**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess, monitor, and provide interventions to prevent decannulation for a resident with known behaviors of self-decannulation; and failed to ensure that staff were provided tracheostomy recannulation education for extubation for 1 of 2 residents (R3) reviewed for tracheostomy in the sample of 2. The failure resulted in R3's self-decannulation of her tracheostomy which compromised R3's health status. R3 required emergency transfer to the local hospital on [DATE] and required two attempts at reinsertion of the tracheostomy and arterial line placement. After reinsertion of R3's tracheostomy by an ENT physician, R3 became hypoxic with oxygen saturation in the 80's and had increased work for breathing. R3's hospital records document R3 ultimately died on [DATE] with clinical impression of tracheostomy complications, cardiopulmonary arrest and heart block. R3's death certificate is pending investigation. This failure has the potential to affect all residents with tracheostomy medical needs.The Immediate Jeopardy began on [DATE], when R3 was admitted to the facility with a tracheostomy tube. R3's Infectious Disease Progress Note dated [DATE] documents R3 had a history of tracheostomy tube decannulation prior to being admitted to the facility. R3's care plan dated [DATE] had no documented interventions to prevent R3 from self-decannulating tracheostomy tube. R3 self-decannulated her tracheostomy tube at the facility on [DATE] and she was transferred to the emergency room and readmitted to the facility the same day. No interventions were added to R3's care plan to prevent her from decannulating the tracheostomy again. On [DATE] staff documented R3 removed her tracheostomy again and was transferred to the emergency room. R3's clinical impressions included tracheostomy complications, cardiopulmonary arrest and heart block. On [DATE] at 9:26 AM PM V1, Administrator, V2 DON and V28 Regional Nurse were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on [DATE], but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R3's Infectious Disease Physician Progress Note, dated [DATE] documents R3 pulled out her tracheostomy tube 3 weeks prior.On [DATE] at 2:00 PM V2, DON provided a timeline of R3's health status. The timeline documented R3 had a history of decannulating her tracheostomy tube prior to being admitted to the facility. R3's Undated Face Sheet documents she was initially admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, tracheostomy, pneumonia, colostomy, gastrostomy and high blood pressure. R3's admission Nurse Assessment, dated [DATE] documents reason for admission: pneumonia, peg-tube and IV (intravenous) ABT (antibiotics.) No behaviors documented. No documentation R3 had a tracheostomy tube upon admission. R3's Physician's Order Sheet (POS), dated [DATE] documents oxygen humified at 6 LPM via trach collar continuous two times a day for shortness of breath. R3's Comprehensive Care Plan, dated [DATE] documents R3 has the presence of a tracheostomy at this time r/t (related to) DX (diagnosis) of acute respiratory failure. Goal: R3 will have no complications r/t tracheostomy through next review date. Interventions: all orders r/t tracheostomy will be followed, and MD (physician) updated with any concerns. No documentation of interventions to prevent R3 from decannulating her tracheostomy tube. R3's Nurse Progress Notes dated [DATE] through [DATE] no documentation R3 was agitated, restless or behaviors of pulling on tracheostomy tube or collar. R3's admission Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively impaired, had no behaviors exhibited, a tracheostomy and a diagnosis of respiratory failure. R3's Nurse Progress Note dated [DATE] documents at 6:19 AM, writer entered resident's room at 5:15 AM to administer morning medication and discovered trach dislodged. R3 was transferred to the emergency room. R3's Health Status Note, dated [DATE] at 5:15 PM, documents resident returned to facility from the ER (emergency room) following a trach tube replacement. Trach was replaced due to dislodgement. R3's Comprehensive Care Plan has no documentation of interventions to prevent R3 from decannulating her tracheostomy tube after removing it on [DATE] documented. R3's form dated [DATE] through [DATE] documents follow up question: Did resident display change in mood? [DATE] through [DATE] documents No change. [DATE] at 2:02 PM, Other documented.R3's Health Status Notes, dated [DATE] through [DATE], no documentation of R3 being agitated, restless or having behaviors of pulling on tracheostomy tube. R3's Nurse Progress Note dated [DATE] at 1:25 PM V12, RN documented Res noted to be restless and pulled bag off colostomy and trach out. MD notified and orders to send to ER, POA notified. R3's Emergency Medical Services (EMS) Run Report, dated [DATE] documents the primary complaint is that the trachea tube pulled out, with an estimated onset time of 11:00 AM on [DATE] and a duration of 3 days. The patient's level of distress is mild. The primary impression is muscle weakness signs, and the secondary impression is shortness of breath.On [DATE] at 12:05 PM V16, CNA stated he was familiar with R3 and her care. V16 stated prior to [DATE] he observed R3 pull on her trach, G-tube and colostomy but he wasn't aware R3 had pulled her trach out before this day. V16 stated [DATE] day shift and he recalled R3 had a tracheostomy tube, G-Tube and colostomy bag and exhibited behaviors of pulling on all of them in the past. V16 stated the morning of [DATE] he recalled R3 was anxious and pulled her colostomy bag off and he let V12, RN know, and she assist R3 to get the colostomy bag back on. V16 stated he didn't know R3 had a history of taking her trach out and didn't know of any interventions in place to prevent R3 from pulling it out again. On [DATE] at 11:30 AM V12, RN stated she was assigned to R3 on [DATE] from 6:00 AM to 6:00 PM and she suctioned R3 2-3 times that shift and recalled R3 pulled her colostomy bag off, so she had to replace it in the morning and R3 was also pulling on her g-tube as well. V12 stated she didn't notify R3's physician of the behavior of pulling on everything, she looked at R3's POS but there were no medications for anxiety to administer. V12 stated she wasn't aware that R3 had a history of pulling her trach out and if she did, she would have notified the physician of the pulling behavior to try to prevent R3 from pulling it out. R3's trach collar was on, and the trach was in place when she administered R3's morning medications via G-Tube. At one-point V16, CNA notified her R3 pulled her colostomy bag off again and when she entered R3's room she noted her trach was on her bed. She didn't know what to do so she got V11, LPN to assist her and V11 told her to call R3's physician the physician stated to send the resident to the emergency room to get the trach replaced. V12 stated V11 assisted her to suction R3 as well that day because she was new to trach's and wanted to ensure she was doing it properly and she suctioned R3 2-3 times that day but V12 stated she doesn't recall if she documented she suctioned R3 on her MAR or not. V12 called 911 and R3 was transferred to the local emergency room for trach replacement. V11 told V12 that they do not attempt to put a trach cannula back in at the facility so neither her or V11 attempted to put R3's trach back in and there was no trauma to R3's trach area. V12 stated she works at the facility PRN and hasn't received training on re inserting a trach and didn't feel comfortable doing that. V12 stated staff took R3's vital signs and noted her oxygen saturation was in the low 90's and that was another reason R3 was transferred to the emergency room.On [DATE] at 11:45 AM V11, LPN stated she worked on [DATE] 6:00 AM to 6:00 PM and recalled V12 asked her to assist her in suctioning R3 a few times that morning and she went and R3's trach collar was on and intact. After lunch V12 reported to her that R3's trach cannula was on her bed, she told her to call R3's physician and find out what they want to do, she called, and they called 911 to transfer R3 to the emergency room for trach placement. V11 stated she assisted R3 onto the stretcher when EMS arrived at the facility, and she didn't assess any trauma to R3's trach area. V11 stated R3's oxygen saturation was around 93% after she pulled her trach out. V11 stated she's new to working at the facility and she didn't know if there was an emergency trach available and she wasn't trained on how to re insert a trach either. V11 stated she is an LPN, and she doesn't think it's in her scope of nursing practice to re insert a trach and she thought that reinserting the trach would be an emergency room procedure. On [DATE] 3:45 PM V20, LPN/MDS/Care Plan Coordinator stated R3 had a G-Tube, colostomy and a trach and she was considered a high acuity resident. V20 stated staff did frequent checks on R3 from admission because she was so high acuity. At the end of [DATE] R3 pulled her trach out and R3 was readmitted to the facility the same day and the trach was reinserted in the emergency room. V20 stated staff did frequent checks on R3 after she pulled her trach out at the end of [DATE] but didn't know of any new interventions the facility put in place to prevent R3 from pulling out her trach again. V20 stated she hadn't received tracheostomy reinsertion training at the facility and wouldn't feel comfortable attempting to reinsert a tracheostomy tube, she'd just call 911 and send the resident to the emergency room. On [DATE] at 8:45 AM V5, CNA stated she was assigned to R3 often and she recalled R3 was always fidgety, pulling on her colostomy bag, G-Tube and trach area. V5 stated she wasn't working when R3 pulled her trach out either time and no staff said anything about new interventions to prevent R3 from pulling the trach out again after she pulled it out the first time. On [DATE] at 3:40 PM, V9 PTA and V10 Director of Therapy stated they provided therapy to R3 prior to her pulling her tracheostomy tube out at the end of [DATE] and during the therapy session V9 and V10 stated they recalled R3 pulled on her tracheostomy collar often and they redirected her not to pull on it multiple times during the therapy sessions. V10 stated she reported R3 pulling on her tracheostomy collar to the nurse (name unknown) when it occurred. On [DATE] at 3:30 PM V18, LPN stated R3 had behaviors of pulling on her colostomy, G-Tube and tracheostomy collar. V18 stated she didn't know R3 had a history of decannulating her tracheostomy tube prior to doing it the first time at the facility at the end of [DATE] and she didn't know of any new interventions that were put in place after R3 was readmitted to the facility after pulling her tracheostomy tube out. V18 stated she had not received training on reinserting a tracheostomy tube and wouldn't be comfortable reinserting a tracheostomy tube in an emergency. On [DATE] at 1:05 PM V3, RN/Assistant Director of Nurses (ADON) stated she is new working at the facility, but she hasn't been trained on re inserting a trach and wouldn't feel comfortable doing so. On [DATE] at 1:15 PM V25, RN stated she works night shift and has worked 2 shifts at the facility and is still on orientation and hasn't been trained on trach re insertion and wouldn't feel comfortable with reinserting a trach. On [DATE] at 1:58 PM V2, DON stated she hasn't been trained on trach decannulation and she wouldn't feel comfortable reinserting a trach after it came out. V2 stated V15 LPN, V20 LPN, V22 LPN, V24 LPN, V26 LPN and V27 LPN have received tracheostomy tube reinsertion in case of an emergency. On [DATE] at 2:00 PM V15, LPN stated she received emergency tracheostomy reinsertion training but would only feel comfortable attempting to reinsert a resident's tracheostomy tube if she had assistance of another nurse to ensure she was doing it correctly. On [DATE] at 2:05 PM V7, LPN stated she received emergency tracheostomy reinsertion training, but she couldn't recall what facility trained her and she would only feel comfortable reinserting a tracheostomy tube with the assist of another knowledgeable nurse assisting her. On [DATE] at 2:09 PM V24, LPN stated she has not received emergency tracheostomy reinsertion training at the facility and wouldn't feel comfortable reinserting a tracheostomy tube. On [DATE] at 9:30 AM V2, Director of Nurses (DON) stated R3 was initially admitted to the facility with a tracheostomy tube, G-Tube and a colostomy so she was considered to be a high acuity resident, and staff did frequent checks on her from admission. V2 stated R3 had chronic respiratory failure and that's why she had the tracheostomy tube which had a physician's order for continuous humidified oxygen to her trach collar at 6 liters. V2 stated R3's family took the oxygen off R3's tracheostomy tube for up to 30 minutes at a time and R3's oxygen saturation stayed stable. V2 stated R3 pulled her tracheostomy tube out at the end of [DATE], and she was sent to the emergency room and readmitted to the facility. V2 stated she would have to look into R3's medical records and see what interventions the facility documented they put in place to ensure R3 didn't pull her tracheostomy tube out again but that she knew staff were doing frequent checks and they had the tracheostomy tube tied to the collar to prevent it from coming out. V2 stated she reviewed R3's medical record and no staff documented she was restless until she pulled her tracheostomy tube out the second time at the facility on [DATE]. V2 stated the nurse assessed R3, notified her physician that the tracheostomy tube was removed and sent R3 to the emergency room per physician's orders. V2 stated she spoke to the nurses who assessed R3 after she removed the tracheostomy tube on [DATE] and they stated R3 wasn't in respiratory distress at that time and she expected the assessment to be documented in R3's nurse progress notes, including her vital signs. V2 stated R3 was transferred to the hospital on [DATE] where she was diagnosed with pneumonia and when R3 was readmitted to the facility her family abruptly discontinued her Hydralazine and Adamine and V2 stated she looked into it and that abrupt discontinuation of those medications could cause agitation, delirium and restlessness which could occur within hours to days after the discontinuation. R2 stated no staff reported to her that R3 was ever restless or having behaviors of pulling on her tracheostomy tube and there is no documentation of that in R3's medical record either, until [DATE]. On [DATE] at 2:39 PM V2, DON stated she can't find staff education documentation that shows staff were educated on recanalization of a tracheostomy tube and she probably won't be able to.On [DATE] at 2:00 PM V1, Administrator went through the facility's tracheostomy policy and stated it doesn't address reinsertion of a tracheostomy in an emergency situation. V1 stated he would have V2 add it to the policy and reinservice nurses to ensure they are properly trained on how to reinsert it in an emergency situation. On [DATE] at 8:45 AM V28, Regional Nurse stated she understood the facility's tracheostomy policy that was given to IDPH on [DATE] didn't address reinsertion of a tracheostomy in an emergency situation and that she added that to the facility's tracheostomy policy and had inserviced nurses so they were educated on this topic. Reviewed hospital emergency room records dated [DATE]. They document due to resident decannulated tracheostomy which required two attempts at reinsertion of the tracheostomy and arterial line placement. After reinsertion of R3's tracheostomy by an ENT physician, R3 became hypoxic with oxygen saturation in the 80's and had increased work for breathing. R3's hospital records document R3 ultimately died on [DATE] with clinical impression of tracheostomy complications, cardiopulmonary arrest and heart block.On [DATE] at 9:56 AM V21, R3's Physician stated R3 had a lengthy hospitalization in 2025 for acute respiratory failure where she was intubated for a long period of time. R3 had a physician's order for humidified oxygen to the trach collar and that was to keep the trach moisturized not to prevent hypoxia. V21 stated you can't restrain residents in long term care so when R3 was readmitted to the facility after pulling her tracheostomy tube out the first time, he expected staff to remind the resident to not pull out her tracheostomy tube and to do frequent checks on the resident. V21 stated if R3 was restless or having behaviors of pulling on her tracheostomy tube/collar he would have expected staff to notify him so he could review her medications. V21 stated he wasn't aware R3's family removed the oxygen from the trach, but he was OK with it as long as R3's oxygen saturation level was OK. The tracheostomy tube was medically necessary because R3 was intubated for so long she needed to be slowly downgraded from being intubated. V21 stated the tracheostomy tube should not be removed abruptly because it could cause hypoxia which could lead to cardiac arrest which if not corrected could lead to death. V21 stated when R3 was observed to have removed her tracheostomy tube the second time at the facility nurses assessed her, notified him and R3 was transferred to the emergency room to be assessed and have the tracheostomy tube reinserted.The Facility Assessment Updated [DATE], documents they accept 1-2 tracheostomy residents a year with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, Chronic Lung Disease and Respiratory Failure.The Facility's Undated Tracheostomy Care Procedure documents the purpose of this procedure is to guide tracheostomy care and the cleaning of resuable tracheostomy cannulas. The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy:Immediate Jeopardy Removal Plan: On, [DATE] R3 admitted to the facility with a HX of decannulation. On [DATE] resident decannulated her trach. Facility nursing staff attempted to re-insert her Trach without success and was sent to local Hospital for re-insertion of the Trach. Resident returned to the facility on the same day. On [DATE] resident decannulated her trach, no respiratory distress and O2 saturation WNL, PCP notified and gave orders to send to ED for reinsertion of trach. Facility called EMS for transfer to hospital for reinsertion of trach. Staff were in-serviced/trained on tracheostomy recannulation by the RNC. Education will be ongoing. Staff on vacation or FMLA will be in serviced before returning to work by Administrator/DON, nurse management. Administration will monitor for compliance. [DATE] and Ongoing. New hires will be trained on tracheostomy recannulation as part of their general orientation before starting by DON or nurse management. [DATE] and Ongoing. DON in serviced by RNC on tracheostomy recannulation and respiratory assessment and care planning. [DATE] and Ongoing. Resident respiratory assessments for all residents that require Trach care will be completed each shift. Any resident in the facility that requires trach care will have individualized interventions to prevent decannulation. This will be reviewed and updated accordingly by the IDT team. Trach care plans reviewed and updated by the IDT team. Trach care and suction assessments and care plans will be reviewed by IDT at least quarterly and after any incident or resident change in behavior. [DATE] and Ongoing. Tracheostomy recannulation drill was performed on [DATE] by DON/RNC and will be performed weekly for one month and monthly thereafter for 6 months. Staff will be re-in-serviced on tracheostomy recannulation and upon annual review of annual policy by DON, nurse management, and administration. New hires will be in serviced on during their general orientation. [DATE] and Ongoing. Recanalization supplies are in each resident area for those that have tracheostomies. [DATE] and Ongoing. QAPI review with Medical Director to review tracheostomy recanalization incident and plan of action. Action plan will be reviewed monthly at QAPI meeting. Medical Director approved of plan with no further recommendations. [DATE] and Ongoing. Medical Director notified of incident on [DATE] in the facility by the Administrator and reviewed the facility's immediate action plan. He agreed with immediate action plan. [DATE]. R3 no longer resides in the facility. [DATE].