**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure care plan interventions regarding emergency tracheostomy care were developed for one of five residents (Resident (R) 5) sampled for tracheostomy care. Additionally, the facility failed to ensure care plan interventions regarding emergency tracheostomy care were implemented for three of five residents (R23, R27, and R31) sampled for tracheostomy care. On 2/8/2022, 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 and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 2/8/2022 at 6:46 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/7/2022. The IJ is outlined as follows: The facility failed to ensure four of five residents with a tracheostomy had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency tracheostomy kits at the bedside. The facility had five residents with tracheostomies. Upon observations on 2/7/2022 and 2/8/2022, four of the five residents, R5, R23, R27, and R31 did not have necessary emergency tracheostomy supplies at bedside and additional supplies were not located in the facility. In addition, interviews on 2/7/2022 and 2/8/2022 with nursing staff caring for the residents with tracheostomies (Licensed Practical Nurse (LPN)1, LPN2, and LPN3) revealed a lack of knowledge and training regarding emergency tracheostomy supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): K), 42 CFR 483.25(i) -- Respiratory/Tracheostomy Care and Suctioning (F695 S/S: K), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: K), and 42 CFR 483.70 - Administration (F835 S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/Tracheostomy Care and Suctioning (F695 S/S: K). An Acceptable Removal Plan was received on 2/10/2022. The removal plan included placing tracheostomy supplies at the bedside in the resident's room and extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, and re-education of administration staff. Through interviews with facility staff, observation of tracheostomy supplies, clinical record review of revised care plans, 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 2/10/2022. 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 facility-provided policy titled, Person-Centered Care Plan, dated 06/21/19 revealed, . A comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. Care plans will be . communicated to appropriate staff . Review of the facility-provided policy titled, Tracheostomy Care-Suctioning dated 09/19/20 revealed, . The facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Review of facility-provided undated policy titled, Oxygen Administration revealed, .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician order for this procedure .Review the resident's care plan to assess any special needs of the resident . 1. Review of R5's undated Face Sheet provided by the facility revealed R5 was admitted to the facility on [DATE]. R5 was admitted with a tracheostomy. Review of R5's current Care Plan, located in the electronic medical record (EMR) under the Care Plan tab, revealed R5 had a tracheostomy and addressed tracheostomy general care; however, the care plan did not address emergency care and supplies for R5's tracheostomy. 2. Review of R23's undated Face Sheet, provided by the facility revealed R23 was admitted to the facility on [DATE] with a tracheostomy. Review of R23's current Care Plan, located in the EMR under the Care Plan tab, revealed R23 had a tracheostomy and addressed emergency tracheostomy care as follows: Tube out procedures: Keep extra trach [tracheostomy] 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 able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help immediately. R23's care plan did not include the location of emergency supplies. Observations on 02/07/22 at 2:15 PM and 2:42 PM revealed an ambu (self-inflating bag resuscitator) bag hanging on R23's closet door and a red cloth bag hanging on the closet door. An interview and observation on 02/08/22 at 9:16 AM with the ADON revealed R23 had an emergency kit (red cloth bag) that was missing sterile gloves, lubricating jelly, and obturator. 3. Review of R27's undated Face Sheet, provided by the facility revealed R27 was admitted to the facility on [DATE] with a tracheostomy. Review of R27's current Care Plan, located in the EMR under the Care Plan tab, revealed R27 had a tracheostomy, and the care plan addressed emergency tracheostomy care as follows: Tube out procedures: 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 able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help immediately. R27's care plan did not include the location of emergency supplies. Observations on 02/07/22 at 2:12 PM, 3:22 PM, and 4:44 PM (with LPN3) revealed no emergency supplies available in R27's room. 4. Review of R31's electronic medical record (EMR), labeled R31, under the tab Clinical revealed R31 was admitted to the facility on [DATE] with a re-admission date of 02/04/22. R31 was re-admitted with a tracheostomy. The Care Plan tab of R31's EMR revealed, R31's care plan included tracheostomy care (He does exhibit anxiety related to his trach, suctioning and trach care at times) as follows: Administer oxygen as ordered .Change Trach tube/inner cannula as ordered by physician .Provide education related to trach and trach care needs .Trach care as ordered . and addressed tracheostomy emergency .Tube out procedures: 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 able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help immediately. There was no information regarding trach cannula size. Review of R31's Physician Orders, located in R31's EMR under the Orders tab revealed, R31's orders did not include any tracheostomy information including, physician orders for tracheostomy size, no physician orders for tracheostomy care management or emergency management. Review of R31's Medication Administration Record (MAR) for the month of February 2022, contained no information regarding trach management, suctioning, cleaning or changing inner cannula, trach cannula size, trach emergency management or oxygen administration through trach mask. Attempted to review, the Treatment Administration Record (TAR), the results obtained were No Order data found for TREATMENT ADMINISTRATION RECORD. An observation was conducted on 02/07/22 at 12:38 PM, entered R31's room (during the initial tour) there were no emergency tracheostomy supplies visible in R31's room. During an interview on 02/09/22 at 1:58 PM, the Medical Director confirmed the residents' EMR under care plans should include all aspects of care for trach on resident's care plan including trach care management, the size of the trach, suctioning procedure and trach emergency management care. An interview was conducted on 02/10/22 at 9:09 PM with MDS Coordinator (MDSC) 1 regarding R5, R23, R27, and R31. MDSC1 stated the tracheostomy care plans should have included, but not limited to, the following: risk for complications, location of emergency supplies, doctor orders, emergency process if tracheostomy becomes dislodged. MDSC1 stated R5 did not have comprehensive care plan that addressed the emergency process regarding tracheostomy care. MDSC1 also stated R23, R27, and R31's care plan had not been implemented. An interview was conducted on 02/10/22 at 9:11 PM with the MDSC2 regarding R5, R23, R27, and R31. MDSC2 confirmed R5's tracheostomy care plan was not comprehensive. Cross refer to F695.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policies titled NSG Trach Care and Tracheostomy Emergency Bedside Supplies, the facility failed to have emergency tracheostomy supplies readily available at the bedside for four of five residents (Resident (R) 5, R23, R27, and R31) sampled for tracheostomy care. On 2/8/2022, 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 and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 2/8/2022 at 6:46 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/7/2022. The IJ is outlined as follows: The facility failed to ensure four of five residents with a tracheostomy had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency tracheostomy kits at the bedside. The facility had five residents with tracheostomies. Upon observations on 2/7/2022 and 2/8/2022, four of the five residents, R5, R23, R27, and R31 did not have necessary emergency tracheostomy supplies at bedside and additional supplies were not located in the facility. In addition, interviews on 2/7/2022 and 2/8/2022 with nursing staff caring for the residents with tracheostomies (Licensed Practical Nurse (LPN)1, LPN2, and LPN3) revealed a lack of knowledge and training regarding emergency tracheostomy supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): K), 42 CFR 483.25(i) -- Respiratory/Tracheostomy Care and Suctioning (F695 S/S: K), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: K), and 42 CFR 483.70 - Administration (F835 S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/Tracheostomy Care and Suctioning (F695 S/S: K). An Acceptable Removal Plan was received on 2/10/2022. The removal plan included placing tracheostomy supplies at the bedside in the resident's room and extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, and re-education of administration staff. Through interviews with facility staff, observation of tracheostomy supplies, clinical record review of revised care plans, 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 2/10/2022. 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 facility's policy titled, NSG Trach Care, revised 01/02/19, indicated, A replacement tracheostomy tube must be available at the bedside at all times. The policy further stated, A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. Review of facility's undated policy titled, Tracheostomy Emergency Bedside Supplies, revealed, .Each tracheostomy patient will have the following supplies at the bedside: Spare tracheostomy tube with obturator of the same make and size currently used, or one size smaller if the same size is not available .syringe .manual resuscitation bag, any necessary connectors to fit patient's tracheostomy tube. 1. Review of R5's undated Face Sheet provided by the facility revealed R5 was admitted to the facility on [DATE] with a tracheostomy. Review of R5's Physician Orders, located in the resident's electronic medical record (EMR) under the Orders tab revealed an order dated 10/19/21 of Shiley (brand of tracheostomy) #6. Upon entering R5's room during the initial tour on 02/07/22 at 11:44 AM, emergency tracheostomy supplies were not visible. An additional observation by a second surveyor was completed on 02/07/22 at 12:15 PM. During this observation, there were no emergency supplies visible at bedside or in R5's room. An interview was conducted on 02/07/22 at 4:14 PM with LPN2 regarding R5. LPN2 confirmed there were no emergency supplies available in R5's room. LPN2 stated she did not know how to use the emergency tracheostomy kit. An interview and observation were conducted by two surveyors on 02/08/22 at 9:21 AM with the Assistant Director of Nursing (ADON) regarding R5. The ADON stated the tracheostomy emergency supplies should be readily visible in the resident's room. The ADON looked through R5's bedside table drawers and found the emergency kit with the following items: three foam tracheostomy ties, tracheostomy cleaning kit, Shiley size 7.6 mm (millimeter), Shiley size 6.4 mm, and tracheostomy mask. The ADON confirmed there were no sterile gloves, lubricating jelly, or obturator in R5's room. Review of a Respiratory Therapy note, provided to the survey team by the facility's Respiratory Therapist (RT), dated 01/06/22 revealed the following for R5: Pt needs #8 trach @ [at] bs [bed side] for emergency purposes, a red airway emergency bag . 2. Review of 23's undated Face Sheet provided by the facility revealed R23 was admitted to the facility on [DATE]. R23 was admitted with a tracheostomy. Review of R23's Physician Orders located in the resident's EMR under the Orders tab, revealed an order dated 10/24/21 of Shiley #6. Upon entering R23's room during the initial tour on 02/07/22 at 2:15 PM, there was an ambu (self-inflating bag resuscitator) bag hanging on the resident's closet door and a red cloth bag hanging on the closet door. At the time of observation, the contents of the red cloth bag were unknown. An additional observation by a second surveyor was completed on 02/07/22 at 2:42 PM. During this observation, R23's had an ambu bag and red cloth bag remained hanging on the closet door. An interview was conducted on 02/07/22 at 4:46 PM with LPN3 regarding R23. LPN3 stated she did not know the location of tracheostomy emergency supplies for R23. An interview and observation were conducted by two surveyors on 02/08/22 at 9:16 AM with the ADON regarding R23. The ADON confirmed R23 had an ambu bag and emergency kit containing the following supplies: Shiley size 5.0 mm, two Shiley size 6.4, suctioning kit, tracheostomy cleaning kit, two foam tracheostomy ties, tracheostomy mask. The ADON confirmed there were no sterile gloves, lubricating jelly, or obturator in R23's room. 3. Review of R27's undated Face Sheet provided by the facility revealed R27 was admitted to the facility on [DATE]. R27 was admitted with a tracheostomy. Review of R27's Physician Orders located in the EMR under the Orders revealed an order dated 12/02/21 for Shiley #6. Review of R27's significant change Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/20/21 indicated R27 had a Brief Interview for Mental Status (BIMS) of 13 out of 15, which indicated the resident was cognitively intact. Upon entering R27's room during the initial tour on 02/07/22 at 2:12 PM, emergency tracheostomy supplies were not visible. An additional observation by a second surveyor was completed on 02/07/22 at 3:22 PM for R27. During this observation, the ambu bag was covered by other items and there was no emergency tracheostomy supplies available. An interview was conducted on 02/07/22 at 4:44 PM with LPN3 regarding R27. LPN3 confirmed there were no emergency supplies available in R27's room. An interview was conducted by two surveyors, with the ADON present, on 02/08/22 at 9:14 AM with R27. The resident stated that she has an ambu bag in her room but does not have the emergency kit. R27 further stated, I have heard other people receiving the red emergency kit, but I didn't get one. Review of a Respiratory Therapy note, provided to the survey team by the facility's RT, dated 01/06/22 revealed the following for R27: Pt needs placed @ bs: red emergency airway bag, #6 trach and #4 trach for emergency bs equip. An additional RT note, dated 12/17/21 revealed the following for R27: Pt needs emergency bs equipment noted as well as a red emergency airway bag. An additional RT note dated 12/08/21 revealed the following for R27: Pt needs emerg bs equipment - Ambu bag/mask, #6 trach, #4 trach (red airway bag). These items should remain visible and easily accessible. An interview and observation were conducted by two surveyors on 02/08/22 at 9:10 AM with the ADON regarding R27. The ADON stated the tracheostomy emergency supplies should be readily visible in the resident's room. The ADON searched through R27's drawers, closets, and bathroom. The ADON confirmed the emergency supply kit was not in R27's room nor an obturator but did find the ambu bag behind R27's curtain. 4. Review of R31's electronic medical record (EMR), labeled R31, under the tab Clinical revealed R31 was admitted to the facility on [DATE] with a re-admission date of 02/04/22. R31 was re-admitted with a tracheostomy. Review of R31's Physician Orders, located in the resident's EMR under the Orders tab revealed, R31 had no information regarding his trach including, physician orders for tracheostomy size, no physician orders for tracheostomy care management or emergency management and no physician order for oxygen administration. Review of R31's Medication Administration Record (MAR) for the month of February 2022, contained no information regarding trach management, suctioning, cleaning, or changing inner cannula, trach cannula size, trach emergency management or oxygen administration through trach mask. Attempted to review, the Treatment Administration Record (TAR), the results obtained were No Order data found for TREATMENT ADMINISTRATION RECORD. The Med Review of R31's Med Diag [diagnosis] tab located in the resident's EMR revealed multiple diagnoses including tracheostomy (03/21/21), malignant neoplasm of glottis and absence of larynx, acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD). An observation was conducted on 02/07/22 at 12:38 PM, entered R31's room (during the initial tour) there were no emergency tracheostomy supplies visible in R31's room. An interview was conducted on 02/07/22 at 3:46 PM with LPN1 regarding R31. LPN1 confirmed and verified there were no emergency supplies available in R31's room. LPN1 further stated she had not received tracheostomy care or emergency tracheostomy training from the facility. An interview and observation were conducted by two surveyors on 02/08/22 at 8:47 AM with LPN4 regarding R31. LPN4 stated there should be a replacement tracheostomy at R31's bedside. LPN4 confirmed with two surveyors that there was no replacement tracheostomy in R31's room. LPN4 stated she received training last year on suctioning and cleaning the tracheostomy but not on emergency tracheostomy (in the event R31's tracheostomy became dislodged). LPN4 further stated she would obtain a replacement tracheostomy from the nursing supply room. An interview and observation were conducted by two surveyors on 02/08/22 at 8:56 AM with the ADON regarding R31. The ADON stated the tracheostomy emergency supplies should be readily available and visible in the resident's room. The ADON confirmed the emergency supplies were not available or visible. The ADON searched R31's room and found the emergency supply kit in the resident's closet. The ADON confirmed the emergency supply kit contained the following: tracheostomy cleaning kit, inner cannula size 6.4 mm, and an opened suction catheter. The ADON stated the emergency supply kit should have also contained the following: extra tracheostomy, lubricating jelly, sterile gloves, suction cannula, and obturator. The ADON further stated she would check the nursing supply room for tracheostomy supplies if the supplies were not available in the resident's room. An interview and observation were conducted by two surveyors on 02/08/22 at 9:04 AM in the supply room with the ADON regarding the nursing supply room on the Gardenia Unit. The ADON stated the supply room did not have the following items: emergency tracheostomy kits, inner cannulas, sterile gloves, or suctioning catheter kits. An interview was conducted on 02/08/22 at 10:07 AM, with the ADON, Director of Nursing (DON) and Administrator. The DON and Administrator confirmed and verified emergency tracheostomy equipment was not at bedside for R5, R23, R27, and R31. The DON and Administrator verified emergency tracheostomy equipment should be visible and available for residents residing at the facility with tracheostomies. An interview was conducted on 02/10/22 at 3:25 PM with the facility's RT regarding R5, R23, R27, and R31. She stated the following emergency equipment should be at bedside, readily visible and accessible: suction machine, ambu bag with mask, same size tracheostomy and a size smaller, and obturator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of facility's policies, the facility failed to ensure tracheostomy (trach) care management for an artificial airway (cuff inflation, airway cleaning, tube changes, assessments and ongoing monitoring of respiratory functioning) was provided by competent, trained and skilled licensed staff, who were allowed to provide tracheostomy care for four of five sampled residents (Resident (R) 5, R24 R37 and R31). On 2/8/2022, 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 and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 2/8/2022 at 6:46 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/7/2022. The IJ is outlined as follows: The facility failed to ensure four of five residents with a tracheostomy had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency tracheostomy kits at the bedside. The facility had five residents with tracheostomies. Upon observations on 2/7/2022 and 2/8/2022, four of the five residents, R5, R23, R27, and R31 did not have necessary emergency tracheostomy supplies at bedside and additional supplies were not located in the facility. In addition, interviews on 2/7/2022 and 2/8/2022 with nursing staff caring for the residents with tracheostomies (Licensed Practical Nurse (LPN)1, LPN2, and LPN3) revealed a lack of knowledge and training regarding emergency tracheostomy supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): K), 42 CFR 483.25(i) -- Respiratory/Tracheostomy Care and Suctioning (F695 S/S: K), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: K), and 42 CFR 483.70 - Administration (F835 S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/Tracheostomy Care and Suctioning (F695 S/S: K). An Acceptable Removal Plan was received on 2/10/2022. The removal plan included placing tracheostomy supplies at the bedside in the resident's room and extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, and re-education of administration staff. Through interviews with facility staff, observation of tracheostomy supplies, clinical record review of revised care plans, 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 2/10/2022. 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 facility-provided paper document titled, Facility Assessment Tool, dated 04/22/21 under the heading Staff training, education and competencies ., revealed .Training and competencies are maintained in the associates personnel file and updated periodically & annually as determined by center and recertification needs. Review of facility-provided paper document titled, Assistant Director or Nursing [ADON] job description revealed .Ensures that staff participates in training programs .relevant policies and procedures Review of facility-provided paper document titled, Licensed Practical Nurse [LPN] job description revealed .Attends continuing education programs to maintain competency . Requested from the facility a policy for tracheostomy management and tracheostomy emergency management. The facility did not provide policy for review. Review of the facility-provided policy titled, Tracheostomy Care-Suctioning dated 09/19/20 date revealed, .The facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. 1. Review of R5's undated Face Sheet provided by the facility revealed R5 was admitted to the facility on [DATE]. R5 was admitted with a tracheostomy. Review of R5's Physician Orders, located in the resident's electronic medical record (EMR) under the Orders tab revealed an order dated 10/19/21 of Shiley (brand of tracheostomy) #6. Observations on 02/07/22 at 11:44 AM and 12:15 PM revealed no emergency supplies visible at bedside or in R5's room. An interview was conducted on 02/07/22 at 4:14 PM with Licensed Practical Nurse (LPN) 2 regarding R5. LPN2 stated she did not know how to use an emergency tracheostomy kit. LPN2 further stated she had not received tracheostomy care or emergency tracheostomy training at this facility. 2. Review of 23's undated Face Sheet provided by the facility revealed R23 was admitted to the facility on [DATE]. R23 was admitted with a tracheostomy. Review of R23's Physician Orders located in the resident's EMR under the Orders tab, revealed an order dated 10/24/21 of Shiley #6. Observations on 02/07/22 at 2:15 PM and 2:42 PM revealed an ambu (self-inflating bag resuscitator) bag hanging on R23's closet door and a red cloth bag hanging on the closet door. The emergency kit (red cloth bag) was missing sterile gloves, lubricating jelly, and obturator. An interview was conducted on 02/07/22 at 4:46 PM with LPN3 regarding R23. LPN3 stated she did not know the location of tracheostomy emergency supplies for R23. 3. Review of R27's undated Face Sheet provided by the facility revealed R27 was admitted to the facility on [DATE]. R27 was admitted with a tracheostomy. Review of R27's Physician Orders located in the EMR under the Orders revealed an order dated 12/02/21 for Shiley #6. Observations on 02/07/22 at 2:12 PM and 3:22 PM, and 4:44 PM (with LPN3) revealed no emergency supplies available in R27's room. An interview was conducted on 02/07/22 at 4:44 PM with LPN3 regarding R27. LPN3 stated she did not know what emergency equipment would be used if R27's tracheostomy became dislodged. LPN3 further stated she received approximately two minutes of training regarding suctioning of tracheostomy but did not receive training on emergency care. 4. Review of R31's electronic medical record (EMR), labeled R31, under the Clinical tab, revealed R31 was re-admitted to the facility on [DATE] with a tracheostomy. An observation was conducted on 02/07/22 at 12:38 PM and there were no emergency tracheostomy supplies visible in R31's room. An interview was conducted on 02/07/22 at 3:46 PM with LPN1 regarding R31. LPN1 further stated she had not received tracheostomy care or emergency tracheostomy training from the facility. An interview and observation were conducted by two surveyors on 02/08/22 at 8:47 AM with LPN4 regarding R31. LPN4 stated there should be a replacement tracheostomy at R31's bedside. LPN4 stated she received training last year on suctioning and cleaning the tracheostomy but not on emergency tracheostomy (in the event R31's tracheostomy became dislodged). Review of the Daily Assignment Sheet, provided to the survey team by the facility, revealed that the LPNs interviewed were the primary caregivers for R5, R23, R27, and R31. Review facility-provided paper document titled Trach Training by RT [Respiratory Therapist] dated 10/07/21 (2 hours) revealed six licensed staff members signatures. The content of the material taught was not provided by the facility. An informal interview was conducted on 02/08/22 at 10:30 AM with the Administrator who verified and confirmed the facility's staff had no access to facility's policies and procedures. The Administrator also verified and confirmed facility's policy and procedures were for guidance for staff members including licensed staff. The Administrator confirmed and verified, DON was not able to access facility's policies or procedures. The Administrator further stated the DON was a new employee at the facility and did not have authorization to access the information in the computer. An interview conducted on 02/10/22 at 3:09 PM revealed, Respiratory Therapy (RT), confirmed she provided trach education to LPN staff regarding trach care on 10/07/21. The RT confirmed only six staff attended the trach education class at the facility on 10/07/21. The RT stated, the content of the material covered in the class included: trach suctioning, trach care, 30-day replacement, manual resuscitation (ambu) for trach residents. The RT confirmed emergency trach equipment should be kept at resident's bedside and visible, including an ambu bag for manual ventilation. The RT also confirmed and verified she taught LPN staff to reinsert trachs for residents with dislodged or displaced trachs. The RT stated the staff could cover the trach stoma with their finger and perform rescue breathing using an ambu bag mask, sealed over resident's nose and mouth to aid with oxygen replacement, for respiratory distress (in the event of an emergency (for displacement or dislodged trach).

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable level of well-being four of five residents (Resident (R) 5, R23, R27, and R31) sampled for tracheostomy care. Specifically failing to ensure that competent nursing staff were available and trained to care for residents admitted with special care needs such as care for a tracheostomy. The facility also failed to ensure staff had adequate supplies in the event of an emergency for residents with tracheostomies. On 2/8/2022, 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 and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 2/8/2022 at 6:46 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/7/2022. The IJ is outlined as follows: The facility failed to ensure four of five residents with a tracheostomy had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency tracheostomy kits at the bedside. The facility had five residents with tracheostomies. Upon observations on 2/7/2022 and 2/8/2022, four of the five residents, R5, R23, R27, and R31 did not have necessary emergency tracheostomy supplies at bedside and additional supplies were not located in the facility. In addition, interviews on 2/7/2022 and 2/8/2022 with nursing staff caring for the residents with tracheostomies (Licensed Practical Nurse (LPN)1, LPN2, and LPN3) revealed a lack of knowledge and training regarding emergency tracheostomy supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): K), 42 CFR 483.25(i) -- Respiratory/Tracheostomy Care and Suctioning (F695 S/S: K), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: K), and 42 CFR 483.70 - Administration (F835 S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/Tracheostomy Care and Suctioning (F695 S/S: K). An Acceptable Removal Plan was received on 2/10/2022. The removal plan included placing tracheostomy supplies at the bedside in the resident's room and extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, and re-education of administration staff. Through interviews with facility staff, observation of tracheostomy supplies, clinical record review of revised care plans, 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 2/10/2022. 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 facility administrator's job description revealed under the Administrative Functions Plan, develop, organize, implement, evaluate, and direct facility's programs and activities, and Assist in development of written policies and procedures that govern operation of facility . Staff Development Participates in in-service training prior to performing tasks that are new or that employee does not feel competent performing . Competency section Maintains competency & is tested to be competent in: subject to change based on educational needs of staff . Equipment & Supply Functions Ensure that all personnel have proper equipment needed to do their job. Review of the facility-provided paper document titled, Director of Nursing . [DON's] job description revealed the position was, .plan, organize, develop, and direct the overall operations of the Nursing Service Department .to ensure that the highest degree of quality of care is maintained at all times . Facility Administration, including the Administrator and DON, failed to consistently and effectively oversee areas of the facility that were included in their job descriptions. 1. Administration failed to ensure care plan interventions regarding emergency tracheostomy care were developed for R5; and failed to ensure care plan interventions regarding emergency tracheostomy care were implemented for R23, R27, and R31. Cross refer to F656. 2. Administration failed to ensure emergency tracheostomy supplies were readily available at the bedside for R5, R23, R27, and R31. Cross refer to F695. 3 Administration failed to ensure residents with tracheostomies (R5, R24 R37 and R31) were provided nursing care by competent, trained and skilled licensed staff. Cross refer to F726. R5, R23, R27, and R31 were observed on 02/07/22 with lack of emergency tracheostomies supplies at bedside. An interview and observation were conducted by two surveyors on 02/08/22 at 9:04 AM in the supply room with the ADON regarding the nursing supply room on the Gardenia Unit. The ADON stated the supply room did not have the following items: emergency tracheostomy kits, inner cannulas, sterile gloves, or suctioning catheter kits. An interview was conducted on 02/08/22 at 10:07 AM with the ADON, Director of Nursing (DON) and Administrator. The DON and Administrator confirmed and verified emergency tracheostomy equipment was not at bedside for R5, R23, R27, and R31. The DON and Administrator verified emergency tracheostomy equipment should be visible and available for these residents. The Administrator stated, the trach supplies were delivered to the facility on Friday and currently are sitting outside on the dock in boxes. The Administrator stated the staff would not know to look for tracheostomy supplies on the dock outside. An interview was conducted on 02/08/22 at 10:30 AM with the Administrator, DON, and the Regional Director of Operations. The Administrator verified and confirmed the facility's staff had no access to facility's policies and procedures. The Administrator verified and confirmed facility's policy and procedures were for guidance for staff members including licensed staff. The Administrator confirmed and verified, DON was not able to access facility's policies or procedures. The Administrator stated the DON was a new employee at the facility and did not have authorization to access the information in the computer. The Regional Director of Operations stated the staff at the facility did not have access to the policies and procedures due to the company recently purchasing the building and the policies and procedures had not transitioned from the corporate level to the facility level. An interview was conducted on 02/10/22 at 10:06 PM with the Administrator. The Administrator stated he was not aware tracheostomy supplies were not at R5, R23, R27, and R31's bedside, and was unaware of the lack of tracheostomy supplies in the nursing supply closet. The Administrator also stated tracheostomy care was not included in any of the facility quality assurance plans.