**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, and policy review, the facility failed to ensure that one of one resident (Resident (R) 23) reviewed for tracheostomy (trach) care out of a total sample of 20 residents was provided necessary suctioning of the airway, had the necessary supplies at the bedside in the event of a life-threatening emergency, and failed to train staff on appropriate emergency tracheostomy care in the event that a resident's airway was compromised, which placed residents with a tracheostomy at increased likelihood of serious harm or death and resulted in harm to R23 who was admitted to the hospital with diagnoses of pneumonia due to an infectious organism, AMS (altered mental status), SOB (shortness of breath), rigors (fever causing severe chills and shaking), respiratory distress, increasingly thick trach secretions, and sepsis (injury to tissues and organs due to infection). On 11/29/22 at 10:30 PM, the Administrator in Training (AIT), the Regional Clinical Supervisor, and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) at F695-J: Respiratory/Tracheostomy Care and Suctioning. The Immediate Jeopardy began on 11/29/22 when the survey team identified the concerns related to the facility staff not providing suctioning of R23's tracheostomy (surgical opening into the windpipe for breathing) and no emergency tracheostomy supplies and/or staff training in the event of dislodgement of the trach from the airway for R23. The facility provided an acceptable removal plan on 12/01/22 at 6:30 PM. The removal plan included physician order revisions, placing tracheostomy supplies at the bedside in the resident's room, placing extra tracheostomy supplies in the medication room, in-servicing nursing staff on the location of tracheostomy supplies and tracheostomy care, care plan revisions, policy development of emergency management of trach, and re-education of all clinical staff. Following interviews with facility staff, observation of tracheostomy supplies, clinical record review of revised care plans and physician orders, and review of staff in-services for emergent trach care, the survey team verified implementation of the Removal Plan and removed the IJ on 12/02/22 at 8:30 PM. During the exit conference, the Associate Regional Director and the Regional Clinical Supervisor were notified that the IJ was removed but the deficient practice existed at F695-G (isolated harm). Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) Respiratory/Tracheostomy Care and Suctioning (F695 S/S: J). Findings include: Review of R23's undated admission RECORD, located in the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] with multiple diagnosis to include malignant neoplasm of larynx (cancer of the voicebox), tracheostomy status, and dysphagia (difficulty swallowing). Review of R23's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/22 and located EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R23 was cognitively intact, had a tracheostomy, and required suctioning while not a resident but no suctioning required while a resident at the facility. Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing. Review of R23's comprehensive Care Plan, under the Care Plan tab located in the EMR and revised on 08/23/22, revealed .has a tracheostomy r/t [related to] impaired breathing mechanics . Further review of the care plan revealed no information for suctioning, for emergency management of tracheostomy, no style, size, or cuff or uncuffed tracheostomy information, and no intervention related to tracheostomy care including suctioning, cleaning, or ensuring, oxygenation. Review of R23's Physician's Orders, under the Orders tab located in the EMR revealed the following: .Trach suctioning as needed . dated 08/23/22 and in conflict with the physician's order for no suctioning dated 09/02/22. .Tracheostomy care WITH NO SUCTIONING. ALLOW PATIENT TO COUGH OUT PHLEGM . dated 09/02/22 without specific definition of tracheostomy care such as cleaning the skin around the stoma and assessing for complications. Normal functions of the upper airway include warming, filtering, and humidifying inspired air]. .change disposable inner cannula [secretions can adhere to the internal lumen of a tracheostomy tube and severely reduce the inner lumen diameter over time. This potentially can increase the work of breathing and/or obstruct the patient's airway] every shift every day . dated 11/14/22 and without specific information about the inner cannula [it should be noted that there can be significant differences between the different manufacturer's tubes]. O2 [oxygen] concentrator set to 2 liters/min [minute] PRN [as needed] to maintain SPO2>92% [oxygen levels] . dated 09/02/22 and without route (nasal, face mask or trach) of oxygen administration. .# [number] 6 Shiley [brand of tracheostomy] and Ambu bag [bag used as a method of artificial ventilation] at bedside check every shift . dated 08/23/22 and without information if the Shiley was to be cuffed or uncuffed. Uncuffed tubes allow airway clearance but provide no protection from aspiration (foreign objects such as fluids or foods entering the lungs). Cuffed tracheostomy tubes allow secretion clearance and offer some protection from aspiration, and positive-pressure ventilation can be more effectively applied when the cuff is inflated. Further review of the physician orders revealed no order for an emergency tracheostomy kit at the bedside. Review of R23's Treatment Administration Record (TAR), located in the EMR and dated for 11/22, revealed: .Trach suctioning as needed Pre/Post Treatment . dated 08/23/22, with no staff's initials documented indicating the procedure was not performed from 11/01/22 through 11/30/22. .Tracheostomy care WITH NO SUCTIONING. ALLOW PATIENT TO COUGH OUT PHLEGM . dated 09/02/22, and with no specific direction for cleaning the skin around the stoma and assessing for complications. Review of this TAR revealed staff initials documented for 11/01/22 through 11/29/22 indicating care was provided with no suctioning. .change disposable inner cannula every day shift . ordered on 08/23/22 and discontinued and restarted on 11/14/22 without specific information of size of inner cannula. Review of the November 2022 TAR revealed staff initials from 11/01/22 through 11/29/22 indicating the cannula was changed every day shift. .#6 Shiley and Ambu bag at bedside check every shift . ordered 08/23/22 without specific order for cuffed or uncuffed Shiley. Review of this TAR revealed staff's initials indicating the ambu bag was at the bedside from 11/01/22 through 11/29/22. .Change disposable inner cannula every 12 hours as needed . dated 11/14/22 without information of size of inner cannula with no staff's initials for 11/14/22 through 11/29/22 indicating the order was not performed. .O2 concentrator set to 2 liters/min PRN to maintain SPO@>92% as needed . without route (nasal, face mask or trach mask) . Further review of this TAR revealed no staff's initials indicating the treatment was not provided from 11/01/22 through 11/30/22. .Change trach ties after bath/shower and as needed . dated 08/23/2022 with no staff's initials documented indicating the procedure was not performed from 11/01/22 through 11/30/22. Trach ties are bands that go around the neck to keep the trach tube in place. During an interview on 11/29/22 at 5:32 PM, Licensed Practical Nurse (LPN) 1 stated R23 did not have a physician's order to suction his trach. During an interview on 11/29/22 at 6:37 PM, Certified Nursing Assistant (CNA) 2, who indicated she provided care for R23, stated the facility did not provide her with emergency management care training in the event the trach became dislodged. During an observation on 11/29/22 at 6:39 PM, R23 was observed in his room sitting on his bed awake and alert. R23 had a trach with a large amount of white sputum at the trach site. R23 did not have a trach emergency medical kit or an ambu bag visible at his bedside. R23 had a suction machine on his bedside table but there was no suction tubing connected to the suction machine. During an observation and interview on 11/29/22 at 6:47 PM, LPN1, assigned to R23, confirmed that there was no emergency kit, no ambu bag, and no extra trach at R23's bedside. LPNl stated if the trach became dislodged, she would let the manager know as she (LPN1) had no trach emergency management training. LPNl stated she would not know what to do if there was no manager on duty. LPN1 stated she had not performed suction for R23's trach. During observation and interview on 11/29/22 at 7:0 PM, LPN2 confirmed there was no emergency kit at the bedside. LPN2 stated she worked at the facility for one year and had not been provided emergency management training in the event the trach became dislodged. LPN2 stated she had not performed suction for R23's trach. During an observation and interview on 11/29/22 at 7:13 PM, the DON confirmed R23 did not have an emergency trach kit at his bedside or an ambu bag. The DON, who as part of the leadership team was responsible for providing staff training, stated trach emergency management was not provided by the facility for the staff. During an interview on 11/29/22 at 7:22 PM, the DON verified there was no emergency trach kit in the supply room. The DON stated R23 moved to another room recently and staff did not follow the order and placed an ambu bag at his bedside. During an interview on 11/29/22 at 7:25 PM, the Unit Manager (UM-Registered Nurse)1 stated she had been at the facility for 13 years. UM1 confirmed the facility had not provided her with tracheostomy emergency management training and confirmed the physician's orders were conflicting concerning suctioning. During an interview on 11/29/22 at 7:28 PM, the Assistant Director of Nursing (ADON) confirmed he was employed at the facility for a year and the facility had not provided him with tracheostomy emergency management training. During an interview on 11/29/22 at 8:13 PM, the Medical Director confirmed he expected the facility's staff to be provided training with tracheostomy emergency management training. An interview attempt was made on 11/29/22 at 8:47 PM with the facility's Administrator and was unsuccessful. During an observation and interview on 11/29/22 at 10:41 PM of R23's room with the ADON, the DON, and UM1 revealed R23 did not have emergency trach supplies at his bedside. UM1 confirmed the facility crash cart did not contain any tracheostomy supplies. UM1 stated the facility may have a size smaller of tracheostomy in the outside storage shed. UM1 confirmed R23 did not have a physician's order with specifications regarding if the tracheostomy was cuffed or uncuffed. UM1 confirmed R23's physician's order should contain whether his tracheostomy was cuffed or uncuffed to ensure the correct replacement tracheostomy was at his bedside. Review of R23's Progress Note, under the Progress Notes tab located in the EMR revealed the following: 11/30/22 .Called into room to assess resident. Resident not able to answer questions, making groaning noises. SpO2 69% [out of 100%] on room air. Non-rebreather [mask] applied. Resident with twitching movements. MD called and order given to sent (sic) to ER [Emergency Room] via 911. 911 called .resident was pick [sic] up at 2:20pm taking to ER . During an interview on 12/01/22 at 1:16 PM, UM1 confirmed R23 was sent to the emergency room for hypoxia and altered mental status on 11/30/22 at 2:20 PM. UM1 confirmed Respiratory Therapist (RT)2 was providing ventilation by ambu bag to R23's trach and did not provide trach suctioning while awaiting the ambulance to arrive. UM1 confirmed R23 had audible rhonchi (coarse rattling lung sounds usually caused by secretions in the airways), with low oxygen saturation, twitching behavior, and a foul odor from his tracheostomy site. UM1 also confirmed that respiratory therapy did not provide suctioning to R23 during routine care. Review of an untitled hospital document, provided by R23's family and dated 11/30/22, revealed XR [x-ray of] CHEST .Hypo aeration [can be caused by blockages in the air passages] of the lungs, compatible with decreased inspirations .Asymmetric left basilar bandlike opacity appearance favors basilar atelectasis [Bibasilar atelectasis is a condition that happens when you have a partial collapse of your lungs. This type of collapse is caused when the small air sacs in your lungs deflate.], with minimal right basilar atelectasis .Problem List .Pneumonia due to infectious organism .AMS [altered mental status] SOB [shortness of breath] rigors [fever causing severe chills and shaking], respiratory distress, and increasingly thick trach secretions .trachea-pneumonitis [pneumonitis is a general term for lung inflammation. It can cause difficulty breathing and is often accompanied by a cough.] .Found to have GAS [Group A Strep bacteria] bacteremia [Invasive GAS infections are defined as bacteremia, pneumonia, osteomyelitis, septic arthritis, or any other infection associated with the isolation of GAS from a normally sterile body site] , likely pathogen of PNA [inflammation of the lungs, usually due to infection with bacteria, viruses, or other pathogens.] .Pt [patient] will need frequent suctioning .Tracheal suction with 100 cc of brown/yellowish output .Sepsis likely 2/2 [secondary to] GAS bacteremia .Pt observed to upper airway congestion, and copious [abundant] secretions coming through his trach. His cough is [NAME], but no secretions are expectorated from his mouth. Trach was cleaned and suctioned . During an interview on 12/01/22 at 2:31 PM, the Doctor of Osteopathic Medicine-Pulmonologist (DOP) confirmed it was standard of practice for a resident with a trach to have a physician's order for brand, style, size, and cuff or uncuffed trach.The DOP confirmed if the facility did not provide a resident with trach suctioning it could cause a mucous plus in the resident's airway which causes pneumonia and the resident's lungs to collapse During an interview on 12/01/22 at 6:29 PM with R23's Family Member (FM)1 with the team of surveyors present in the conference room at the facility, FM1 confirmed he was informed by the hospital staff R23 may not survive. FM1 confirmed R23 had a bad lung infection due to suctioning not being provided by the facility. FM1 confirmed R23 was diagnosed with pneumonia and sepsis by the hospital staff on 11/30/22. During an interview on 12/02/22 5:33 PM, the Medical Director confirmed he was responsible for writing physician orders and ensuring the physician's orders were correct. The Medical Director stated he may have overlooked incomplete or conflicting physician orders. The Medical Director confirmed R23's physician's orders contained conflicting orders to provide suction and to not suction R23's trach. The Medical Director stated he expected the nursing staff to know when to suction the resident with a trach (even with conflicting physician's orders). The Medical Director confirmed it was important that R23's physician's orders contained specifics regarding his trach to include brand, size, type of his inner cannula and trach. The Medical Director confirmed R23's oxygen administration physician's orders should include the route of administration of the oxygen. The Medical Director stated he did not have clinical experience with replacing resident's trach. The Medical Director stated if R23's trach became dislodged, he would call 911 and attempt to locate a trach replacement and attempt to replace R23's because it would be considered a life-or-death situation. The Medical Director confirmed not providing a resident with a trach with suctioning could potentially cause formation of mucous plug, respiratory distress, pneumonia, lung collapse, and most importantly death. Review of facility-provided policy titled, Tracheostomy Care revealed .This policy is to instruct on how to effectively clean a patient's tracheostomy and surrounding area to reduce the risk of infection and maintain a patent airway .Each resident has a specific trach tube, as ordered by a Physician .Each trach resident should have a spare back up trach at the bedside .Tracheostomy tubes have different sizes and styles .Cuffed and un-cuffed .Fenestrated and non-fenestrated .Disposable inner cannulas and non-disposable inner cannula .Different sizes .Different brands .Trach tubes and stoma sites require regular cleaning .If there is redness, bleeding or drainage from stoma, it should be reported to the resident's nurse .Whenever the tube is manipulated, respiratory, cardiovascular and skin parameters should be assessed .Suctioning is necessary to insure patent airway .Procedure for Changing Disposable Inner Cannula .equipment .Sterile disposable inner cannula .Sterile suction catheter .Sterile container .Sterile gloves .Sterile gloves .Trach Ties .Drain sponge .Sterile cotton applicators .Have a manual resuscitator available in case of respiratory distress .It is recommended infection control practice that trach care be performed on each shift . NJAC 8:39-27.1(a)