**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, and policy review, the facility failed to maintain an environment free from verbal and physical abuse for eight residents (R#156, R#16, R#11, R#23, R#25, R#39, R#101 and R#27) of 47 sampled residents. Specifically: 1. R#68 engaged in ongoing verbal and physical abuse of residents including R#156, R#16, R#11, R#23, R#25, R#39, and R#101. 2. R#27 was physically held down by a staff member while being dressed. On 11/10/22 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 residents. The facility's Administrator and the Regional Consultant were informed of the Immediate Jeopardy for F600 on 11/11/22 at 4:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/7/22. An Acceptable Removal Plan was received on 11/13/22. The survey team interviewed facility staff, reviewed policies and staff in-services on abuse prevention and reporting. R#68 was observed to be on continuous one to one supervision. The survey team verified all elements of the facility's IJ Removal Plan and removed the IJ on 11/13/22. 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 related to abuse. Findings include: Review of the facility's abuse policy titled Abuse, Neglect, and Exploitation, undated, revealed: The facility must: 1.) not use verbal, sexual, physical abuse, corporal punishment, or involuntary seclusion. 2.) Ensure all residents are free of physical or chemical restraints . 5.) Prevention of Abuse .a.) train staff appropriate interventions to deal with residents aggressive and/or catastrophic reactions by residents . d.) Education on what constitutes abuse, neglect, or misappropriation. e.) react to all allegations or questionable abuse from residents, staff, family members, and/or visitors. f.) Take appropriate actions whenever abuse is reported/suspected .13.) In response to allegations of abuse, neglect, exploitation, or misappropriation the facility MUST: a.) Ensure all alleged violations involving abuse, neglect, .misappropriation or mistreatment, including injuries of unknown origins . are reported immediately, but not later than two hours after the incident occurs b.) have evidence that all alleged violations are thoroughly investigated .d.) Report the results of investigations to the administrator .and other government officials in accordance with state laws, including reporting to the State Survey Agency .and corrective action must be taken. 1. Review of R#68's Face Sheet located in the electronic medical record (EMR) under the Basic Information tab, revealed an admission date of 4/30/22, with medical diagnoses that included schizoaffective disorder (serious mental illness of hallucinations [hearing, seeing, smelling, touching objects not there] and delusions [firmly held unrealistic beliefs]), insomnia, unspecified psychosis (loss of reality), major depression, anxiety disorder, bipolar disorder (mental illness with periods of depression and mania), and auditory hallucinations. Review of R#68's Quarterly Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/21/22, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R#68 was cognitively intact. The MDS revealed R#68 had physical behaviors directed toward others. Review of a facility investigation report revealed that R#68 (the alleged perpetrator) was admitted on [DATE] and two residents had been his roommates without incident for over a year. R#68, the aggressor, was ambulatory with stand-by assist. R#68 readily admitted that he hit R#156 when he was interviewed by the CNAs and the DON at the time the investigation was initiated and reported to the SSA. R#68 insisted that .[R#156] stole one of his shoes and he was going to beat it out of him . Review of Progress Notes, found in R#68's EMR under the Progress Note tab and dated 5/1/22 at 10:59 a.m., revealed, Resident [R#68] up this shift pacing on hallway. Resident was noted yelling at another resident [R#16] stating stop staring at me, she always stares at me. Staff continues to monitor and to redirect . Review of the Progress Note, found in R#68's EMR under the Progress Notes tab and dated 7/8/22, indicated Resident [R#68] was noted yelling out at another resident [R#11] stated that the other resident asked him to move out of the way . Resident was noted pacing on the hallway most of the shift. Psychiatrist was notified and new orders received to begin congentin [Anti-Tremor] 1mg po [by mouth] tid [three times per day], Haldol [Anti-Psychotic] 5mg po every 8 hours x14 days for agitation. Review of Social Services (SS) Progress Note, dated 7/10/22 at 2:44 a.m., revealed R#68 was transported out to the hospital for behavior management evaluation following a physical altercation with R#23. This resident [R#68] punched another resident [R#23] in the face inflicting injury to his nasal region. The latter fell on the floor as a result of the punch . Family responsible party made aware. MD notified and verbal order given to transfer to the hospital for evaluation. No new orders were received. Review of a SS Progress Note, dated 10/17/22 at 4:49 p.m., revealed .SS spoke to resident [R#68] about the incident. Resident is alert and oriented x3. Resident stated that he punched another resident [R#11] several times because he kicked him several times after he was called the N word. Both exchanged verbal abuse at that time and then [R#68] began punching the discharged resident [R#11] and pushed him out of his wheelchair onto the floor. Both residents were separated . [the psychiatrist] was notified about the incident; she requested behavior health assessment followed up with inpatient treatment. During an interview on 11/7/22 at 12:15 p.m., R#25 stated R#68 threatened to hit her on Monday (11/7/22) night. R#25 stated, He scares me, I'm afraid he will come into my room and hurt me. R#25 stated she's heard that R#68 will go into rooms and steal things. R#25 stated the nurse witnessed R#68 who threatened her and told R#68 to go away. During an interview on 11/8/22 at 8:00 a.m., R#68 was asked about altercations with other male residents, and he stated he had two incidents one with a resident that had been discharged and another who was still at the facility. When asked about altercations with female residents R#68 denied having any problems. During an interview on 11/8/22 at 9:51 a.m., R#25 stated interaction with R#68 occurred on the morning of 11/8/22 between 8:00 a.m. and 9:00 a.m. R#25 stated R#68 asked her, Why am I looking at him like that? She stated he accused her of using the N word. She stated the Administrator observed the interaction and sent her to her room. R#25 stated it was not fair that she be sent to her room. She stated, I'm not a kid, I'm not four, I felt like a bad girl. She stated on the morning of 11/7/22 she had another interaction with R#68. She stated he was so close to me I could feel him spitting on my face. She stated the night nurse had observed the interaction and yelled at R#68 to leave her alone. She stated the nurse said, I've called the police on you before, I'll do it again. R#25 stated, I felt scared. R#25 stated R#68 said, I've never hit a woman, but you might be the first. R#25 stated R#68 then grabbed the wheelchair handle and shook it. She stated, I'm feeling like I can't leave my room without him looking at me, why me, I'm [AGE] years old. She stated she was not comfortable going to the social worker because she will get angry, R#68 is her pet. An observation by the survey team on 11/8/22 at 11:20 a.m. near the nurse's station and lobby area, revealed two residents (R#39 and R#68) in a verbal altercation both were screaming and exhibiting aggressive behaviors. R#68 stated he was called the N-word, but the other resident denied that. The situation was escalating when the Administrator approached and separated the two residents. The Administrator reported the incident and began an investigation. During an interview with Certified Nursing Assistant (CNA) 2 on 11/8/22 at 4:48 p.m., CNA2 stated she received abuse training in October 2022. CNA2 stated that verbal abuse and neglect were the only types of abuse. CNA2 stated if she overheard a resident state I've never hit a resident, you might be the first, she would not consider that abuse. She said if she saw two residents fighting, she would try to get them to stop. CNA2 stated she had seen R#68 walk by R#101's room and R#101 made a comment and R#68 rushed at her. CNA2 stated she walked with him away from the room and reported this to her nurse. CNA2 did not recall the date of the event. CNA2 stated she was aware the resident went to the hospital frequently for his behaviors, but he kept coming back to the facility. During an interview with the Administrator on 11/8/22 at 5:42 p.m., she stated she did not have the investigations from the incidents with R#68 on 5/1/22 or 7/10/22. The Administrator stated she was currently working on both investigations. Observations throughout the day on 11/9/22 revealed R#68 up and walking all over the facility with no staff present. There were no further altercations observed; however, there was no increased supervision of the resident. During an interview with the Administrator, on 11/9/22 at 1:17 p.m., she stated she was not aware of the incident between R#25 and R#68 on Tuesday (11/8/22) morning. The Administrator stated she would talk to R#25. She said yesterday she talked with R#25 and assured her they would do everything, so she [R#25] did not have to be afraid. The Administrator stated they had started the process on 11/9/22, to find R#68 a more appropriate place to live and had sent referral paperwork to one facility. She stated she was waiting to hear from them and would follow up. During an interview with the Medical Director, on 11/9/22 at 3:03 p.m., he stated that he was aware that R#68 had been aggressive, but the facility had been looking for placement. He stated having an aggressive resident in a facility was similar to having a neighbor who was aggressive. He stated there was no way to guarantee protection of residents due to staffing restrictions and [residents] history of mental impairment. The Medical Director stated he was concerned that another resident was afraid but trusted that staff were monitoring R#68. He stated unfortunately we cannot restrain or medicate the resident. The Medical Director said he was usually not part of conversations related to R#68's behavior. During an interview with Licensed Practical Nurse (LPN) 2 on 11/10/22 at 1:20 p.m., LPN2 stated when R#68 had behaviors, staff would review the care plan, look at interventions, and document the behaviors in the nurses' behavior notes. LPN2 stated anytime abnormal behavior was observed those behaviors should be documented in the behavior notes. LPN2 reviewed the notes and confirmed there were no behaviors documented for R#68 from 5/1/22 through 11/10/22. During an interview with the Director of Nursing (DON) on 11/9/22 at 7:47 p.m., the DON stated the facility had not put any other interventions in place for R#68 or increased supervision of the resident since his last incident on Monday morning (11/7/22). She stated they have begun looking for another placement for R#68. During an interview with R#39 and R#25 on 11/10/22 at 11:22 a.m., R#39 stated approximately one month ago, he had a list of residents who were afraid of R#68. R#39 stated that he had given it to the social worker. R#39 stated that when he talked to the Administrator (after the incident with R#68 on 11/8/22), the Administrator did not know about the list. R#39 stated he told the Administrator I had given it to the social worker to give to you. 2. Review of the undated EMR Face Sheet, revealed R#27 was admitted to the facility on [DATE] with diagnoses including dementia, hemiplegia (paralysis on one side), and schizophrenia (serious mental illness of hallucinations [hearing, seeing, touching, smelling objects not present] and delusions [firmly held beliefs not real]). Review of R#27's quarterly MDS with an ARD of 8/22/22, revealed R#27 was ambulatory via wheelchair, occasionally exhibited behaviors/refusals of care, and had a BIMS score of 10 out of 15 indicating R#27 was moderately impaired cognitively. During an interview in R#27's room on 11/8/22 at 10:00 a.m. and 11/10/22 at 2:30 p.m., R#27 was pleasantly confused at both visits. He stated he kind of remembered the incident but couldn't remember who it was that punched me or exactly when it happened. He stated, they took care of it . when asked who took care of it, he replied them and pointed to his door toward staff. He didn't offer additional info when prompted but did say he feels safe in the facility when asked. Review of the facility's investigation revealed that when the Administrator interviewed CNA5, and in CNA5's written statement, CNA5 said . he had to hold [R#27] down to get him dressed and cleaned up. In the written statement CNA5 reported . I used one hand to dress him and with left hand pressed my arm into his shoulder because he was trying to get up . CNA5 was hired with appropriate background checks on 3/26/20 and terminated related to the determination of resident abuse on 5/22/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, electronic and paper medical record reviews, facility policy reviews, and staff interviews, the facility failed to ensure care plan interventions for emergency tracheostomy (trach) care were developed for four residents (R) (R#6, R#91, R#96, and R#256) reviewed for tracheostomy care. Additionally, the facility failed to ensure a care plan was developed to include special treatments (hemodialysis) for one resident (R#85) reviewed for dialysis. The sample size was 47 residents. On 11/10/22 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 residents. The facility's Administrator, the Regional Consultant, and the Director of Nursing were informed of the Immediate Jeopardy for F656 on 11/10/22 at 11:10 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/7/22. An Acceptable Removal Plan was received on 11/13/22. The removal plans included placing tracheostomy supplies at the bedside in the residents' rooms, extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revisions, and re-education of all clinical staff. The survey team interviewed facility staff, observed tracheostomy supplies, reviewed revised care plans, and reviewed staff in-services for emergent trach care. The survey team verified all elements of the facility's IJ Removal Plan and removed the IJ on 11/13/22. 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 an undated facility policy titled Care Planning-Interdisciplinary Team, indicated, The comprehensive, person-centered care plan will include identifying problem areas .and developing interventions that are targeted and meaningful . The resident's physician (or primary healthcare provider) is integral to this process. 1. Review of R#6's undated Face Sheet, provided by the facility, revealed R#6 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy (surgical procedure to open a direct airway through an incision in the trachea [windpipe]). Review of R#6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/6/22, located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview Mental Status (BIMS) score of 10 out of 15 indicating R#6 was moderately cognitively impaired and had a tracheostomy and required suctioning. Review of R#6's comprehensive Care Plan, located in R#6's EMR, revealed no interventions for the tracheostomy (trach) including size, type, or style (cuffed or uncuffed) and no intervention for emergency management of the tracheostomy. 2. Review of R#256's undated Face Sheet, provided by the facility, revealed R#256 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy. Review of R#256's RESPIRATORY NOTES, dated 11/9/22 and provided by the facility, revealed .Suction (PRN) (as needed) . Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing. Review of R#256's comprehensive Care Plan, located in R#256's EMR, revealed no interventions for trach including size, type, or style (cuffed or uncuffed) and no intervention for emergency management of tracheostomy. 3. Review of R#91's undated Face Sheet, provided by the facility, revealed R#91 was admitted to the facility on [DATE] with a re-admission on [DATE] and multiple diagnoses to include tracheostomy. Review of R#91's quarterly MDS with an ARD of 9/15/22, located in the EMR under the MDS tab, revealed a BIMS without a score, and indicated R#91 was severely cognitively impaired, had a tracheostomy, and required suctioning. Review of R#91's comprehensive Care Plan, located in R#91's EMR, revealed no interventions for trach including size, type, or style (cuffed or uncuffed) and no intervention for emergency management of tracheostomy. 4. Review of R#96's undated Face Sheet, provided by the facility, revealed R#96 was admitted to the facility on [DATE] with a re-admission on [DATE] and multiple diagnoses to include tracheostomy. Review of R#96's comprehensive Care Plan, located in the EMR, revealed no interventions for trach including size, type, or style (cuffed or uncuffed) and no intervention for emergency management of tracheostomy. During an interview on 11/9/22 at 1:01 p.m., the Director of Nursing (DON) confirmed there were no emergency procedures documented on Care Plans for R#6, R#256, R#91, or R#96. The DON also stated that the Care Plans should most definitely address emergency care for tracheostomies. 5. Review of R#85's electronic medical record (EMR) located under the Basic Information tab, revealed R#85 was admitted to the facility on [DATE] with diagnoses including anemia, hypertension, end stage renal disease, anxiety disorder, and depression. Review of R#85's MDS with an ARD of 10/18/22 revealed R#85 was assessed as having a BIMS score of 14 out of a possible 15 which indicated R#85 was cognitively intact. Review of R#85's Physician's Orders, dated 11/7/22, revealed R#85 was to have hemodialysis: Monday, Wednesday, Friday, and monitor dialysis access on right side chest for intact lines and signs/symptoms of infection. Review of R#85's Care Plan, dated 7/1/22, revealed no information regarding her dialysis care. Review of R#85's paper chart also did not contain a Care Plan regarding dialysis care. During an interview with the DON on 11/9/22 at 3:29 p.m., confirmed that R#85's Care Plan in the EMR did not address dialysis care. The DON also stated that it was an expectation to address dialysis care on R#85's Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff interviews, and policy review, the facility failed to ensure staff were trained for emergency care of tracheostomies (trachs) and provide emergency tracheostomy kits for four of four residents (R) (R#96, R#91, R#6, and R#256) 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, placed all residents with tracheostomies at increased likelihood of serious harm or death. On 11/10/22 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 residents. The facility's Administrator, the Regional Consultant, and the Director of Nursing were informed of the Immediate Jeopardy for F695 on 11/10/22 at 11:10 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/7/22. An Acceptable Removal Plan was received on 11/13/22. The removal plans included placing tracheostomy supplies at the bedside in the residents' rooms, extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revisions, and re-education of all clinical staff. The survey team interviewed facility staff, observed tracheostomy supplies, reviewed revised care plans, and reviewed staff in-services for emergent trach care. The survey team verified all elements of the facility's IJ Removal Plans and removed the IJs on 11/13/22. 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 a facility-provided document titled Trach Care, dated 8/2/22 revealed eleven licensed staff members signed the sign in sheet. Review of the content of the material taught was titled Tracheostomy Care and revealed The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas . and did not contain information regarding trach emergency kits or trach emergency management. During an interview on 11/8/22 at 6:30 p.m., the Director of Nursing (DON) confirmed the facility did not provide the clinical staff training for accidental dislodgement of a tracheostomy or emergency trach kits. DON stated the facility did not have a policy for trach emergency kits or dislodgement of resident's tracheostomy. 1. Review of R#96's undated Face Sheet, provided by the facility, revealed R#96 was admitted to the facility on [DATE] with a re-admission on [DATE] and multiple diagnoses to include tracheostomy (trach). Review of R#96's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/22 and located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R#96 was cognitively intact, had a tracheostomy, and required suctioning. Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing. Review of R#96's Physician's Orders, for November 2022 and under the Orders tab in the EMR, revealed . TRACH CARE EVERY SHIFT AS NEEDED . The order did not include orders for trach emergency management, tracheostomy size, type, style (cuffed or uncuffed), suctioning trach, and/or changing the trach dressing or collar. During an observation on 11/8/22 at 5:46 p.m. of R#96's room, with the DON and another surveyor, emergency tracheostomy supplies were not visible. The DON confirmed R#96 should have an emergency tracheostomy kit at his bedside and visible in the event of an emergency situation for staff to provide care. Review of R#96's Telephone Orders, under Physician Orders located in the hard chart, revealed the following orders for emergency care of the tracheostomy: 8/30/22 Send Resident to ER for Eval & TX [evaluation and treatment] [resident] pulled out trach Review of R#96's Progress Note, under the Progress Notes tab located in the EMR revealed the following: 08/30/2022 12:17 p.m. 07:45: During morning rounds, charge nurse for A hall noticed resident's trach collar was loose and out of place. Upon assessment the nurse noticed the entire trach and inner cannula was out of the stoma [opening into trachea/windpipe] and laying [sic] on his upper chest. Attempts to reinsert was [sic] unsuccessful because the stoma was closed . Resident transferred to the ER at approximately 09:30 a.m. During an interview on 11/11/22 at 3:03 p.m., the ADON confirmed R#96 was sent out to the ER because of dislodgement of his tracheostomy in August 2022. The ADON confirmed the facility failed to ensure the nursing staff were competent with trach care for the past year. The ADON confirmed the facility did not provide R#96 with quality care for his tracheostomy. During an interview on 11/11/22 at 5:02 p.m., the Wound Care Nurse-Licensed Practical Nurse (WC) confirmed she called 911 twice to transfer R#96 to the hospital since his admission to the facility. WC stated once R#96's trach came out and she could not replace it. WC stated the second time R#96 had respiratory distress and his oxygen saturations kept dropping. WC confirmed she was not provided trach training competency, in the past year at the facility. WC confirmed the facility should have provided training to her for tracheostomy care. WC confirmed residents' complications with tracheostomy and respiratory could be life threating. WC confirmed residents' tracheostomy was their airway and the only way they could breathe to keep them alive. 2.Review of R#91's undated Face Sheet, provided by the facility, revealed R#91 was admitted to the facility on [DATE] with re-admission on [DATE] and multiple diagnoses to include tracheostomy. Review of R#91's quarterly MDS with an ARD of 9/15/22, located in the EMR under the MDS tab, revealed a BIMS without a score, which indicated R#91 was severely cognitively impaired, had a tracheostomy, and required suctioning. Review of R#91's Physician's Orders, for November 2022 under Orders tab in the EMR revealed . TRACH CARE EVERY SHIFT AS NEEDED . SUCTION AS NEEDED EVERY SHIFT, order dated of 7/22/22. The order did not include trach emergency management, tracheostomy size, type, or style (cuffed or uncuffed), and/or orders for changing the trach dressing or collar. Review of R#91's Progress Notes under Progress Notes tab located on R#91's EMR revealed 9/25/22 9:45 a.m. This writer notified by charge nurse that resident pulled his trach [NAME] [sic] out. Resident assessed and in no form of resp distress at this time. 911 called to transfer resident to . ER for track (sic) reinsertion . 9/26/22 12:12 a.m. Resident returns . [from] ER at 5:30 p.m. via stretcher accompanied by two ambulance attendants for [after] trach re-insertion . During an interview on 11/8/22 at 4:04 p.m., Certified Nursing Assistant (CNA) 3 confirmed she has provided routine care for R#91. CNA3 confirmed the facility had not provided her with training/in-service for caring for residents with a trach. During an observation on 11/8/22 at 5:46 p.m. of R#91's room, with the DON and another surveyor, no emergency tracheostomy supplies were available. The DON confirmed R#91 should have an emergency tracheostomy kit at his bedside and visible in the event of an emergency situation for staff to provide care. During an interview on 11/12/22 at 1:45 p.m., the ADON confirmed R#91 was sent to the emergency room because his tracheostomy was dislodged, and the facility staff attempted but were unable to re-insert his tracheostomy. 3. Review of R#6's undated Face Sheet, provided by the facility, revealed R#6 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy. Review of R#6's quarterly MDS with an ARD of 10/6/22. located in the EMR under the MDS tab, revealed a BIMS score of 10 out of 15 indicating R#6 was moderately cognitively impaired, had a tracheostomy, and required suctioning. Review of R#6's Physician's Orders, for November 2022 under Orders tab in the EMR, revealed an order for . TRACH CARE EVERY SHIFT AS NEEDED . SUCTION TRACH AS NEEDED EVERY SHIFT . dated 9/26/22 without an order for trach emergency management, tracheostomy size, type, or style (cuffed or uncuffed), changing trach dressing or collar. During an interview on 11/8/22 at 4:15 p.m., Registered Nurse (RN) 2 confirmed the facility did not provide her with trach training and would not know what to do if R#6's trach became dislodged. During observation on 11/8/22 at 5:30 p.m., RN2 confirmed she was providing care for R#6 on 11/8/22. RN2 confirmed R#6 did not have an emergency trach kit at his bedside. During an observation on 11/8/22 at 5:40 p.m. of R#6's room, with the DON and another surveyor, revealed emergency tracheostomy supplies were not visible. DON confirmed R#6 should have an emergency tracheostomy kit at his bedside and visible in the event of emergency situation for staff to provide care. 4. Review of R#256's undated Face Sheet, provided by the facility, revealed R#256 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy. Review of R#256's Physician's Orders, for November 2022 under Orders tab in the EMR, revealed no order for trach emergency management, tracheostomy size, type, or style (cuffed or uncuffed), suctioning trach or changing trach dressing or collar. Review of R#256's RESPIRATORY NOTES, dated 11/9/22 and provided by the facility, revealed . Suction (PRN) (as needed) . During an observation on 11/8/22 at 5:46 p.m. of R#256's room, with the DON and another surveyor, emergency tracheostomy supplies were not visible. The DON confirmed R#256 should have an emergency tracheostomy kit at his bedside and visible in the event of an emergency situation for staff to provide care. During an interview 11/12/22 at 12:02 p.m., the ADON confirmed R#256's tracheostomy was surgically inserted in October 2022 and was admitted to the facility on [DATE]. The ADON confirmed that a physician was the only discipline/professional able to perform R#256's first tracheostomy replacement. The ADON confirmed the facility's nursing staff were not made aware of R#256's tracheostomy post op date and was not aware that a physician would have to change the tracheostomy for the first time. During an interview on 11/12/22 at 12:10 p.m. the ADON confirmed the facility did not have a process to ensure the facility staff was aware of the date of surgical insertion of trach or to ensure the physician was the staff responsible for re-insertion the resident's first trach. During an interview/observation on 11/8/22 at 4:04 p.m., CNA6 confirmed she provided care for residents with trachs, including R#96. CNA6 confirmed the facility had not provided her with training/in-service for caring for residents with a trach. During an interview on 11/8/22 at 4:38 p.m., Unit Manager (UM) 1 stated he had worked in the facility nearly five years, and he regularly worked with residents with tracheostomies. When asked what to do if a residents trach came out UM1 stated, that's a 911 situation - we would call the MD & 911. When asked how he would maintain the resident's airway until EMS arrived, UM1 had no answer. UM1 stated he had been trained a few months ago when an RT (respiratory therapist) came in and showed them how to reinsert a trach. When asked about the emergency trach care supplies, he had no response regarding what was needed at bedside in case of an emergency. UM1 confirmed on 11/8/22 that he provided and was responsible for caring for three of the four residents with trachs. During an interview on 11/8/22 at 4:40 p.m. CNA 4 confirmed the facility did not provide him with trach care training and stated that [training for trach care] was only for the nurses. During an interview on 11/8/22 at 4:48 p.m., CNA2 stated we work with every patient, and rotate halls [for assignments]. CNA2 stated she had received trach training in September 2022 and was trained to clean the trach. CNA2 stated she was trained to clean around the trach with cotton and would notify the nurse if the trach needed suctioning. CNA2 stated she knew nothing about an emergency kit for tracheostomy. During an interview on 11/8/22 at 5:00 p.m., CNA5 confirmed she was assigned to the hallway with three of the four residents with trachs and provided routine care. CNA5 confirmed the facility did not provide her training or in-service for caring for residents with a trach. During an interview on 11/8/22 at 5:05 p.m., CNA1 stated she did not remember ever receiving trach training and did not know anything about an emergency kit for trachs. CNA1 stated she would call the nurse if the trach fell out. During an interview at 11/8/22 at 5:45 p.m., the DON confirmed all the facility staff including CNAs should have in-service training provided by the facility for providing care for residents with trach. The DON confirmed the facility had a respiratory therapist on staff who provided services at the facility once a week. The DON stated if dislodgement of a resident's trach occurred, she expected the nursing staff to re-insert the resident's trach. DON stated the staff would be expected to use the old trach to maintain the trach opening to maintain the airway while another staff member retrieved a new trach to insert. The DON confirmed if the staff were unable to insert the new trach, she would expect the staff to call 911. During an interview on 11/8/22 at 6:30 p.m., the DON confirmed the facility did not provide the clinical staff training for accidental dislodgement of a tracheostomy or emergency trach kits training. DON stated the facility did not have a policy for trach emergency kits or dislodgement of resident's tracheostomy. During an interview and observation on 11/8/22 at 9:50 p.m. with ADON and DON confirmed they were unsure if the facility had an arbitrator/hemostat (required in an emergency kit) for all four of the residents with trachs in the building. ADON confirmed that before 11/8/22 at 4:00 a.m. the physician's orders in the medical records for all four of the residents with trachs did not include whether the trachs were cuffed or uncuffed or the type or size of the trachs. The ADON confirmed that information was necessary for the care of the trach. During an interview on 11/9/22 at 2:59 p.m., the Medical Director confirmed he provided care for residents with trachs. The Medical Director confirmed he expected the facility to have emergency equipment at the bedside for trach residents that was appropriate, but that the respiratory therapist would have all the emergency equipment. (The respiratory therapist came to the facility once a week). The Medical Director confirmed he would expect the physician's order would include type, size, and cuff or non-cuffed trach. The Medical Director confirmed he expected the facility policies would include emergency management and trach care .The Medical Director confirmed he expected the facility would provide education for CNA staff training with basic knowledge of providing care for residents with a trach. The Medical Director confirmed he expected the facilities to educate the nursing staff on emergency management of residents with trach. During an interview on 11/9/22 at 3:28 p.m., the Administrator stated she was not aware the facility needed a specific emergency kit to provide care for the residents with a tracheostomy. The Administrator confirmed the staff had not been trained on trach care. The Administrator confirmed there were some nurses trained and not all the staff regarding tracheotomy and no emergency management of tracheotomy training was provided to the facility's staff. The Administrator confirmed the facility should provide CNA staff training for providing care for residents with a tracheostomy. The Administrator confirmed she, along with the DON and ADON, were responsible for ensuring residents had the necessary medical supplies including trach emergency kits. The Administrator stated she was not aware of any residents with tracheostomy at the facility suffering dislodgement. The Administrator confirmed resident (with tracheostomy) care plans should include specific interventions, including tracheostomy emergency management. The Administrator stated the facility assessment included the facility accepted residents with tracheostomy. The Administrator verified the facility assessment included trach as condition accepted. The Administrator confirmed the facility did not provide quality care to the four residents with traches residing at the facility. The Administrator confirmed the facility was not prepared to provide care for the four residents with tracheotomy prior to their admission because the facility did not have proper supplies and the staff were not properly trained. The Administrator confirmed the facility's administration did not follow through with their responsibilities for the four residents with tracheotomy. The Administrator confirmed the facility did not have a policy regarding trach emergency management and should have a policy. The Administrator stated the staff would not be able to provide the proper care in a trach emergent situation without training.

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 four residents (R) (R#96, R#91, R#6, and R#256) reviewed for tracheostomy care and for seven residents reviewed for abuse (R#156, R#16, R#11, R#23, R#25, R#39, R#101 and R#27). Specifically: 1. The facility administration failed to ensure competent clinical staff and provide supplies to care for residents with tracheostomies to include emergency care for accidental trach dislodgement for four of four residents (R) (R#96, R#91, R#6, and R#256). Cross Refer to F695. 2. The facility administration failed to ensure the environment was maintained free from abuse from R#68. Cross refer to F600. On 11/10/22 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 residents. The facility's Administrator, the Regional Consultant, and the Director of Nursing were informed of the Immediate Jeopardy for F835 on 11/10/22 at 11:10 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/7/22. An Acceptable Removal Plan was received on 11/13/22. The removal plans included placing tracheostomy supplies at the bedside in the residents' rooms, extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revisions, re-education of all clinical staff related to tracheostomy care, re-education of all staff related to abuse and the Elder Care Act, and placing R#68 on continuous one to one supervision until appropriate placement can be found. The survey team verified all elements of the facility's IJ Removal Plan and removed the IJ on 11/13/22. 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 and includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care related to abuse. Findings include: Review of the facility Administrator's job description revealed Lead and direct the overall operation of the facility in accordance with resident needs . training employees . and under the ESSENTIAL JOB FUNCTIONS heading revealed . Directs and coordinates medical, nursing and administrative staffs and services . Implements and communicates policies and procedures for various departments . Maintain a working knowledge and ensure compliance with all governmental regulations . Understands, complies with and promotes all rules regarding Residents' Rights . 1. Review of the facility-provided document titled, Facility Assessment, undated, under the heading Staff training, education and competencies . revealed . Ongoing staff training/education and competencies are necessary to provide the level and types of support and care needed for our resident population . education, training, competency instruction, and testing policies . specialized care . trach [tracheostomy] care/suctioning. Review of a facility-provided document titled Trach Care, dated 8/2/22 revealed eleven licensed staff members signed the sign in sheet. Review of the content of the material taught was titled Tracheostomy Care and revealed The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas . and did not contain information regarding trach emergency kits or trach emergency management. During an interview on 11/8/22 at 6:30 p.m., the Director of Nursing (DON) confirmed the facility did not provide the clinical staff training for accidental dislodgement of a tracheostomy or emergency trach kits. DON stated the facility did not have a policy for trach emergency kits or dislodgement of resident's tracheostomy. The following residents were observed, and staff interviewed regarding emergency trach supplies: During an observation on 11/8/22 at 5:46 p.m. of R#96's room, with the Director of Nursing (DON) and another surveyor, emergency tracheostomy supplies were not visible. The DON confirmed R#96 should have an emergency tracheostomy kit at his bedside and visible in the event of an emergency situation for staff to provide care. During an interview on 11/12/22 at 12:36 p.m., the admission Director confirmed he discussed R#96's admission to the facility with the Administrator prior to R#96's admission and the Administer was aware R#96 had a tracheostomy. During an interview on 11/12/22 at 1:04 p.m., the Administrator confirmed she approved R#96's admission to the facility and was aware he was admitted with a trach. During an interview on 11/8/22 at 4:15 p.m., Registered Nurse (RN) 2 confirmed the facility did not provide her with trach training and would not know what to do if R#6's trach became dislodged. During observation on 11/8/22 at 5:30 p.m., RN2 confirmed R#6 did not have an emergency trach kit at his bedside and no ambu bag (a handheld manual resuscitator used to provide ventilation to an individual not breathing on their own) visible in his room. During an observation on 11/8/22 at 5:46 p.m. of R#256's room, with the DON and another surveyor, emergency tracheostomy supplies were not available. The DON confirmed R#256s should have an emergency tracheostomy kit at his bedside in the event of emergent situation for staff to provide care. During an interview on 11/12/22 at 12:38 p.m. the admission Director confirmed he discussed R#256's (with tracheostomy) admission to the facility with the DON and the DON approved her admission. The admission Director confirmed the Administrator was informed of all facility resident admissions prior to admission to the facility. During an interview on 11/8/22 at 4:40 p.m., CNA4 confirmed the facility did not provide him with trach care training and stated that was only for the nurses. During an interview on 11/8/22 at 4:38 p.m., Unit Manager (UM) 1 stated he had worked in the facility nearly five years, and he regularly worked with residents with tracheostomies. When asked what to do if a residents trach came out UM1 stated, that's a 911 situation - we would call the MD [physician] & 911. When asked how he would maintain the resident's airway until EMS arrived, he had no answer. UM1 stated he had trained a few months ago when a Respiratory Therapist came in and showed them how to reinsert trachs. When asked about the emergency trach care supplies UM1 had no response regarding what was needed at bedside in case of an emergency. During an interview on 11/8/22 at 4:48 p.m., CNA2 stated the staff work with every patient, and rotate halls. CNA2 stated she had received trach training in September and was trained to clean the trach. CNA 2 stated she was trained to clean around the trach with cotton and would notify the nurse if the trach needed suctioning. CNA2 stated she knew nothing about an emergency kit for trachs. During an interview with CNA1 on 11/8/22 at 5:05 p.m., she stated she did not remember ever receiving trach training. CNA1 stated she would never clean a trach and did not know anything about the emergency kit for trachs in the facility. CNA1 stated she would call the nurse if the trach fell out. During an interview at 11/8/22 5:45 p.m., the DON confirmed all the facility staff including CNAs should have in-service training provided by the facility for providing care for residents with trachs. The DON confirmed the facility had a respiratory therapist on staff who provided services at the facility once a week. The DON stated if dislodgement of a resident's trach occurred, she expected the nursing staff to re-insert the resident's trach. The DON stated the staff would be expected to use the old trach to maintain the trach opening or maintain the airway with the old trach holding with gauze while another staff member retrieved a new trach for the staff to insert. The DON confirmed if the staff were unable to insert the new trach, she would expect the staff to call 911. The DON stated she expected the staff to hold the oxygen mask over resident's trach site. During an interview on 11/9/22 at 3:28 p.m., the Administrator stated she was not aware the facility needed a specific emergency kit to provide care for the residents with trachs. The Administrator confirmed some nurses were trained on trach care and that no emergency management of trachs training was provided to the facility's staff. The Administrator confirmed the facility should provide CNA staff training for providing care for residents with trachs because it would affect how the CNA staff provided the care for those residents. The Administrator confirmed she (along with DON and ADON) were responsible for ensuring residents had the necessary medical supplies including trach emergency kits. The Administrator confirmed the facility did not have any trach emergency kits in the facility. The Administrator confirmed the facility should have emergency kits for all four of the residents with trachs. The Administrator verified the facility assessment included tracheostomies as a condition accepted. The Administrator confirmed the facility was not prepared to provide care for the four residents with trachs prior to their admission because the facility did not have proper supplies and the staff were not properly trained. The Administrator confirmed the facility did not have a policy regarding trach emergency management, did not have a trach emergency kits that staff would not be able to provide the proper care in a trach emergency situation without training. 2. Review of the facility's abuse policy titles Abuse, Neglect, and Exploitation, undated, revealed: The facility must: 1.) not use verbal, sexual, physical abuse, corporal punishment, or involuntary seclusion. 2.) Ensure all residents are free of physical or chemical restraints . 5.) Prevention of Abuse .a.) train staff appropriate interventions to deal with residents aggressive and/or catastrophic reactions by residents . d.) Education on what constitutes abuse, neglect, or misappropriation. e.) react to all allegations or questionable abuse from residents, staff, family members, and/or visitors. f.) Take appropriate actions whenever abuse is reported/suspected .13.) In response to allegations of abuse, neglect, exploitation, or misappropriation the facility MUST: a.) Ensure all alleged violations involving abuse, neglect, .misappropriation or mistreatment, including injuries of unknown origins . are reported immediately, but not later than two hours after the incident occurs b.) have evidence that all alleged violations are thoroughly investigated .d.) Report the results of investigations to the administrator .and other government officials in accordance with state laws, including reporting to the State Survey Agency .and corrective action must be taken. During an interview with the Administrator, on 11/9/22 at 1:17 p.m., she stated she was not aware of the incident between R#25 and R#68 on Tuesday (11/8/22) morning. The Administrator stated she would talk to R#25. She said yesterday she talked with R#25 and assured her they would do everything, so she [R#25] did not have to be afraid. The Administrator stated they had started the process on 11/9/22, to find R#68 a more appropriate place to live and had sent referral paperwork to one facility. She stated she was waiting to hear from them and would follow up. During an interview with the Medical Director, on 11/9/22 at 3:03 p.m., he stated that he was aware that R#68 had been aggressive, but the facility had been looking for placement. He stated having an aggressive resident in a facility was similar to having a neighbor who was aggressive. He stated there was no way to guarantee protection of residents due to staffing restrictions and [residents] history of mental impairment. The Medical Director stated he was concerned that another resident was afraid but trusted that staff were monitoring R#68. He stated unfortunately we cannot restrain or medicate the resident. The Medical Director said he was usually not part of conversations related to R#68's behavior. During an interview with the Director of Nursing (DON) on 11/9/22 at 7:47 p.m., the DON stated the facility had not put any other interventions in place for R#68 or increased supervision of the resident since his last incident on Monday morning (11/7/22). She stated they have begun looking for another placement for R#68.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff interviews, and policy review, the facility failed to ensure competent clinical staff were trained to care for residents with tracheostomies and for emergency care for accidental trach dislodgement for four of four residents (R) (R#96, R#91, R#6, and R#256) reviewed for tracheostomy care. The facility's failure to properly train staff for complex care of tracheostomies and emergency airway maintenance placed all residents with tracheostomies at increased likelihood of serious harm or death. On 11/10/22 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 residents. The facility's Administrator, the Regional Consultant, and the Director of Nursing were informed of the Immediate Jeopardy for F695 on 11/10/22 at 11:10 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/7/22. An Acceptable Removal Plan was received on 11/13/22. The removal plans included placing tracheostomy supplies at the bedside in the residents' rooms, extra tracheostomy supplies in the nursing supply room, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revisions, and re-education of all clinical staff. The survey team interviewed facility staff, observed tracheostomy supplies, reviewed revised care plans, and reviewed staff in-services for emergent trach care. The survey team verified all elements of the facility's IJ Removal Plans and removed the IJs on 11/13/22. 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, undated, under the heading Staff training, education and competencies . revealed, . Ongoing staff training/education and competencies are necessary to provide the level and types of support and care needed for our resident population . education, training, competency instruction, and testing policies . specialized care . trach [tracheostomy] care/suctioning. Review of the facility-provided document titled, Director of Nursing . 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 . Review of the facility-provided paper document titled, Assistant Director or Nursing (ADON) job description revealed . Assists in developing and maintaining nursing service objectives, standards of nursing practice, nursing policy and procedure . Review of facility-provided paper document titled; Licensed Practical Nurse LPN job description revealed . Attends in-services and participates in training new staff . Review of facility-provided paper document titled, Certified Nursing Assistant (CNA) job description revealed . Assist in orientation and training of other staff. Attend orientation, mandatory in-service, and education programs . The facility administration failed to ensure sufficient and competent clinical staff to care for residents with tracheostomies and for emergency care for accidental trach dislodgement. a. Review of R#96's undated Face Sheet, provided by the facility, revealed R#96 was admitted to the facility on [DATE] with a re-admission on [DATE] and multiple diagnoses to include tracheostomy (trach). Review of R#96's Physician's Orders, for November 2022 and under the Orders tab in the EMR, revealed . TRACH CARE EVERY SHIFT AS NEEDED . The order did not include orders for trach emergency management, tracheostomy size, type, style (cuffed or uncuffed), suctioning trach, and/or changing the trach dressing or collar. Review of R#96's Telephone Orders, under Physician Orders located in the hard chart, revealed the following orders for emergency care of the tracheostomy: 8/30/22 Send Resident to ER for Eval & TX [evaluation and treatment] [resident] pulled out trach During an interview on 11/8/22 4:04 p.m., CNA3 confirmed she provided care for R#96. CNA3 confirmed the facility had not provided her with training/in-service for caring for residents with trach. During an interview on 11/11/22 at 3:03 p.m., the ADON confirmed R#96 was sent out to the emergency room because of dislodgement of his tracheostomy in August 2022. The ADON confirmed the facility failed to ensure the nursing staff were competent with trach care for the past year. The ADON confirmed the facility did not provide R#96 with quality care for his tracheostomy. b. Review of R#91's undated Face Sheet provided by the facility revealed R#91 was admitted to the facility on [DATE] with re-admission on [DATE] and multiple diagnoses to include tracheostomy. Review of R#91's Physician's Orders, for November 2022 under Orders tab in the EMR revealed .TRACH CARE EVERY SHIFT AS NEEDED . SUCTION AS NEEDED EVERY SHIFT, order dated of 7/22/22. The order did not include trach emergency management, tracheostomy size, type, or style (cuffed or uncuffed), and/or orders for changing the trach dressing or collar. Review of R#91's Progress Notes under Progress Notes tab located in the EMR revealed 9/25/22 9:45 a.m. This writer notified by charge nurse that resident pulled his trach [NAME] [sic] out. Resident assessed and in no form of resp distress at this time. 911 called to transfer resident to . ER for track (sic) reinsertion . 9/26/22 12:12 a.m. Resident returns . [from] ER at 5:30 p.m. via stretcher accompanied by two ambulance attendants for [after] trach re-insertion . During an interview on 11/12/22 at 1:45 p.m., the ADON confirmed R#91 was sent to the emergency room because his tracheostomy was dislodged, and the facility staff attempted but were unable to re-insert his tracheostomy. c. Review of R#6's undated Face Sheet, provided by the facility, revealed R#6 was admitted to the facility on [DATE] and multiple diagnoses to include tracheostomy. During an interview on 11/8/22 at 4:15 p.m. Registered Nurse (RN) 2 confirmed the facility did not provide her with trach training. RN 2 confirmed she had no idea what to do if R#6's trach became dislodged. During observation on 11/8/22 at 5:30 p.m. RN2 confirmed she provided care for R#6 on 11/8/22. d. Review of R#256's undated Face Sheet, provided by the facility, revealed R#256 was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy. Review of R#256's Physician's Orders, for November 2022 under Orders tab in the EMR, revealed no order for trach emergency management, tracheostomy size, type, or style (cuffed or uncuffed), suctioning trach or changing trach dressing or collar. Review of R#256's RESPIRATORY NOTES, dated 11/9/22 and provided by the facility, revealed .Suction (PRN) (as needed) . During an interview/observation on 11/8/22 at 4:04 p.m., CNA6 confirmed she provided care for residents with trachs, including R#96. CNA6 confirmed the facility had not provided her with training/in-service for caring for residents with a trach. During an interview on 11/8/22 at 4:38 p.m., Unit Manager (UM) 1 stated he had worked in the facility nearly five years, and he regularly worked with residents with tracheostomies. When asked what to do if a residents trach came out UM1 stated, that's a 911 situation - we would call the MD & 911. When asked how he would maintain the resident's airway until EMS arrived, UM1 had no answer. UM1 stated he had been trained a few months ago when an RT (respiratory therapist) came in and showed them how to reinsert a trach. When asked about the emergency trach care supplies, he had no response regarding what was needed at bedside in case of an emergency. UM1 confirmed he provided and was responsible for caring for three of the four residents with trachs on 11/8/22. During an interview on 11/8/22 at 4:40 p.m. CNA4 confirmed the facility did not provide him with trach care training and stated that [training for trach care] was only for the nurses. During an interview on 11/8/22 at 4:48 p.m., CNA2 stated we work with every patient, and rotate halls [for assignments]. CNA2 stated she had received trach training in September 2022 and was trained to clean the trach. CNA2 stated she was trained to clean around the trach with cotton and would notify the nurse if the trach needed suctioning. CNA2 stated she knew nothing about an emergency kit for tracheostomy. During an interview on 11/8/22 at 5:00 p.m., CNA5 confirmed she was assigned to the hallway with three of the four residents with trachs and provided routine care. CNA5 confirmed the facility did not provide her training or in-service for caring for residents with a trach. During an interview on 11/8/22 at 5:05 p.m., CNA1 stated she did not remember ever receiving trach training and did not know anything about an emergency kit for trachs. CNA1 stated she would call the nurse if the trach fell out. During an interview at 11/8/22 5:45 p.m., the DON confirmed all the facility staff including CNAs should have in-service training provided by the facility for providing care for residents with trach. During an interview 11/8/22 at 6:30 p.m., DON confirmed the facility did not provide the clinical staff training for accidental dislodgement of tracheostomy or emergency trach kits training. DON stated the facility did not have a policy for trach emergency kits or dislodgement of resident's tracheostomy. During an interview on 11/9/22 at 1:04 p.m., the Administrator stated the DON and ADON were responsible for all training. The Administrator stated she was in the process of hiring a Staff Development Coordinator. During an interview on 11/9/22 at 2:59 p.m., the Medical Director expected the facility to provide education for CNA staff training with basic knowledge of providing care for residents with a trach. The Medical Director confirmed he expected the facilities to educate the nursing staff on emergency management of residents with a trach. During an interview on 11/9/22 at 3:28 p.m., the Administrator confirmed not all the nursing staff were trained, and the training did not include emergency management of a trach. The Administrator confirmed the facility should provide all the nursing staff training and include trach emergency management. The Administrator confirmed the facility should provide CNA staff training for providing care for residents with a trach. The Administrator stated the staff would not be able to provide the proper care in a trach emergent situation without training. During an interview on 11/9/22 at 5:15 p.m., the Respiratory Therapist (RT) confirmed that a resident's dislodgement of their trach was a life-threatening emergency. RT confirmed she provided trach care in-service to some nursing staff at the facility in August 2022. RT confirmed she instructed the nursing staff to replace the resident's dislodged tract during the in-service. The RT confirmed the facility's entire nursing staff or CNAs did not attend the in-service. RT stated nursing staff without trach emergency management or trach care should not be assigned to provide care for residents with trach. RT stated nursing staff without trach emergency management training should call their supervisor or 911 if the resident's trach became dislodged or fell out. RT confirmed it was important to have emergency supplies at the residents with trach bedside, trach correct size and size smaller, obturator, and ambu bag.