**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement effective fall interventions and supervision for a dependent resident assessed as a high risk for falls. This failure affected one resident (R2) of four residents reviewed for falls. This failure resulted in (R2) having a fall, being sent out to the emergency room, and sustaining a laceration to right eyebrow requiring 3 sutures. Findings include: R2 is a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnoses including but not limited to: Functional quadriplegia, atrial fibrillation, bradycardia, and hypertensive heart disease with heart failure. R2's Minimum Data Set (MDS) section C0500 dated 2/18/2025 documents Brief Interview for Mental Status (BIMS) Score = 15 which suggests cognition is intact. MDS section GG0130 dated 2/18/2025 documents resident is dependent on staff for the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Care plan with initial date of 2/20/2025 but revision date of 2/23/2025 documents Focus: R2 is high risk for falls due to weakness, functional decline, co-morbidities such as functional quadriplegia, DM-II (Diabetes Mellitus type 2), AFIB (Atrial fibrillation), hypertensive heart disease, HLD (hyperlipidemia), depression, anemia, BPH (benign prostatic hyperplasia) without UTI (urinary tract infection), neuropathy. Goal: R2 will be free of falls through the next review date. Interventions: I prefer to keep all needed items like water pitcher, tissue box, urinal, etcetera, within reach. o I prefer to keep the bed in the low position for safety. o I would like staff to keep furniture in locked position during transfers and nursing care. o Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with a prompt response to all requests for assistance. R2's Progress note dated 3/27/2025 documents: Note Text: Called Hospital to follow up patient status. Patient admitted diagnosis: head Laceration. Bed hold. R2's Progress note dated 3/27/2025 documents in part: Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: Patient had a fall. He is on Eliquis 5 mg BID. Has wound on right eyebrow area. 2. This started on: 03/27/2025. 2f. Describe symptoms or signs: Had a fall incident today. Patient c/o (complaint of) pain in both arms. He also had a wound on right eyebrow. 8c. Is there any bleeding noted from the injury? Yes 8c1. If there is a bleeding, choose one of the following: Scant Recommendation: Appearance 1. Summarize your observations and evaluation: Patient has wound on right eyebrow area and c/o pain in both arms after a fall incident. He is on Eliquis 5 mg BID. He was sent to the hospital ER (emergency room) via 911 for further evaluation and management. 3. Additional information on the change in condition: Patient was sent out to ER by 911. MD (medical doctor) and family were notified. R2's Progress note 3/27/2025 documents in part: Incident Summary: Summoned to patient's room by V8 Certified Nursing Assistant (CNA). R2 is observed lying on the floor by his bed. R2 is positioned on his stomach with face turned to left side. There's a chair close to R2's head. Assigned CNA (V8) said she was cleaning patient (R2) and left patient for a second to get more supplies as patient kept on passing stools. Before V8 CNA got back, she heard patient (R2) fell from the bed. R2 c/o (complains of) pain in both arms. Also, noted a wound on his right eyebrow area with small amount of bleeding. R2 remains alert and oriented x4. No loss of consciousness noted during the incident. Patient is on Eliquis 5 mg BID. 911 called for immediate transfer to ER (emergency room). MD (medical doctor) and patient's family notified. R2's Hospitalist History and physical dated 3/27/2025 documents in part: The patient presented to the hospital after mechanical fall out of bed at nursing home. He got a laceration to his right eyebrow which was repaired in the ER. Tetanus was updated. Imaging was negative for any acute injury. Him and his sister stated there feeling that he is neglected at the current nursing home, and they would like to be placed any new nursing home. R2's Laceration repair procedure note from hospital dated 3/27/2025 documents in part: appropriate position and anesthesia around the laceration was obtained by infiltration using 1% lidocaine without epinephrine. The area was then cleansed using alcohol. The laceration was closed with 3-0 Prolene using interrupted sutures. There were no additional lacerations requiring repair. The wound area was then dressed with gauze. The patient's tetanus status was updated with a tetanus booster. Total repaired wound length 2.5 cm. Other Items: Suture count: 3 On 4/22/2025, at 9:39 AM, V8 (CNA) stated the night R2 had a fall, I was doing rounds. I went in to change R2. I was cleaning R2 up, he was on his side. R2 kept having a bowel movement. I asked if R2 was ok and went to the door because my linen cart was by the door. I went to grab more linen and R2 was on the floor. I had left R2 on his side, on the bed. R2 was comfortable on his side. R2 was laying on his side before I walked off and he was fine. R2 did not use any side rails. R2'a bed was not to the floor, but it was not high. I did not raise the bed to do care. I left the bed at the level it was in when I came in. R2's bed was about my hip level. R2 could move his one arm the right arm. R2 could move his legs a little bit but could not move them a lot. I can't even tell you how R2 fell. I know I left R2 in a safe position. R2 was laying on his side for a while as I was cleaning his back. My cart was right by the door, and everything happened so quick. By the time I came back in R2 was on the floor. I did not hear R2 fall. I just heard R2 tell me he was on the floor. R2 did not tell me he was slipping or anything. No one else was in the room when this happened. We do not carry radios or anything. There were three CNAs on that hall that night. I let the nurse know. I stepped to the door and called for V9 Registered Nurse (RN). We (V9 and I) cleared the way for the ambulance to come get R2. We (V9 or I) did not move R2 or put him back in the bed. The ambulance people came and got him off the floor. I did not realize R2 was bleeding until the ambulance came and picked him up. R2 was bleeding from his eye. I think it was the right side. R2 always complains of pain. R2 was not screaming or anything like it was something new. R2 pretty much just laid there talking normal. On 4/22/2025, at 11:29 AM, V9 Registered Nurse (RN) stated, I was working the night R2 had his fall at the end of March. I was at the nurse's station. My CNA (V8) was in the hallway. V8 said, can you come here. R2 is on the floor. V8 said, I was changing the patient and he kept passing stool and I left for a second and V8 said she heard him fall from the bed. When I walked in R2 was on the floor, so I called 911, I did not even move R2. Ambulance came right away within a few minutes. At first, I could not see if R2 was bleeding. R2's right side of his face was on the floor. When 911 got there I seen R2 had about an inch long cut on right eyebrow area that was bleeding a minimal amount. It was shallow. R2 was complaining of pain on the left arm. When I went in the room and seen R2 on the floor the bed was waist high. R2 did not have any bed rails on his bed or half rails that I know of. If I were to be changing the resident and needed more supplies, I would make sure the patient is on his back, the bed is lowered, and make sure resident is safe before I leave the room. I would explain to resident that I need to get supplies and I will be right back in a few seconds. On 4/22/2025, at 2:33 PM, V3, Director of Nursing (DON) stated, if a staff member was changing someone and needed more supplies the staff member could put on the call light and get help. In the situation with R2 the linen cart was right outside the door, I would not expect them (staff) to leave a resident to go all the way to the linen closet. I would expect staff to leave resident in a safe manner ensuring their safety before leaving them briefly for supplies. When asked what a safe manner would be V3 stated, a safe manner would be ensuring resident is not at the edge of the bed, put bed in low position, make sure call light was still in reach. When asked what position the resident should be placed in, V3 stated, I guess the position of the patient depends on the patient. When asked specifically for R2's situation as a quadriplegic what would the safest position be for R2 be, V3 stated R2 was a quadriplegic so his safest position would have been on his back. On 4/23/2025, at 11:25 AM, V1, Administrator stated, my expectation of staff when leaving a resident briefly to get supplies would be that they are left in a safe position. When asked what would constitute a safe position, V1 stated a safe position would be comfortable, center of the bed, and bed lowered. When asked what position the resident should be left in such as on side or on back, V1 stated the position the resident should be in would depend on their orders. Like if a resident has orders to turn every 2 hours, we would follow the doctors' orders. When asked what position should a resident be left in if the staff is just stepping away briefly to get supplies, V1 stated just for staff to step away briefly the optimal position could be on the back. When asked for this particular resident R2 who had quadriplegia and could not fully move legs, what would optimal positioning for this resident be if staff needed to walk away briefly to get supplies, V1 stated optimal positioning for this particular resident R2 would have been on his back due to his quadriplegia. If there is a fall, we do in servicing right away. I know we did in servicing for the date in question. Fall Prevention Program Guideline Policy with review date of August 5, 2022, documents in part: Policy Statement: Fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. This program shall include measures to determine the individual needs of each resident by assessing the risks for fall and the implementation of evidence-based prevention interventions. Procedure 2. Safety interventions shall be initiated and implemented for each resident identified at risk for fall. 3. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. 6. Interventions shall include staff, family and resident education, programs, purchase of equipment or other environmental-related alternatives to prevent the resident from falling. 7. An individualized evidence-based plan of care shall be created to reflect fall prevention interventions which could be but not limited to: h. Residents shall be observed to ensure the resident is safely positioned in bed or chair. Provide care as assigned in accordance with the plan of care. j. Education and communication of resident care to staff. m. provide assistance with activity of daily living to include toileting as needed. ADL (Activities of Daily Living) Care Guidelines Policy with reviewed date of August 5, 2024, documents in part: ADL care is provided for each resident in the facility in accordance to the resident's comprehensive assessment and care plan in order to identify, evaluate, and intervene to, maintain, improve or prevent and avoidable decline in ADL's. Interpretation and Implementation 2. Nurses and CNAs (certified nursing assistants) are trained in providing general/routine ADL care to the residents. The facility has an active program of restorative nursing services which is developed and coordinated through the resident's care plan. 4. ADL nursing care is performed daily for the residents based on the comprehensive assessment, plan of care, physician orders as well as ADL documentation on varios shifts. Such care may include as appropriate but not limited to: g. Incontinent care and bowel and bladder training as indicated; and i. Other ADL support and assistance in accordance to the restorative nursing assessment and/or comprehensive resident assessment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedures for care planning and fall prevention by not implementing previously established fall interventions based on all available information for a resident readmitted to the facility with a history of repeated falls and by not implementing personalized fall interventions or ensuring all available sources of information were utilized to identify and implement effective fall interventions for a resident who was admitted to the facility after being hospitalized from a fall that resulted in multiple significant injuries. This failure applies to two of four residents (R7 and R56) reviewed for falls and resulted in R56 experiencing a fall that resulted in a thigh bone fracture. Findings include: R7 is an [AGE] year-old male with a diagnoses history of Metabolic Encephalopathy, Right and Left Side Pain from Back to Legs, and restless leg syndrome who was admitted to the facility 07/23/2024. R7's admission hospital records dated 02/21/2024 documents he had a history of frequent falls, he was admitted to the hospital after a fall at home, he had previous hospital admissions related to falls in the last few years, he has severe lumbar spine fusion and complains of pain, per family member he has been having more frequent falls as of late, and can be transferred to rehabilitation; the plan for recurrent falls included recommendation of subacute rehab; IDT (Interdisciplinary Team) recommendations also included Bed/Chair alarms, caregiver within arm's reach when out of bed, establish a toileting schedule and ADL (Activities of Daily Living) routine, non-skid socks, use of bedside commode, shades up during the day, lights off and shades down at night, and minimizing overnight disruptions. The facility's Fall Log reviewed 11/18/2024 documents R7 had falls on 10/22 at 11:40 AM and 10/26 at 9:25 PM R7's progress note dated 10/23/2024 documents a certified nursing assistant made writer aware that R7 was observed sitting on the floor. Writer and staff went into resident's room to assess resident. Resident stated he was trying to move to the other bed because his bed had a hole in it, and he slid down on the floor. R7's Fall Risk Management assessment dated [DATE] documents his bed alarm was going off in his room, staff immediately responded, and he was observed lying on the floor; R7 reported he didn't fall but slipped off the bed as he was trying to go to the other bed. R7's Current care plan initiated 07/23/2024 documents he is at risk for falls related to a history of falls, potential medication side effects, poor safety awareness, disease process such as acute respiratory failure with hypoxia, sepsis, aspiration pneumonia, cognitive impairment, acute metabolic encephalopathy, Coronary Artery Disease, Benign Prostatic Hyperplasia, chronic Urinary Tract Infections, Hypertension, Diabetes Mellitus, Acute Kidney Injury, and A fibrillation. R7's care plan interventions did not include Bed/Chair alarms, caregiver within arm's reach when out of bed, establishing a toileting schedule and ADL (Activities of Daily Living) routine, non-skid socks, use of bedside commode, shades up during the day, lights off and shades down at night, or minimizing overnight disruptions. R7's Bed alarm intervention was not implemented until 10/22/2024 and the intervention of frequent rounding and asking if he needs assistance or toileting were not implemented until 10/26/2024. R56 is a [AGE] year-old male with a diagnoses history of Cirrhosis of Liver, Emphysema, Non-traumatic Brain Hemorrhage, Stage 4 Chronic Kidney Disease, Sarcoidosis, Epilepsy, Hepatic Encephalopathy, History of Falling, Multiple Fractures of Ribs, and Bone Disorder who was admitted to the facility 07/12/2024. The facility's Fall Log reviewed 11/18/2024 documents R56 had a fall with injury 07/12/2024 at 10:39 PM. R56's admission Summary progress note dated 7/12/2024 documents patient has arrived at facility via stretcher around 2pm. Writer noted upon assessment patient has multiple bruises all over the body, left ear sutures, and bruising around left eye. Patient is currently in bed, with bed in the lowest position, call light within reach, ice water at bedside; at 11:03 PM it was documented that Writer was notified by certified nursing assistant of patient being on the floor. Upon assessment the writer observed the patient sitting upright at the bedside, as the writer asked the patient what happened his nose started to bleed. The patient had pain rating 10/10 with limited range of motion to the left leg, the patient was extremely confused. Facility Incident Report dated 07/18/2024 documents R56 had an unwitnessed fall 07/12/2024 at 10:10 PM and was admitted to the hospital with an acute right femoral shaft fracture; On 07/12/2024 at approximately 10:10 PM a certified nursing assistant observed patient sitting on the floor of his room, he was observed by nurse sitting upright on his buttocks on the floor by his bed, he was observe with minimal bleeding from nose and was unable to move his right leg, when asked what happened he reported he was trying to get up and use the bathroom, he did not activate the call light for assistance, he was last seen by the nurse before the incident at approximately 9:35 PM sleeping in bed with his call light in reach and bed in the lowest position. On 11/18/24 01:29 PM V26 (Family Member) stated, R56 fell when he first came to the facility, and she doesn't think they did the proper intake when he was admitted . V26 stated, the facility didn't get enough information about R56's needs. V26 stated, R56's other roommates had a better intake process and were better accommodated. V26 stated, she doesn't know how R56 fell but his bed was not equipped with sensors or railings, and his room was far back in the facility at the very end. V26 stated, after R56 fell they added railings to his bed, moved his room closer to nurses station, and added a motion sensor to his bed. V26 stated, when R56 fell he fractured his femur (thigh bone) and hasn't been able to receive therapy. V26 stated, R56 has been discouraged and depressed, has become withdrawn and believes a lot of it has to do with the injury. R56's medical records did not include any information obtained from V26 (Family Member) on the day he was admitted regarding his needs based on his risk of falls and history of falls. R56's hospital report dated 07/24/2024 documents he was recently admitted to the hospital from [DATE] - 07/12/2024 for traumatic subdural hematoma and sub arachnoid hemorrhage (bruising and bleeding near the brain), nasal bone fracture, abnormally low blood cells post bone marrow biopsy and having subsequent worsened confusion. R56's Minimum Data Set section for Functional Abilities dated 07/12/2024 marked as completed at 3:11 PM documents he required supervision and touching assistance with bed mobility and substantial/maximal assistance with transfers. The facility's census report documents when R56 was admitted on [DATE] his room was located in an area that was not close to the nurses station and when he was readmitted to the facility on [DATE] he was placed in a room right outside the nurses station area. R56's physician order history documents 2 quarter side rails to aide with bed mobility and transfers were not ordered until 07/24/2024. R56's Current care plan initiated 07/12/2024 documents he is a high risk for falls due to traumatic subdural hemorrhage, calculus of kidney, stroke, acidosis, right ankle joints and right foot, stage 3 Chronic Kidney Disease stage, sarcoidosis, epilepsy, acute kidney failure, insomnia, and right hip fracture with interventions implemented 07/12/2024 including ensure that his frequent visitors are aware of the use of assistive and adaptive devices; he has periods of forgetfulness and would like staff to frequently reorient him to his surroundings; he would prefer to keep all needed items like water pitcher, tissue box, urinal, etc., within reach; he would prefer to keep the bed in the low position for safety; he would like Physical Therapy and Occupational Therapy to evaluate and treat him as ordered to increase his strength and mobility and prevent further falls; and he would like staff to provide him with a safe environment: even floors, free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; side rails as ordered, and handrails on walls. R56's care planned interventions of a bed alarm to alert staff when he attempts to get out of bed unassisted, or so staff can assist him and prevent falls and the two quarter side rails to aide with mobility and transfers were not implemented until 07/24/2024. R56's care planned interventions of reminding him to ask for assistance; reorienting him on how to use the call light, and if necessary, toileting him to prevent unassisted attempts to go to the toilet were not implemented until 11/09/2024. On 11/20/24 at 1:02 PM V2 (Director of Nursing) stated, initial fall assessments are done upon admission. V2 stated, if a resident has a known history of falls on admission based on information obtained from the resident, the resident's family, or the hospital this information would be including in the admission's assessment. V2 stated, any information obtained from those sources should be included on the admission or baseline care plans. V2 stated, any past medical history of fall interventions should have been incorporated in R56's care plan once he was readmitted to the facility in July 2024. V2 stated, he believes V26 (Family Member) was present and interviewed when he was admitted to the facility and possibly any available information regarding falls would have been obtained from her. On 11/21/24 at 10:33 AM V32 (Physician) replied, yes when asked by surveyor if fall interventions should be personalized to R56's needs. V32 stated, he saw R56 soon after his arrival prior to his fall and V26 (Family Member) was at bedside at this time. V32 stated, he believes there was some concern with R56's neurological status related to his sarcoidosis, and this may have led to him attempting to get out of bed. V32 stated, R56 suffers from a rare illness, and it may have been difficult to anticipate his particular needs and the appropriate precautions needed to be implemented prior to him coming to the facility for the first time. V32 stated, fall interventions are a personalized approach for each patient and should be tailored to the debilities that each patient comes with. On 11/21/24 at 11:32 AM V1 (Administrator) stated, the room R56 was located in on admission is not right near the nurses station and is towards the end of the hall. V1 stated, room R56 is currently located in is closer to the nurses station and is right outside of it. On 11/21/24 at 12:29 PM V2 (Director of Nursing) stated, R56's bed rails were not in place when he fell 07/12/2024. V2 stated, bed rails would not be added until an assessment is done, and consents were given. V2 stated, there was no reason rails could not be applied for R56 on admission, however there was no indications if bed railings were needed or not for R56 and no information was provided by V26 (Family Member) of him needing bed railings. V2 agreed it is not necessary for V26 to initiate the use of bed railings, and railings could be used for mobility or if the staff noticed that the patient was struggling with positioning however there was nothing indicating this during the brief amount of time R56 was admitted prior to his fall. The facility's Fall Occurrence Policy received 11/21/2024 states: It is the policy of the facility to ensure that residents are assessed for risk for falls and that interventions are put in place. A Fall Risk Assessment form will be completed by the nurse or the Falls Coordinator upon admission. Those identified as high risk for falls will be provided fall interventions. An interim Falls Care Plan may be started but a Falls Care Plan is necessary and required after the State required Minimum Data Set was done. If a resident had fallen, the resident is automatically considered as high risk for falls. Therefore, the nurse does not have to fill out the Fall Risk Assessment to determine if the resident is high risk for falls or not, after the resident had fallen. The Falls Coordinator will add the intervention in the resident's care plan. The interventions will be reevaluated and revised as necessary. The facility's Care Planning Policy received 11/21/2024 states: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. Based on the State Operations Manual F656 regulation a comprehensive care plan must be developed after the comprehensive assessment of the resident. The baseline care plan at a minimum should include initial goals based on admission orders, physician orders, and therapy services.

Based on interviews and record review, the facility failed to consistently monitor, assess, and implement pressure relieving interventions to prevent the development of facility acquired pressure ulcers. This affected one resident of three (R1) residents reviewed for pressure ulcer prevention. This failure resulted in R1 developing a stage 3 pressure sore to the coccyx area, and a stage 2 pressure sore to the left buttocks. Findings include: Review of R1's medical record notes R1 was admitted to this facility on 1/25/23 with diagnoses including: severe sepsis with shock related to UTI (urinary tract infection) and pneumonia, malaise, acute respiratory failure with low oxygen levels, chronic obstructive pulmonary disease, heart failure, dementia, and diabetes. R1 was discharged to home on 2/6/23. Review of R1's admission skin assessment, dated 1/25/23, notes no skin breakdown or reddened areas identified. Review of R1's POS (physician order sheet), dated 1/26/23, notes an order for an air mattress for skin integrity. On 2/10/23 at 10:50am, R1's family member stated that on the day of R1's discharge from facility, family member was cleaning R1 and saw wounds on R1's coccyx and buttocks. R1's family member stated when she got R1 home and removed his socks she observed a large blood blister on his right heel. R1's family member stated that facility did not notify her of these wounds. On 2/10/23 at 2:37pm, V4 (unit manager) stated that on 2/6/23 V4 was informed that R1's family member found wounds on R1's sacrum and left buttocks. V4 stated V4 was asked to assess these wounds. On 2/14/23 at 9:50am, V5 (wound care nurse) stated V5 performs a head-to-toe skin assessment on newly admitted residents. V5 stated that V5 informed staff that R1 required an air mattress because R1 did not move much. V5 stated R1 did not receive air mattress during his stay. V5 denied being made aware of any skin breakdown on R1's coccyx and left buttock. V5 stated R1 had a scabbed area on right heel that V5 observed on 1/26/23. V5 stated she applied a foam dressing to R1's heel and changed every three days. V5 stated when residents are discharged home with wounds, the discharge instructions will note orders for wound care treatments. On 2/14/23 at 12:00pm, V10 (nurse) stated V10 provided care to R1 on 2/6/23. V10 stated R1's family member provided most of the care for R1 during his stay. V10 stated sometimes family would ask for staff assistance. V10 stated on 2/6, R1's family member asked V10 for assistance with turning R1. V10 stated family member was standing facing R1's back when he turned and observed wounds on coccyx and left buttocks. V10 stated there was some drainage observed from the wounds. V10 stated V10 informed V9 (unit manager) of R1's wounds. V10 denied contacting R1's physician for treatment orders. V10 stated R1's family member informed V10 that V10 was previously a wound care nurse and requested a calcium alginate dressing for R1's wounds. V10 stated V10 cleaned R1's wounds and applied calcium alginate dressing per family's request. V10 stated V10 also gave R1 some extra dressings for home use. Review of R1's medical record, dated 2/6/23, V10 RN noted new opening noted at coccyx 0.5cm (centimeters) width x 1.5cm length x 0.2cm depth. Review of R1's medical record, dated 2/6/23, V4 (unit manager) noted V4 was asked to assess the new wounds on R1. R1 has a stage 3 pressure ulcer on the coccyx area and a stage 2 pressure ulcer on the left buttocks. Review of R1's care plan, dated 1/26/23, R1 is at risk for alteration in skin integrity related to impaired mobility. Review of this facility's skin care treatment policy, revised 7/28/22, notes charge nurses must document in the nurse's notes and/or the wound report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained from the resident's physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have interventions in place to address the behaviors of a resident pulling out a tracheostomy tube and inner cannula for one resident (R2) reviewed for accidents and incidents in a total sample of 6. This failure resulted in R2 pulling out the tracheostomy tube and being found unresponsive, CPR was initiated and R2 was pronounced deceased in the facility. Findings Include: Respiratory Therapy Note dated [DATE] documents that R2 was being admitted to the facility for rehab and reconditioning. R2's history documents that the resident was hospitalized on [DATE] after a fall where the resident sustained a subdural hematoma requiring a left craniotomy and craniectomy. R2 was placed on a ventilator and a trach and feeding tube was placed. R2 was weaned off the ventilator, decannulated and sent to acute rehab on [DATE]. On [DATE] R2 suffered tracheal stridor and cardio-pulmonary arrest. R2 was transferred back to the hospital, tracheal stenosis was noted, and a new trach was placed. Upon admission to the facility on [DATE] R2 was noted with a 28% aerosol trach collar in place with oxygen at 5 liters. R2 had no signs of respiratory distress, and all vital signs were stable. Trach care and suctioning done every shift and as needed. Social Service Note dated [DATE] documents that R2 has a Brief Interview for Mental Status Score of 13 out of 15 indicating that the resident is cognitively intact. R2 is calm and cooperative and communicates with clear speech as English is the resident's primary language. The resident is her own responsible party. R2 has no history of delusions or hallucinations. R2 ambulates via wheelchair and requires assistance with ADLs. Nurse's Notes dated [DATE] documents that nurse arrived to perform suctioning. Nurse observed R2's removable inner cannula on the bedside table. R2 was asked why she removed the inner cannula and stated because she did not need it. R2 educated on the importance of having the inner cannula in place. Cannula cleaned; suctioning performed but Nurse had trouble putting the cannula back in place. Once the cannula was inserted R2 had complaints of shortness of breath. R2's aerosol trach collar applied and the resident still had complaints of shortness of breath. Nebulizer treatments done with no relief. Normal saline applied to the trach and suctioning done. Nurse removed a thick mucus plug with suctioning and resident no longer had troubles breathing. Vitals were stable, resident reeducated on leaving the inner cannula in place and verbalized understanding. Nurse's Notes dated [DATE] documents that at 10:37am the nurse entered the resident's room to give medications and noted that R2 was unresponsive. The nurse noted that the resident did not have a pulse and did not have respirations. R2's trach collar was in place but the tracheal tube and inner cannula had been removed from the stoma and was found in bed under the resident's covers. The nurse reinserted the tracheal tube and inner cannula and initiated CPR. The paramedics were called and R2 was pronounced deceased at 11:16am. The Death Certificate documents that the cause of death was acute respiratory insufficiency and mucus plug of the tracheal tube. On [DATE] at 12:30pm V3 (Respiratory Therapist) stated, The resident was admitted to the facility with a trach that required maintenance after having a thyroid surgery where a partial tumor resection was done. The maintenance included suctioning, breathing treatments, cleaning out the cannula and this was the responsibility of the nursing staff when I'm not here. I work Monday through Friday during the day and I round 1-2 times per shift on all my residents. The resident was receiving humidity through the aerosol trach collar to maintain the airway. The resident was not on a ventilator and only required about 4-5 liters of oxygen. R2 did have a history of pulling out the trach, she had done this before at another facility. R1 did pull out the inner cannula while here and I went in and educated the resident on the importance of keeping that inner cannula in place. The resident did not give a reason why she pulled out the inner cannula but she did verbalize understanding after education was complete. On [DATE] at 2:35pm V5 (Nurse) stated, I was coming back to the resident's room to give medications. The CNA was in the room with her so I went to take care of another resident and came back later. When I came back the resident was lying on the bed with her legs hanging out of the bed looking straightforward at the TV. R2 didn't respond to me when I spoke to her and that was abnormal because she talks with the trach. I asked if she was ok, she didn't respond so I assessed her and there was no pulse and she was not breathing. I called a code blue and initiated CPR. R2 had the aerosol collar on but it was loose. The trach was sitting on the opening of the ostomy site. The CNA was in the room with the resident providing care 10 minutes prior to this incident. A couple of days before this happened, R2 was with family and I was called in the room because the resident was having trouble breathing. R2 had the collar covering the neck but she was asking to be suctioned. That's when I noticed the inner cannula was not in, it was on the bedside table. I had trouble getting the inner cannula back in, I called the supervisor and had to use saline to get it in. Education was done on not pulling it out because it causes mucus plugs. The resident said she pulled it out because she didn't need it. I notified the supervisor and the nurse practitioner. I don't recall any new interventions being put into place. I just tried to monitor the resident every hour or so. On [DATE] at 2:40pm V6 (Nurse Practitioner) stated, R2 was stable. She had the aerosol trach collar and was not on oxygen. The resident pulled the trach out over the weekend and that call would've gone to the on-call person, but there were no new interventions put into place. R2 was on nebulizers and getting suctioned as needed. R2 was alert and oriented x 3 and able to make her needs known. R2 did pull out the trach at another facility and there was a previous incident of the resident taking out the inner cannula. The care plan was reviewed and documents that R2 has a risk for respiratory impairment related to the presence of a tracheostomy. Staff is to monitor for signs of respiratory distress, suction and provide trach care based on physician's orders and as needed. There was no care plan or updated interventions in place to address the behavior of the resident pulling out the trach tube.