscitation. The POLST contained a concurring physician signature dated 3/22/2023. Interview on 9/27/2023 at 1:57 pm MDS Care Plan Coordinator confirmed that R19 care plan did not indicate the use of a C-PAP and stated it should have been updated for the use of C-PAP with her last quarterly assessment. During further interview she verified the care plan revealed residents' Advanced Directive indicated 'Full Code' with Physician Order for DNR. She did not have an explanation why the care plan for Advance Directive did not match the Physician Order. Interview on 9/29/2023 at 1:03 pm DON revealed that during the daily clinical meeting, all new orders, and residents with changes in care are discussed. The DON further stated that the MDS /Care Plan Coordinator attends the meeting each day and gathers information needed for MDS assessments and care plan updates/revisions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the policy titled Tracheostomy Care, the facility failed to ensure staff were trained for emergency care of tracheostomies (trachs) and provide emergency tracheostomy kits for one resident (R) R69 reviewed for tracheostomy care. The facility's failure to train staff and provide emergency tracheostomy kits in the event that the resident's airway was compromised, resulted in R69 trach tube becoming dislodged and an emergency room visit to have tube re-inserted. In addition, the facility failed to properly store resident respiratory care equipment when not in use for R19's Continuous Positive Airway Pressure (C-PAP) mask and for R70's nebulizer mask. There were 18 residents receiving respiratory services. On September 29, 2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Regional Nurse Consultant (RNC), and Assistant Regional Nurse Consultant (ARNC) were informed of the Immediate Jeopardy (IJ) on September 29, 2023, at 9:32 am The noncompliance related to the Immediate Jeopardy was identified to have existed on August 5, 2023, when R69 tracheostomy tube attempted to become dislodged and the nurse held the tube in place until emergency medical services arrived, due to facility not having emergency tracheostomy supplies at bedside or in the facility. An Acceptable Removal Plan was received on October 3, 2023. The removal plan included reassessing R69, placing tracheostomy supplies at the bedside in the resident's room and extra tracheostomy supplies on the crash cart, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, re-education of administration staff, and review/revision of policies and procedures for tracheostomy care. Through interviews with facility staff, observation of tracheostomy supplies, observations of R69, clinical record review of revised care plan, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on October 1, 2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies. Findings include: Review of the policy titled Tracheostomy Care dated 2/22/2022 revealed Compliance Guidelines: Number 3. Tracheostomy care will be provided according to the physician orders, comprehensive assessment, and individualized care plan such as monitoring for resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate. General considerations include: b. Maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an Ambu bag easily accessible for immediate emergency care. Review of documents titled Licensed Nurse Competency, provided by the DON, revealed three licensed nurses had completed competency checklist for Basic Nursing Skills tracheostomy care. The checklist did not reveal competency training for emergency trach management. The DON stated that he could not locate any additional education related to tracheostomy care. 1. Review of the clinical record for R69 revealed he was admitted to the facility on [DATE] with multiple diagnoses including tracheostomy status (surgical procedure to open a direct airway through an incision in the trachea [windpipe]), acute respiratory failure, and dysphasia (language disorder which affect the ability to produce and understand spoken language). Review of the quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not recorded with documentation that resident is rarely/never understood. Section O revealed the resident received oxygen therapy and had a tracheostomy. Review of the care plan revised on 6/23/2023 revealed a focus for tracheostomy related to impaired breathing with respiratory failure-requires continuous oxygen. Interventions to care include observe/document for restlessness, agitation, confusion, increased heart rate, and bradycardia, observe/document respiratory rate, depth, and quality every shift and document, provide good oral care daily and as needed, suction as necessary, use universal precautions, and assist with coughing as needed. Additional intervention Tube Out Procedure keep extra trach tube and obturator at bedside, if tube is coughed out, open stoma with hemostat, if tube cannot be reinserted, monitor/document for signs of respiratory distress. If unable to breathe spontaneously elevate the head of bed 45 degrees and stay with resident. Obtain medical help immediately. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not scored and documented resident is rarely/never understood. Section G revealed the resident was totally dependent on staff for bed mobility, locomotion on and off unit, dressing, eating, toilet use, bathing and personal hygiene and required two-person physical assistance. Section O revealed the resident required tracheostomy care. Review of R69 September 2023 Order Summary Report revealed an order dated 8/17/2023 for trach care daily and as needed, without orders for trach tube type, size, or whether the trach is to be cuffed or uncuffed, or emergency management if the trach should become dislodged. Further review revealed continuous oxygen at two liters per minute (lpm) via nasal cannula dated 3/32/2023. Review of Progress Note dated 8/5/2023 at 11:11 am revealed Licensed Practical Nurse (LPN) AA documented residents' trach attempted to become dislodged. The writer held trach in place and applied oxygen and suction . until emergency medical services (EMS) personnel arrived. Review of document titled After Visit Summary from [name] Healthcare, dated 8/5/2023, indicated reason for the visit was tracheostomy tube change with diagnosis of unspecified tracheostomy complication. Notated on the document is a handwritten note that reads: Trach size is not here, called they were unable to tell writer size. Observation on 9/26/2023 at 10:15 am R69 was observed lying in bed alert but nonverbal. He had a tracheostomy with oxygen at four liters per minute (LPM) via tracheostomy. Observation of a plastic bag hanging on a pole with contents including a Shiley #5 inner canula and a manual resuscitator bag. Sitting on the bedside table was a suction machine and canister with a suction catheter attached. There were no other trach supplies located in the room. Interview on 9/26/2023 at 4:44 pm with Registered Nurse (RN) BB revealed she works at the facility through a staffing agency since early 2022. She stated she provides basic trach care for R69, including suctioning and changing the tracheostomy ties. RN BB stated she had not received any training from the facility related to emergency care for trach decannulation. During further interview, she stated if the trach came out, she would put something over the stoma, attempt to put it back in, make sure resident was oxygenated, and call the DON for assistance. Interview on 9/26/2023 at 4:55 pm with RNC CC stated emergency items to be kept at bedside for tracheostomy residents include a manual resuscitator bag, replacement trach tubes, an obturator, and a suction machine and cannister. She verified the only supplies in R69's room were a Shiley #5 inner cannula and a manual resuscitator bag. Sitting on the bedside table was a suction machine and canister with a suction catheter attached. She searched the room for supplies and was unable to locate an obturator or extra trach tubes. She stated if decannulation should occur, she hoped the nursing staff has been trained in providing emergency care for decannulation. Interview 9/26/2023 at 5:13 pm with RNC DD verified R69's Oxygen flow rate was set at four LPM with the current Physician Orders were for oxygen at two LPM via nasal cannula. She verified there was no evidence in Physician Orders to indicate the type and size of the trach tube R69 was using, or any emergency care orders for accidental dislodgment of the trach. During further interview, she stated that in an emergency, the nurses would have to look through the progress notes to locate the size of the trach tube resident had in place. Interview 9/26/2023 at 5:27 pm the DON stated the only competency/skills checklist he could locate were for three nurses. He stated the competency/skills checklist for tracheostomy care did not indicate procedures for emergency care for dislodged trach cannulas, or information for emergency trach kits. He stated he was not sure whether the facility had a policy for emergency care for trach dislodgement or a policy for trach kits. During further interview he stated that if resident's trach came out, he would expect the nurse to put an inner cannula in the stoma, make sure resident can still breath and to try to re-insert the trach at the facility if possible. The DON confirmed R69 should have an emergency tracheostomy kit at his bedside and visible to the staff in the event of an emergency. Interview on 9/26/2023 at 5:42 pm with RN PP revealed she has worked at the facility since March 2023 and stated she has provided care for R69. She stated she had basic training for general trach care but indicated she had not been provided training related to replacing the trach or emergency decannulations. Interview on 9/27/2023 at 9:53 am with LPN KK revealed she had not received any training on the facility protocol or what to do in an emergency situation if R69's trach came out. LPN KK further stated she would look for a smaller size trach to put back in if the trach came out. but if one was not available, she would call for help. She stated she was not familiar with the facility's policy on trachs. Interview on 9/27/2023 at 1:17 pm LPN AA revealed that on 8/5/2023 she noticed R69's trach was coming out. She stated she attempted to tighten the trach ties and push the trach back in, but it would not go in. She stated she did not see another trach tube at resident's bedside, so she yelled out for someone to call 911. During further interview, she stated she held the trach in place until emergency medical services (EMS) arrived so he would not cough it completely out. She stated that she called the hospital and was informed that the trach was out and had to be replaced. Interview on 9/29/2023 at 2:47 pm with RNC DD revealed R69 now had a #6 Shiley trach at bedside with an obturator. She stated she entered the Physician Order for the Shiley #6 XLT trach after searching through the electronic record for the information for the trach size and RNC DD looked at the trach and revealed the resident had a Shiley #5 trach in place. During further interview, she stated the orders she had obtained and entered into the electronic record were not correct. Interview on 10/2/2023 at 11:12 am LPN UU revealed that she works at the facility through a staffing agency. She stated that she had not had any training from the facility on what to do in an emergency situation with the trach. During further interview, LPN UU revealed that supplies at the facility for trach residents are a hit and miss. She stated there was an issue with needed supplies in the facility to care for R69's trach. Interview on 10/2/2023 at 1:20 pm with Nurse Practitioner (NP) TT revealed that she works in the facility Monday through Friday. NP TT stated it is her expectation that the nurses are trained on how to care for tracheostomies in emergency situations and how to reinsert the trach tube at the bedside if a decannulation occurs. Telephone interview on 10/2/2023 at 6:36 pm with Medical Doctor (MD) DDD revealed the staff should have been educated/trained to care for R69 prior to resident being admitted to the facility. MD DDD further stated the staff should be skilled enough to replace the trach in the event of decannulation and the facility should always have trach supplies readily available to care for the needs of the residents with tracheostomies. 2. Review of the clinical record for R19 revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure unspecified whether with hypoxia or hypercapnia, pneumonia, and sleep apnea. Review of the care plan revised 8/3/2023 indicated R19 has a potential risk for altered respiratory status related to pneumonia, chronic respiratory failure. Interventions to care include administering medications as ordered, head of bed elevated or out of bed during episodes of difficulty breathing, monitor for signs and symptoms of acute respiratory insufficiency or distress. There is no evidence that resident is care planned to use C-PAP machine at night. Review of the quarterly MDS dated [DATE], revealed BIMS was coded as 13, indicating no cognitive impairment. Section O revealed the resident used a C-PAP machine. Review of R19's September 2023 Order Summary Report revealed an order dated 6/22/2023 to apply (C-PAP) Continuous Positive Airway Pressure machine on night shift indicating resident will keep on throughout the night. Review of Electronic Medication Administration Records (E-MAR) dated April 2023 through September 2023, indicated the C-PAP machine was documented as being used nightly. Review of Progress Note dated 4/14/2023 revealed R19 resident used the C-PAP intermittently while napping during the day. Observation on 9/26/2023 at 11:27 am revealed resident lying in bed with eyes closed. The C-PAP mask was lying on the floor on the left side of the residents' bed. Observation on 9/27/2023 at 9:45 am revealed the C-PAP mask was placed on the dresser un-bagged. Interview on 9/27/2023 at 9:45 am with R19 confirmed she uses the C-PAP mask at night. Resident nodded her head no when asked if the mask is usually stored in a bag when not in use. Interview and observation on 9/27/2023 at 12:21 pm LPN KK verified the C-PAP mask was on the dresser and not properly stored. She stated that the mask should be stored in a bag when not in use. During further interview, she stated R19 removes the C-PAP herself, but stated the staff is responsible for cleaning and storing the C-PAP mask in a bag. Interview on 9/27/2023 at 12:38 pm the DON stated that all respiratory masks are supposed to be stored in a plastic bag and placed in the drawer of the dresser when not in use. 3. Review of the clinical record for R70 revealed he was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS dated [DATE] revealed a BIMS of 15, which indicated the resident was cognitively intact. Section J indicated health conditions listed as shortness of breath (SOB) with exertion, sitting, and lying flat. Section O revealed the resident used Oxygen. Review of the care plan revised 8/2/2023 indicated R70 has a potential risk for altered respiratory status related to COPD. Interventions to care include give nebulizer treatments and oxygen therapy as order, monitor/document/report to physician as needed any signs/symptoms of respiratory infection, acute respiratory insufficiency, respiratory distress, implement treatment as ordered by physician, and observe/document breathing patterns, pace/schedule activities providing adequate rest periods. Review of the September 2023 Clinical Physician's Order revealed orders for Advair, tiotropium bromide (Spiriva Respimat), albuterol sulfate inhalation aerosol powder, and oxygen two LPM via nasal cannula (NC). Observation on 9/26/2023 at 10:47 am and 5:30 pm in R70's room revealed on the nightstand on the right side of the bed, nebulizer mask lying beside the machine on the table. The nebulizer mask was not bagged or covered, and the tubing was not dated. Observation on 9/27/2023 at 9:50 am revealed the nebulizer mask continued to be lying on the nightstand beside the nebulizer machine uncovered and the tubing was not dated. Interview on 9/26/2023 at 10:47 am R70 stated when his breathing treatment is finished, he lays the mask on his bedside table. He stated the staff do not offer a bag or cover the mask when not in use. Interview on 9/27/2023 at 1045 am LPN YY confirmed R70's nebulizer mask was lying on the nightstand un-bagged. She confirmed the tubing was not dated. Interview on 9/27/2023 at 11:02 am the DON revealed his expectation was that the nebulizer mask be stored in a clear bag and the date clearly marked on the tubing as well as the bag. He stated the tubing and mask are changed weekly on Sunday nights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, review of the facility assessment, and review of job descriptions for the Administrator and the Director of Nursing (DON), the facility administration failed to provide oversight and monitoring to ensure that competent nursing staff are available and trained to care for residents admitted with special care needs (such as care for a tracheostomy- a surgical procedure to open a direct airway through an incision in the trachea/windpipe). In addition, administration failed to ensure open communication between nursing staff to facilitate ordering of supplies needed to care for a resident with a tracheostomy and ensure there were emergency tracheostomy supplies available at bedside and crash cart for one resident (R) R69 sampled for tracheostomy care. On September 29, 2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to a resident. The facility's Administrator, Director of Nursing (DON), Regional Nurse Consultant (RNC), and Assistant Regional Nurse Consultant (ARNC) were informed of the Immediate Jeopardy (IJ) on September 29, 2023, at 9:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on August 5, 2023, when R69's tracheostomy tube attempted to become dislodged and the nurse held the tube in place until emergency medical services arrived, due to facility not having emergency tracheostomy supplies at bedside or in the facility. An acceptable Removal Plan was received on October 3, 2023. The Removal Plan included purchasing and placing tracheostomy supplies at the bedside in the residents' room, extra tracheostomy supplies in the crash cart, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revisions, and education of all licensed staff on emergency care for trach tube dislodgement. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on October 1, 2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies. Findings include: 1. Administration failed to ensure that nursing staff are trained and competent to care for residents admitted with special needs such as emergency care for tracheostomy tube dislodgement. 2. Facility administration failed to maintain emergency tracheostomy supplies in the event of accidental dislodgement of trach tube. Cross Refer F695 3. Facility Administrator and Director of Nursing failed to perform duties of their job descriptions that facilitated medical care to the residents of the facility. 4. Facility Administration failed to implement care plan interventions that addressed emergency care and supplies at bedside for R69 admitted with a tracheostomy. Cross Refer F656 Review of the Facility Assessment Tool reviewed 5/25/2023 revealed every patient considered for admission is reviewed by the Director of Nursing or designee to assure clinical needs can be met. Regarding care areas, diagnosis or conditions not previously supported, appropriate education and competency assessment will be completed prior to admission. Needed medical supplies or resources not maintained in the facility will be acquired from contracted suppliers, local vendors, or other healthcare facilities. Review of the undated document titled Job Description and Performance Standards for the Administrator revealed the purpose of this position was to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet the needs of residents in compliance with federal, state, and local requirements. The primary functions and responsibilities include: 2. Establish written policies regarding responsibilities and activities of individuals employed. 3. Establish systems to enforce the facility policies and procedures. 8. Supervise all department supervisors and administrative staff. 10. Assume responsibility with department supervisors to implement effective policies to ensure adequate staffing to meet facility needs. 14. Ensure that all necessary supplies are purchased and available. 26. Establish systems to ensure compliance with all federal, state, and local regulations. Review of the undated document titled Job Description and Performance Standards for the DON revealed the purpose of the position was to provide nursing management, set resident care standards for all direct care providers, and provide complete supervision and management for the nursing department. The primary functions and responsibilities include: 1. Assume responsibility for the development of nursing service objectives and performance standards of nursing practice for nursing personnel. 2. Assume Accountability for the development, organization and implementation of approved policies and procedures. 3. Supervise and evaluate all direct resident care and initiate corrective action as necessary. 4. Assess resident care needs and assist in the development of individualized plans of care. 5. Assess resident pre-admission and/or admission information and determine appropriate level of care. 17. Direct and implement nursing service educational programs including, but not limited to orientation and in-services for licensed nursing personnel. 19. Demonstrate consistent management of nursing service problems, emergency situations, and initiated life-saving measures. 20. Assume responsibility for nursing service compliance with federal, state, and local regulations. 21. Ensure availability of equipment for nursing personnel. 22. Assess equipment and supply needs. Review of the clinical record revealed R69 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with tracheostomy (a surgical procedure to open a direct airway through an incision in the trachea/windpipe), hypertension, and dysphagia following cerebrovascular disease. Review of R69 September 2023 Physician Orders revealed an order dated 8/16/2023 for pulmonology consult per family request related to decannulation, continuous oxygen at two liters per minute (lpm) via nasal cannula dated 3/21/2023, and trach care daily and as needed dated 8/17/2022. There was no indication what type or size of trach tube used, or emergency care for dislodged tube. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not scored and documented resident is rarely/never understood. Section G revealed the resident was totally dependent on staff for bed mobility, locomotion on and off unit, dressing, eating, toilet use, bathing and personal hygiene and required two-person physical assistance. Section O revealed the resident required tracheostomy care. Review of Nurses Note dated 8/5/2023 at 11:11 am revealed Licensed Practical Nurse (LPN) AA documented residents' trach attempted to become dislodged. The writer held trach in place and applied oxygen and suction . until Emergency Medical Services (EMS) personnel arrived. Observation on 9/26/2023 at 10:15 am of R69's room revealed resident had tracheostomy and oxygen in use at four liters per minute via tracheostomy. Observation of a plastic bag hanging on a pole with contents including a Shiley #5 inner canula and a manual resuscitator bag. Sitting on the bedside table was a suction machine and canister with a suction catheter attached. Observation on 9/26/2023 at 5:25 pm of the emergency crash cart revealed there were not any emergency trach supplies available on the cart. Observation on 9/29/2023 at 8:09 am in R69's room revealed there were no emergency trach supplies or obturator found at bedside or in chest of drawers. Interview on 9/26/2023 at 4:55 pm in R69's room with Registered Nurse (RN) CC and the Director of Nursing (DON) stated emergency items to be kept at bedside for tracheostomy residents include a manual resuscitator bag, replacement trach tubes, an obturator, and a suction machine and cannister. RN CC stated if decannulation should occur, she hoped the nursing staff had been trained in providing emergency care for decannulation. The DON verified the only supplies in R69's room in the bedside chest were three suction catheters, Ipratropium Bromide and Albuterol sulfate nebulizer meds, and an unbagged nebulizer mask. One trach mask is not in a bag. Interview on 9/26/2023 at 5:13 pm with RN CC stated the oxygen flow rate ordered for R69 is continuous oxygen at two liters (L) via nasal cannula/trach. During further interview, she stated the staff would have to look through the progress notes to determine the size for the trach tube. Interview on 9/26/2023 at 5:18 pm with RN DD confirmed there were no orders for the trach size for R69, or specific orders for emergency care for dislodgement. Interview on 9/26/2023 at 5:27 pm DON revealed there are suction catheter kits in the facility but stated there were no trach obturators in the facility. He revealed he doesn't know if R69's trach is a Shiley five or six. He stated he uses the Order Wizard to keep information on what trach supplies have been ordered. During further interview, the DON stated there are no obturators, emergency trach tubes, ties, or cleaning kits in the facility. He stated I am almost sure that R69 is the only trach resident the facility had, beside the resident in 4/2022. Interview on 9/26/2023 at 5:42 pm with RN PP revealed she had training on trach suctioning, cleaning, changing out the inner cannula. She indicated she had not had any training on what to do if decannulation happened, but stated if the tube comes out, she will give oxygen with mask over the trach. During further interview, she stated if resident had another tube, she would put it back in. Interview on 9/27/2023 at 9:53 am Licensed Practical Nurse (LPN) KK stated she had not received any formal training on the facility protocol or what to do in an emergency if the trach tube came out. The LPN stated some facilities allow nurses to replace trach tubes so she would look for a smaller size tube to put back in but if there are not any in the facility, she would call for help. During further interview, she stated she is not familiar with the facility's policy on tracheostomies. Interview on 9/27/2023 at 1:17 p.m. with LPN AA stated on 8/5/2023 she noticed R69's trach was coming out. She revealed that the trach ties were intact, so she attempted to push the trach back in, but it would not go in. LPN AA stated when this event happened, she did not see a replacement trach tube or any other emergency supplies at the bedside, so she yelled out for someone to call 911. During further interview, she stated that she held the trach in place until EMS arrived. Interview on 10/2/2023 at 11:12 am with LPN UU indicated she completed a skills checklist prior to working at the facility. She revealed she had training related to providing trach care at another facility but stated she had not had any training from the facility. During further interviews, she stated that she had not had any training in what to do in an emergency with tracheostomies if the tube became dislodged. LPN UU further stated that supplies at the facility for the trach resident are a hit and miss and that there are issues with needed supplies in the facility to care for R69. Interview on 10/22/2023 at 1:20 pm with Nurse Practitioner (NP) GG revealed it is her expectation that the nurses in the facility are trained in basic care and cleaning of the tracheostomy. Continued interview revealed NP GG stated the nurses should be trained on how to use the emergency equipment and how to reinsert the trach at the bedside in an emergency, if the trach tube comes out.