**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's Advance Directives (a document which provides an individual's wishes for emergency and lifesaving care) were honored for 1 (R #101) of 1 (R #101) residents when staff provided cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation) to R #101 when the resident had a documented Do Not Resuscitate (DNR; lifesaving measures are not desired) Advanced Directive on file at the facility. If staff do not follow a resident's Advanced Directives, then the resident may feel undignified and as if they do not have control over her own choices.The findings are: A. Record review of R #101's face sheet revealed an admission date of [DATE]. B. Record review of R #101's New MexicoMedical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves)form,dated [DATE] andsigned by R #101, revealed the residentchose DNR. C. Record review of R #101's physicians progress notes, dated [DATE], revealed R #101 discussed her options for code statuswith her doctorand selected DNR status. D. Record review of R #101's physicians orders dated [DATE] revealed a Do Not Resuscitate status. E. Record review of R #101's nurses progress notes, dated [DATE] at 2:00 am, revealedthe resident was well and did not have any changes from her baseline (normal condition). The resident requested to go to the restroom. When the resident returned from the restroom, she complained of nausea. The resident began to feel better, but she was tired and wanted a nap. R #101 became unconscious. Staff called 911 (emergency service number) and started CPR at 2:05 am. The resident regained consciousness. When Emergency Medical Services (EMS) arrived, staff notified EMS that R #101 documented a DNR status on her MOST form. R #101 became unconscious again, and EMS did not perform CPR. Resident was pronounced dead at 2:25 am. F. On [DATE] at 4:00 pm during an interview, the Administrator (ADM) stated she could not recall whether she was informed of the incident, and it was not reported to the State Agency. She stated she was not aware of any staff training directly related to the failure of honoring resident code status. G. On [DATE] at 4:10 pm during an interview, the Director of Nursing (DON) stated the facility enters all residents as full code status on admission. He further stated they realized R #101 was a DNR status when they collected the paperwork for the Emergency Medical Technicians (EMTs). H. On [DATE] at 4:15 pm during an interview, an anonymous nursing staff stated they referred to the resident's medical record to determine code status during an emergency event. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified to have occurred on [DATE] when the facility provided CPR to R #101. The facilityAdministratorwas notifiedin personon [DATE] at 4:33 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on [DATE] at 11:12 am. Plan of Removal Corrective Action: - The identified resident that was affectedwas no longera resident ofthe facility. - Current residents have the ability to be affected by this deficient practice. - On [DATE], an initial audit was conducted to ensure all resident code statuses and MOST forms match. The DON/designee ensured all code status orders in the EMR matched the MOST forms.One resident was identified. The resident'sorder in the EMR updated to DNR to match the resident's MOST form. - The Center reviewed the Code Status Order Policy and noted that allresidentsrequire a code status order as soon as possible upon admission and, if the resident experiences cardiopulmonary arrest prior to indicating their advance directive wishes, the Center will default to Full Code and perform CPR. - The Center will provide the resident/resident representative with the opportunity to indicate their advanced directive wishes at admission. Their wishes will be reflected on the MOST form and an order will be entered into the EMR. - On [DATE], all licensed nurses in the building will be educated by the Director of Nursing/designee on this process, specifically to review the resident's medical record to include the hospital discharge paperwork and admission paperwork to ensure a resident's code status is accurate. - If the resident's wishes are different from the hospital medical records or admission orders, the nurses will immediately document theresident'swishes in the medical record, notify the physician, obtain the correct order, and complete the MOST form. - All other licensed nurses will be educated on their next scheduled shift. - The DON/designee will monitor each new admission/readmission daily for three months to ensure that the resident/resident representative is provided with the opportunity to indicate their advanced directive wishes at admission, the MOST form is completed as applicable, and the code status order is updated in the EMR to match the resident's wishes. - The DON/designee will follow up to ensure corrections are made immediately and additional education is provided as needed to ensure compliance. - The DON/designee will report the outcome measures of the monitoring to the Quality Assurance Performance Improvement (QAPI) monthly for 3 months or until full compliance is noted. Implementation of the POR was verified onsite on [DATE], and the IJ was removed on [DATE] at 12:30 pm. The scope and severity was reduced from a J to an E. Implementation of the POR was verified by the following: -Record review of the facility's Code Status Policy, dated [DATE], revealed the following: - Upon admission/readmission, a code status is required as soon as possible as part of the resident's admission order set. - Staff should verify patient's wishes with regard to code status upon admission. - Record review of the facility's audit of all current residents,dated [DATE],revealed one other resident had unmatching code status on MOST form and face sheet. Staff corrected immediately so all information in the resident's record matched. -Record review of the facility's follow-up audit of all current residents,dated [DATE],revealed all current residents had matching code status orders on their MOST forms and face sheets. - Record review of staff signature sheets,dated [DATE] and [DATE], revealed education was provided to the licensed staff, regarding MOST form accuracy, advance directive orders, and residents documented code status on the face sheetshould be the same. - On [DATE] at 11:55 am during an interview, Registered Nurse (RN) #5 stated nursing staffhad a training on [DATE] regarding MOST form accuracy, advance directive orders, and residents documented code status on the face sheetshould be the same. - On [DATE] at 12:06 pm during an interview with the DON, he stated an audit of all residents' MOST forms and code status orders were completed to verify they contained matching information. He stated the facility identified a discrepancy for one other resident during the audit. He stated nursing staff who were on shift yesterday received the training regarding MOST form accuracy, advance directive orders, and the face sheet matching. He stated the nurses who were not on shift on [DATE] will receive the training on their next shift. The DON stated the Plan of Correction will be discussed at the next scheduled Quality Assurance and Performance Improvement (QAPI) meeting. - On [DATE] at 12:10 pm during an interview, RN #6 stated she received training on [DATE] onMOST forms. She stated the MOST form was signed on admission. She stated if the resident was unable to speak or sign, then staff should call the resident's family for the code status. She stated staff could also look up a resident's code status from their hospital documentation. She stated if staff were unable to find a code status for a resident, then the resident would be considered full code status. - On [DATE] at 12:17 pm during an interview, RN #7 stated staffhad MOST training on [DATE]. He stated staff are trained to complete MOST forms when a resident was admitted . He stated if a resident was unable to sign, then staff were to reach out to their Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) or the resident's family. He stated staff could also look at the resident's hospital paperwork to verify their code status. He stated the admitting nurse should update the resident's code status in their medical record upon admission or same day. - On [DATE] at 12:26 pm during an interview, Licensed Practical Nurse (LPN) #2 stated she received instruction on [DATE] that residents needed to sign the MOST forms upon admission. She stated if the resident was non-verbal, then staff should call family or the POA for the resident's code status. - On [DATE] at 12:30 pm during an interview, RN #3 stated staff received training on [DATE] regarding resident code status. She stated staff were instructed to immediately contact the resident's POA or next of kin when a resident was unable to speak. She stated staff were instructed to check a resident's medical record if the POA did not respond.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure that six of six residents (Resident (R)23, R83, R50 , R65, R79 and R90 ) reviewed for tracheostomy (trach) care out of a total sample of 33 residents 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. On 12/13/22 at 2:32 PM, the Administrator, the Regional Nurse, and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) at F695-K: Respiratory/Tracheostomy Care and Suctioning. The Immediate Jeopardy was identified on 12/12/22 when the survey team identified the concerns related to the facility without emergency tracheostomy supplies and staff training for emergency preparedness for maintaining airways if trachs were dislodged from the airway for R23, R83, R50, R65, R79, and R90. Findings include: A. Review of facility-provided training documents revealed no documents with tracheostomy emergency management training. B. A request was made for a facility policy related to emergency care for tracheostomies and none was provided. C. 1. Review of R23's undated admission RECORD located in his Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with multiple diagnoses to include acute respiratory failure and tracheostomy. D. Review of R23's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/22/22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not assessed and was severely impaired cognitively, had a tracheostomy and was provided suction, and oxygen. E. Review of R23's physician's Orders under the Orders tab in the EMR for 12/22 revealed . 6 Bivona [brand of tracheostomy] and Ambu bag [bag valve mask (BVM), sometimes referred to as an Ambu bag, is a handheld tool that is used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths] at bedside .at all times . The Order excluded R23's specific type of tracheostomy (cuffed or uncuffed) and no further tracheostomy emergency management kit items. F. Review of R23 's comprehensive Care Plan under the Care Plan tab located in his EMR dated 11/28/22 revealed .Keep ambu bag and extra trach tube and obturator [used to insert a trach tube] in resident's room. There were no emergency management interventions, specifics for tracheostomy (size, type, or style) or emergency tracheostomy supply kit. G. During an observation on 12/12/22 at 9:32 AM R23's stoma site was covered with a split gauze dressing. R23 had oxygen administered via trach mask. R23 had an ambu bag on the shelf on the left side of his bed. R23 had an unpackaged unsterile obturator in a clear Ziploc bag above the head of his bed pinned to the wall. R23 did not have an emergency tracheostomy kit at his bedside. R23 had two boxes on the shelf beside his bed that included a Bivona Silicone Tracheostomy tube 6 mm (millimeter) cuff and a 7 Shiley Adult Flexible Tracheostomy tube cuffless disposable inner cannula 7 mm. H. During an observation and interview on 12/12/22 at 1:49 PM the Registered Nurse Agency (RNA) 1 verified R23 had a number six Biovono tracheostomy uncuffed in his stoma. RNA1 confirmed R23 did not have an emergency tracheostomy kit at his bedside, a replacement same size tracheostomy or a smaller tracheostomy, lubricant, or hemostats. RNA1 confirmed the nursing staff provided residents with trach suctioning as needed. RNA1 confirmed R23 had an opened (unclean/non-sterile) number six Biovono in his bedside table. RNA1 stated she thought Certified Nursing Assistants (CNAs), respiratory and nursing staff were able to replace a resident's decannulation tracheostomy, because it would be considered an emergency if resident's trach was decannulated or dislodged. RNA1 confirmed she had replaced a resident's tracheostomy about three months ago at the facility for a resident. RNA1 confirmed the facility had not provided her with emergency trach management competency in the past year, or hands-on competency for re-insertion of tracheostomies. RNA1 confirmed the facility expected her to replace a resident's decannulated or dislodged tracheostomy. I. During an observation and interview on 12/12/22 at 2:37 PM the Respiratory Therapy Director (RTD) confirmed R23 had a number six Biovona tracheostomy in his stoma. The RTD confirmed R23 did not have a tracheostomy emergency kit at his bedside, did not have sterile gloves, lubricant, a size smaller tracheostomy, or hemostats at his bedside and should have. The RTD confirmed R23 had an unopened Shiley #7 cuffless in his bedside table. RTD confirmed R23 did not have a number six Biovona tracheostomy or a smaller size at his bedside and should. The RTD confirmed he had not provided the facility nursing staff with emergency trach management or replacing decannulated or dislodged tracheostomy competencies. He stated he thought nursing staff could replace a decannulated or dislodged tracheostomy. The RTD confirmed respiratory therapy department staff was not at the facility for 24 hours a day. RTD stated the facility stored unclean obturators over the resident's bed for easy access, in the event of a resident's trach decannulation/dislodgement. The RTD stated he would not use the unclean un-sterile obturator (stored in a Ziploc bag) above the resident's bed to reinsert a resident's tracheostomy and would use a new sterile tracheostomy. J. During an interview on 12/12/22 at 3:58 PM the DON confirmed she had not provided any staff with emergency tracheostomy management training recently. The DON confirmed she was unsure which nursing staff (Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) were able to perform reinsertion of dislodgement of tracheostomy. K. During an interview on 12/13/22 at 10:40 AM with CNA5 confirmed the facility had not provided her with tracheostomy emergency management training. CNA5 confirmed she was responsible for providing care for residents with tracheostomy. L. During an interview on 12/13/22 at 11:53 AM the Housekeeper (HK)1 confirmed the facility had not provided her with tracheostomy emergency management training. HK confirmed she was responsible for providing cleaning services to the resident's rooms with tracheostomies M. Review of R83's undated admission RECORD located in his EMR revealed he was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy status and acute respiratory failure. N. Review of R83's quarterly MDS with an ARD of 10/31/22 and located in the EMR under the MDS tab, revealed a BIMS without a score and was not assessed. He had a diagnosis of traumatic brain injury. He was provided oxygen, suctioning and tracheostomy care. O. Review of R83's physician's Orders under Orders tab for 12/22 located in his EMR revealed .Bivona and Amub [ambu] bag at bedside .at all times . 08/15/22 and did not include the specific size or type (cuffed or uncuffed) and other tracheostomy emergency management kit items. P. Review of R83 's comprehensive Care Plan under the Care Plan tab located in his EMR revealed .Keep ambu bag and extra trach tube and obturator in resident's room 12/28/21. There were no emergency management interventions, specifics for tracheostomy (size, type, or style) or emergency tracheostomy supply kit. Q. During an observation on 12/12/22 at 9:52 AM R83 had an obturator in a clear Ziploc bag on the board over the head of his bed, unpackaged (not sterile). R83 did not have an emergency tracheostomy kit, and no trach supplies at his bedside visible. R. During an observation and interview on 12/12/22 at 2:00 PM RNA1 verified R83 had a number six Biovono tracheostomy uncuffed in his stoma. RNA1 confirmed R 83 did not have an emergency tracheostomy kit at his bedside. S. During an observation and interview on 12/12/22 at 3:05 PM the RTD confirmed R83 had a number six Biovona uncuffed tracheostomy in his stoma. The RTD confirmed R83 did not have a tracheostomy emergency kit at his bedside, did not have sterile gloves, lubricant, a size smaller tracheostomy, or hemostats at his bedside and should have. The RTD confirmed R83 had an unclean/unsterile obturator in a clear Ziploc bag hanging on the wall over the head of his bed. T. During an interview on 12/13/22 at 11:06 AM Respiratory Therapist (RT)1 confirmed R83's trach had decannulated many times at the facility. RT1 stated she thought he was pulling it out his trach. RT1 confirmed R83 was sent out of the facility to have his trach replaced. RT1 confirmed she was providing care for all the facility's residents with tracheostomies. RT1 confirmed the facility had not provided her with tracheostomy emergency management training/competency or return demonstration of re-insertions of tracheostomies annually. RT1 confirmed the respiratory staff placed residents used/unsterile obturator, over the resident's bed for emergency re-use, during an accidental decannulation or dislodgement of resident's trach. RT1 confirmed all decannulation or dislodgement of a resident's trach was considered an emergency. RT1 stated she expected the facility to provide all the staff with emergency trach training including the CNA staff, OT (Occupational Therapy), PT (Physical Therapy), housekeeping staff and nursing. RT1 stated her expectation for the nursing staff if a resident's trach became dislodged was resources/supplies were readily available including the emergency trach kit to replace the trach or send the resident out. U. Review of R50's undated admission RECORD located in the EMR revealed he was admitted to the facility on [DATE] with multiple diagnoses to include acute and chronic respiratory failure and traumatic brain injury. V. Review of R50 's quarterly MDS with an ARD of 09/29/22 and located in the EMR under the MDS tab, revealed a BIMS was not assessed, he was severely cognitively impaired, had a tracheostomy, and was provided oxygen and suctioning. W. Review of R50's physician's Orders under Orders tab, for 12/22 located in the EMR revealed . 7 Bivona and Ambu bag at bedside .at all times . 02/22/22. The orders did not include the specific type (cuffed or uncuffed) and other tracheostomy emergency management kit items. X. Review of R50 's comprehensive Care Plan under the Care Plan tab located in the EMR revealed .Keep ambu bag and extra trach tube and obturator in resident's room 03/23/22. There were no emergency management interventions, specifics for tracheostomy (size, type, or style) or emergency tracheostomy supply kit. Y. During an observation on 12/12/22 at 12:10 PM revealed R50 had a split dressing under his trach site, and it was clean and dry with a soft trach collar around his neck. R50 did not have a visible emergency tracheostomy kit at his bedside. R50 had an unpackaged unsterile obturator in a clear Ziploc bag and hanging on the wall over his headboard. Z. During an observation and interview on 12/12/22 at 1:53 PM RNA1 verified R50 had a number six Biovono tracheostomy cuffed in his stoma. RNA1 confirmed R50 did not have an emergency tracheostomy kit at his bedside, a smaller tracheostomy, lubricant, or hemostats. AA. During an observation/interview on 12/12/22 at 2:56 PM with the RTD confirmed R50 had a number six Biovona cuffed tracheostomy in his stoma. RTD confirmed R 50 did not have a tracheostomy emergency kit at his bedside, did not have sterile gloves, lubricant a size smaller tracheostomy, or hemostats at his bedside and should have. He further confirmed the resident had an unclean/unsterile obturator in a clear Ziploc bag, hanging on the wall, over the head of his bed. BB. Review of R65's undated admission RECORD located in his EMR revealed he was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy status, acute respiratory failure, and chronic respiratory failure. CC. Review of R65's admission MDS with an ARD of 10/10/22 and located in the EMR under the MDS tab, revealed a BIMS without a score and was not assessed, he was provided oxygen, suctioning and tracheostomy care. DD. Review of R65's physician's Orders under the Orders tab for 12/22 located in the EMR revealed no order for trach brand, type, size, cuff less/cuffed or emergency management tracheostomy supplies. EE. Review of R65's comprehensive Care Plan under the Care Plan tab located in the EMR revealed . Keep ambu bag and extra trach tube and obturator in resident room . There was no information for trach brand, type, size, and cuff less or uncuffed or intervention for emergency management tracheostomy or additional specific tracheostomy emergency management supplies. FF. Review of R65's Progress Notes under the Notes tab located in the EMR revealed on 11/26/2022 at 1:48 AM .Resident accidentally pulled out his trach while checking the tightness of his trach tie. Reinserted trach . GG. During an observation and interview on 12/12/22 at 2:04 PM with RNA1 verified R 65 had a number six Biovono tracheostomy uncuffed in his stoma. RNA1 confirmed R65 did not have an emergency tracheostomy kit at his bedside, a smaller tracheostomy, lubricant, or hemostats. HH. During an observation and interview on 12/12/22 at 2:50 PM the RTD confirmed R65 had a number six Biovona cuffless tracheostomy in his stoma. RTD confirmed R65 did not have a tracheostomy emergency kit at his bedside, did not have sterile gloves, lubricant a size smaller tracheostomy, or hemostats at his bedside and should have. The RTD confirmed R65 did not have a #6 Biovona cuffless or smaller size at his bedside. RTD further confirmed R65 had an unclean/unsterile used obturator in a zip lock bag, hanging over the head of his bed. II. During an interview on 12/13/22 at 10:23 AM R65 stated his tracheostomy came partially out in November and a nurse (unsure) name replaced his trach without difficulty. R65 stated he was unsure what equipment the nurse used for the tracheostomy to advance back into his stoma. R65 stated it was hard to breathe and difficult to speak. R65 stated the nurse basically realigned the tracheostomy and pushed it back in. JJ. During an interview on 12/13/22 at 10:37 AM Certified Occupational Therapy Assistant (COTA) confirmed she was providing care for R65. She confirmed the facility did not provide her with hands on or in-serve for trachs or emergency management in the past year. KK. Review of R79's undated admission Record, located in the EMR under the Profile tab, revealed R79 was admitted to the facility on [DATE] with multiple diagnoses to include acute Respiratory Failure with hypoxia and tracheostomy status. LL. Review of R79's admission MDS with an ARD of 06/15/22 and located EMR under the MDS tab, revealed a BIMS score of 14 out of 15 indicating R79 was cognitively intact. MM. Review of R79's comprehensive Care Plan, dated 11/28/22 under the Care Plan tab located in the EMR revealed, .R79 is at risk respiratory complications r/t [related to] respiratory failure, tracheostomy . R79 will have no complications developed by tracheostomy for 90 days .R79 will have no signs or symptoms of respiratory distress for 90 days. 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. NN. Review of R79's Physician's Orders, under the Orders tab located in the EMR revealed the following: .Trach size 6, Bivona, cuffed undated; No directions specified for order. .change trach tube Bivona every three months and as needed (PRN) dated 07/11/22. .trach suctioning as needed pre/post treatment: Evaluate heart rate, respiratory rate, pulse oximetry and breath sounds dated 06/08/22. .Tracheostomy care every day and evening shift and as needed dated 06/08/22 without specific definition of tracheostomy care such as cleaning the skin around the stoma and assessing for complications. OO. Further review of the physician Orders revealed no order for an emergency tracheostomy kit at the bedside. PP. Review of R79's Treatment Administration Record (TAR), located in the EMR and dated for 11/01/22-11/30/22, revealed: .change trach tube Bivona every 3 months and as needed (PRN) dated 7/11/22, with no staff's initials documented indicating the procedure was completed from 11/01/22 through 11/30/22. .trach suctioning as needed pre/post treatment: Evaluate heart rate, respiratory rate, pulse oximetry and breath sounds dated 06/08/22, Review of this TAR revealed staff initials documented for 11/01-11/02; 11/08-11/09; 11/13; 11/18; 11/21-11/22; 11/26-11/27; indicating care was provided on these dates by nursing. QQ. During an observation on 12/12/22 2:59 PM, R79 was observed in his room sitting upright in bed awake and alert. R79 did not have emergency tracheostomy equipment (sterile gloves, lubricant, a size smaller tracheostomy, or hemostats) readily assessable by the bedside. RR. During an observation/interview on 12/12/22 at 2:59 PM with Respiratory Therapist Director (RTD) who confirmed R79 had a number six Biovona cuffed tracheostomy in his stoma . RTD confirmed R79 did not have a tracheostomy emergency kit at his bedside, did not have sterile gloves, lubricant a size smaller tracheostomy, or hemostats at his bedside. RTD confirmed R79 should have a tracheostomy emergency kit at this bedside including a smaller tracheostomy. RTD confirmed R79 had an unclean/unsterile obturator in a clear Ziploc bag hanging on the wall over the head of R79's bed. RTD confirmed R79 had an unopened number six Biovona cuffed in the drawer of his bedside table. SS. Review of R90's undated admission Record, located in the EMR revealed R90 was admitted to the facility on [DATE] with multiple diagnoses to include acute respiratory failure with hypoxia and tracheostomy status. TT. Review of R90's admission MDS with an ARD of 07/20/22 and located EMR under the MDS tab, revealed a BIMS score of 15 out of 15 indicating R90 was cognitively intact. UU. Review of R90's comprehensive Care Plan, under the Care Plan tab located in the EMR and revised on 08/24/22 revealed . R90 is at risk for respiratory complications related to tracheostomy and need for oxygen therapy .R90 will have no complications developed by tracheostomy for 90 days .R90 will have no signs or symptoms of respiratory distress for 90 days .Suction tracheostomy and airway as needed (PRN) .Tracheostomy care twice per day (BID) and PRN for extra secretions .Tracheostomy tube changed per physician order . VV. Review of R90's Physician's Orders, under the Orders tab located in the EMR revealed the following: . Tracheostomy tube size 7.5, [NAME], cuffless undated; No directions specified for order. . Tracheostomy care every 12 hours as needed (PRN) dated 09/18/22 without specific definition of tracheostomy care such as cleaning the skin around the stoma and assessing for complications. WW. Review of R90's TAR located in the EMR and dated for 11/01/22-11/30/22, revealed: . Tracheostomy care every 12 hours as needed (PRN) dated 9/18/22 without specific definition of tracheostomy care such as cleaning the skin around the stoma and assessing for complications. .Tracheostomy suctioning as needed pre/post treatment: Evaluate Heart rate, respiratory rate, pulse oximetry and breath sounds dated 7/17/22. XX. Review of his TAR revealed nursing staff initials were only documented for the dates 11/02/22; 11/08/22; 11/27/22; indicating tracheostomy suctioning was provided. Further review of this TAR revealed, staff initials only on the date 11/07/22; indicating tracheostomy care was provided. YY. During an observation on 12/12/22 at 11:04 AM R90 was observed in her room lying in bed sleeping. R90 did not have emergency tracheostomy equipment readily assessable by the bedside. There was no water left in humidifier container while in use. ZZ. During an observation/interview on 12/12/22 at 2:53 PM with the RTD confirmed R90 had a number 7 1/2 Shiley cuffed tracheostomy in her stoma. RTD confirmed R90 did not have a tracheostomy emergency kit at her bedside, did not have sterile gloves, lubricant a size smaller tracheostomy, or hemostats at her bedside. The RTD confirmed R90 should have a tracheostomy emergency kit at her bedside including a smaller tracheostomy. The RTD confirmed R90 had an unclean/unsterile obturator in a clear Ziploc bag hanging on the wall over the head of R90's bed. The RTD confirmed R90 had an unopened number 7 1/2 Shiley cuffed trach in the drawer of her bedside table. The RTD confirmed R90 oxygen trach mask was laying on her bedside table, (with no date of change) and not stored in a bag. AAA. During an interview on 12/12/22 at 3:09 PM the RTD confirmed he had not provided the facility clinical staff with emergency tracheostomy management or information regarding dislodgement of tracheostomy. BBB. During an interview on 12/12/22 at 3:58 PM the DON said she had not provided any staff with emergency tracheostomy management training recently. CCC. During an interview on 12/12/22 at 6:27 PM the RTD stated the facility previously had more respiratory (RT) staff available and the facility had 24 hours a day RT coverage, but recently they lost some of the RT staff that worked the night shift. The RTD confirmed the facility did not have sterile hemostats to use to hold stoma open in the event of dislodgement of a resident's tracheostomy. The facility provided an acceptable removal plan on 12/14/22 at 2:58 PM. The removal plan included physician order revisions, placing emergency tracheostomy supplies at the bedside in the resident's room, in-servicing nursing staff on required tracheostomy emergency supplies, competency of re-insertion of a tracheostomy and educating ancillary staff, care plan revisions, policy development of emergency management of trachs. Following interviews with facility staff, observation of tracheostomy supplies, clinical record review of revised care plans, physician orders, and review of staff in-services/competency for emergent trach care and re-insertion, the survey team verified implementation of the Removal Plan and removed the IJ on 12/15/22 at 12:03 PM. The Administrator, the Regional Nurse, and Director of Nursing (DON) were notified that the IJ was removed. During the exit conference the Administrator, the DON and the Regional Nurse were notified that the IJ was removed but the deficient practice existed at F695-E (pattern potential for more than minimal harm). Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) Respiratory/Tracheostomy Care and Suctioning (F695 S/S: K). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to ensure staff followed adequate infection control measures to prevent the spread of COVID-19 among 36 of 113 facility residents. A COVID-19 outbreak began on 11/22/22 with 36 cases of facility-acquired infections from 11/22/22 to 12/12/22. All 36 residents (Resident (R) 79, R26, R31, R43, R61, R1, R64, R34, R49, R3, R6, R80, R9, R47, R19, R16, R32, R18, R2, R14, R73, R5, R106, R29, R111, R11, R25, R88, R74, R63, R13, R366, R109, R78, R108, and R107) had co-morbid diagnoses (the presence of more than one disorder in the same person), which placed them at risk of severe illness or death, 15 of the 36 residents experienced adverse COVID-19 symptoms (difficulty breathing and/or chest pain pressure) (R26, R31, R61, R1, R64, R34, R3, R18, R14, R74, R63, R366, R78, R108, and R107), and three (R1, R49, and R366) of the 36 residents were hospitalized due to COVID-19 complications. Findings include: A. Spread of COVID-19 Infection in the Facility; per the Centers for Disease Control and Prevention (CDC) COVID Data Tracker website, accessed on 12/12/22 at https://covid.cdc.gov/covid-data-tracker, the facility's community transmission rate of COVID-19 was high. B. Upon entrance to the facility on [DATE] at 8:45 AM, the Administrator stated a number of residents currently had COVID-19. A list of residents with COVID-19 was requested from the facility but was not provided. At 9:30 AM, a list of residents with COVID-19 residing on the 200 hall was requested, and at 10:00 AM the Infection Preventionist (IP) provided a list of 16 residents highlighted as having COVID-19. Review of signage on the doors in the 200 hall and verbal confirmation by Licensed Practical Nurse (LPN) 3 at 10:30 AM revealed only 13 residents in the 200 Hall currently had COVID-19. C. Review of the undated facility line listing of residents with COVID-19, provided on paper by the Infection Preventionist (IP) on 12/12/22 at approximately 4:30 PM, revealed there were 22 total residents who currently had COVID-19 in the building. Of these, three residents were living on the 100 hall, 13 residents were living on the 200 hall, five residents were living on the 300 hall, and one resident was living on the 400 hall. Observations throughout the facility on 12/12/22 beginning at 8:45 AM revealed there was no designated space to house the residents with COVID-19 or suspected exposure, and staff were caring for residents with COVID-19 and residents without. D. Further review of the facility's line listing revealed 47 residents had tested positive for COVID-19 from 11/22/22 to 12/10/22. Of those residents, 36 contracted COVID-19 while residing in the facility for over five days. Three of the 36 residents were not vaccinated for COVID-19 (R74, R63, and R366), and three of the 36 residents were hospitalized related to COVID-19 complications. Fifteen of the 36 residents experienced symptoms of COVID-19: E. Review of R79's undated home screen of the Electronic Medical Record (EMR) revealed R79 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/09/22. Per the undated Medical Diagnosis tab of the EMR, R79 had a tracheostomy and diagnoses of acute respiratory failure and degenerative disease of the nervous system. F. Review of R26's undated home screen of the EMR revealed R26 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/09/22. Per the undated Medical Diagnosis tab of the EMR, R26 had diagnoses of Parkinson's disease, heart disease, weakness, and malnutrition. Per the line listing, R26 experienced chest congestion and sore throat. G. Review of R31's undated home screen of the EMR revealed R31 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/09/22. Per the undated Medical Diagnosis tab of the EMR, R31 had diagnoses of chronic obstructive pulmonary disease, pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity), congestive heart failure, anxiety, and weakness. Per the line listing, R31 experienced chest congestion and sore throat. H. Review of R43's undated home screen of the EMR revealed R43 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/09/22. Per the undated Medical Diagnosis tab of the EMR, R43 had diagnoses of stroke with right-sided paralysis, malnutrition, muscle weakness, anxiety, and depression. I. Review of R61's undated home screen of the EMR revealed R61 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/09/22. Per the undated Medical Diagnosis tab of the EMR, R61 had diagnoses of morbid obesity, diabetes, asthma, sleep apnea, and pulmonary hypertension. Per the line listing, R61 experienced coughing. J. Review of R1's undated home screen of the EMR revealed R1 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/08/22. Per the undated Medical Diagnosis tab of the EMR, R1 had diagnoses of sepsis, osteomyelitis, pressure ulcers, diabetes, depression, bipolar disorder, and anxiety. Per the line listing, R1 experienced chest congestion and new or worsening confusion. Review of R1's 12/08/22 change of condition Provider Summary, located in the Notes tab of the EMR, revealed, Resident c/o [complained of] 'not feeling well. Has been shouting and demanding immediate attention. Resident has been crying, stating 'I'm losing my mind.' Refuses to remain in room even after repeated explanation of necessity to quarantine in room. Review of R1's 12/09/22 General Note, located in the Notes tab of the EMR, documented, Head to toe assessment done. Staff noted a small bump on head-right side. Resident denies pain. Neurological checks initiated. Resident assisted to bed. Resident noted to be confused and lethargic. Per MD [physician] on call . resident was transferred to ER [Emergency Room] for further evaluation. K. Review of R64's undated home screen of the EMR revealed R64 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/08/22. Per the undated Medical Diagnosis tab of the EMR, R64 had diagnoses of pulmonary embolism, acute respiratory failure, diabetes, arthritis, and atrial fibrillation. Per the line listing, R64 experienced coughing, headache, and nasal congestion. L. Review of R34's undated home screen of the EMR revealed R34 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/08/22. Per the undated Medical Diagnosis tab of the EMR, R34 had diagnoses of chronic obstructive pulmonary disease, respiratory failure, congestive heart failure, cirrhosis of the liver, diabetes, weakness, and anxiety. Per the line listing, R34 experienced chest congestion and sore throat. M. Review of R49's undated home screen of the EMR revealed R49 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/06/22. Per the undated Medical Diagnosis tab of the EMR, R49 had diagnoses of sepsis, osteomyelitis, pressure ulcers, diabetes, depression, bipolar disorder, and anxiety. Review of R49's 12/08/22 Summary for Providers, located in the Notes tab of the EMR, revealed, The resident has fluctuating oxygen saturation. Monitored closely and changed the oxygen support from nasal cannula to simple face mask and regulated to 6 LPM [liters per minute]. Observed that the resident is still tachypneic [breathing rapidly] and using accessory muscle to breathe. He also has a productive cough and crackles breathe sounds upon auscultation. Placed the patient in a high Fowler's position . Recommendations: Send to the hospital for higher care and further evaluation and management. N. Review of R3's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/06/22. Per the undated Medical Diagnosis tab of the EMR, R3 had diagnoses of chronic obstructive pulmonary disease, obesity, atrial fibrillation, obstructive sleep apnea, heart failure, pulmonary fibrosis, vascular dementia, respiratory failure, and stage II pressure ulcers. Per the line listing, R3 experienced fever, chest congestion, sore throat, and vomiting. O. Review of R6's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R6 had diagnoses of dementia, chronic obstructive pulmonary disease, diabetes, depression, anxiety, and hypothyroidism. P. Review of R80's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R80 had diagnoses of coccidioidomycosis meningitis (valley fever fungus in the brain), weakness, and hyperlipidemia. Q. Review of R9's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R9 had diagnoses of cerebrovascular disease, heart failure, depression, schizophrenia, epilepsy, hypothyroidism, hyperlipidemia, and gastro-esophageal reflux disease. R. Review of R47's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R47 had diagnoses of epilepsy, traumatic brain injury, end stage renal disease, weakness, and anemia. S. Review of R19's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R19 had diagnoses of diabetes, anemia, migraine, cerebral infarction (blockage), depression, hypertension, and gastro-esophageal reflux disease. T. Review of R16's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R16 had diagnoses of dementia, arthritis, glaucoma, hypothyroidism, hypertension, osteoporosis, and macular degeneration. U. Review of R32's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R32 had diagnoses of cerebral infarction, chronic kidney disease, chronic respiratory failure, hyperlipidemia, depression, epilepsy, hypertension, and muscle weakness. V. Review of R18's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R18 had diagnoses of heart disease, hyperlipidemia, depression, spinal fusion, anxiety, arthritis, chronic pain, edema, hypertension, and gastro-esophageal reflux disease. Per the line listing, R18 experienced coughing, sore throat, and headache. -Review of R2's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R2 had diagnoses of cerebral infarction, schizoaffective disorder, chronic obstructive pulmonary disease, depression, Alzheimer's disease, morbid obesity, and hypertension. W. Review of R14's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/03/22. Per the undated Medical Diagnosis tab of the EMR, R14 had diagnoses of osteomyelitis, diabetes, obesity, hypothyroidism, psychotic disorder, hyperlipidemia, hypertension, Down syndrome, depression, insomnia, cerebral infarction, and heart disease. Per the line listing, R14 experienced coughing, chest congestion, and sore throat. X. Review of R73's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/03/22. Per the undated Medical Diagnosis tab of the EMR, R73 had diagnoses of cerebral infarction, viral hepatitis B, hypertension, hydrocephalus, and depression. Y. Review of R5's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/03/22. Per the undated Medical Diagnosis tab of the EMR, R5 had diagnoses of congestive heart failure, muscle weakness, anxiety, diabetes, chronic respiratory failure, schizophrenia, epilepsy, hypothyroidism, and bipolar disorder. Z. Review of R106's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R106 had diagnoses of cerebral infarction, congestive heart failure, muscle weakness, insomnia, diabetes, and hyperlipidemia. AA. Review of R29's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R29 had diagnoses of cerebral infarction, ulcerative colitis, and terminal dementia. BB. Review of R111's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R111 had diagnoses of spinal stenosis, hypertension, diabetes, muscle weakness, obesity, cerebral infarction, and dementia. CC. Review of R11's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R11 had diagnoses of respiratory failure, sepsis, hyperlipidemia, chronic obstructive pulmonary disease, emphysema, chronic kidney disease, osteoporosis, hypertension, prostate cancer, malnutrition, and muscle weakness. DD. Review of R25's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R25 had diagnoses of lumbar fracture, muscle weakness, dementia, epilepsy, osteoporosis, and acute kidney failure. EE. Review of R88's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R88 had diagnoses of cerebral infarction, cellulitis, weakness, chronic wound, and hypertension. FF. Review of R74's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/30/22. Per the undated Medical Diagnosis tab of the EMR, R74 had diagnoses of peripheral vascular disease, arthritis, hypertension, gout, muscle wasting, and urinary incontinence. Review of the facility's undated resident COVID-19 vaccination records, provided on paper by the IP on 12/12/22, revealed R74 had not been vaccinated for COVID-19. Per the line listing, R74 experienced coughing, runny nose, and sore throat. GG. Review of R63's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/28/22. Per the undated Medical Diagnosis tab of the EMR, R63 had diagnoses of diabetes, hypothyroidism, hyperlipidemia, atrial fibrillation, heart disease, gastro-esophageal reflux disease, arthritis, foot wounds, hypertension, peripheral vascular disease, and stroke. Review of the facility's undated resident COVID-19 vaccination records revealed R63 had not been vaccinated for COVID-19. Per the line listing, R63 experienced coughing. HH. Review of R13's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/28/22. Per the undated Medical Diagnosis tab of the EMR, R13 had diagnoses of anemia, esophageal ulcer, hernia, cirrhosis, diverticulosis, muscle wasting, chronic respiratory failure, morbid obesity, and atrial fibrillation. II. Review of R366's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/25/22. Per the undated Medical Diagnosis tab of the EMR, R366 had diagnoses of acute respiratory failure, seizures, anemia, traumatic brain injury, tracheostomy, and gastrostomy. Review of the facility's undated resident COVID-19 vaccination records revealed R366 had not been vaccinated for COVID-19. Per the line listing, R366 experienced fever and elevated heart rate. Review of R366's 11/25/22 General Note, located in the Notes tab of the EMR, revealed Patient needed suction [for respiratory secretions] @1830 [at 6:30] pm some blood noted with secretions, on call [physician] notified and order received to send patient out ER [to the emergency room]. JJ. Review of R109's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/25/22. Per the undated Medical Diagnosis tab of the EMR, R109 had diagnoses of sepsis, dementia, hyperlipidemia, type 1 diabetes, and encephalopathy. KK. Review of R78's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/23/22. Per the undated Medical Diagnosis tab of the EMR, R78 had diagnoses of vertebral fracture, weakness, hypertension, hyperlipidemia, and vascular dementia. Per the line listing, R78 experienced fever. LL. Review of R108's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/22/22. Per the undated Medical Diagnosis tab of the EMR, R108 had diagnoses of encephalopathy, muscle weakness, pneumonia, anxiety, and atrial fibrillation. Per the line listing, R108 experienced coughing. MM. Review of R107's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/22/22. Per the undated Medical Diagnosis tab of the EMR, R107 had diagnoses of end stage renal disease, diabetes, spinal stenosis, muscle weakness, depression, and hypertension. Per the line listing, R107 experienced coughing, chest congestion, and a runny nose. NN. Interview with the Medical Director on 12/14/22 at 12:13 PM revealed she was available to consult with issues related to COVID-19 treatment, and she was involved in prescribing the treatments for residents with COVID-19, but she was not involved in management of the recent COVID-19 outbreak or infection control education. OO. In an interview with the IP on 12/15/22 at 10:30 AM, the IP stated the most recent COVID-19 outbreak began on 11/22/22 with a resident on the 100 Hall. The resident was not admitted to the facility with COVID-19 but went out to dialysis several times a week and could have contracted COVID-19 at the dialysis center. Outbreak testing was conducted on the 100 Hall with staff and residents, and one additional positive resident was discovered on 11/23/22 on the 100 Hall. On 11/28/22, one resident tested positive in the 400 Hall and there were four residents who tested positive in the 100 hall. Outbreak testing was conducted with staff and residents in the 100 and 400 halls. The IP stated R63, who resided on the 200 hall, was friends with the residents who had COVID-19 on the 100 hall, was very social, and spent his days visiting with other residents. Additionally, R63 and the residents on the 100 hall ate their meals together in the dining room. The IP stated R63 most likely spread COVID-19 from the 100 hall to the 200 and 300 halls between 11/28/22 and 12/12/22. On 12/13/22, there were four new positive residents on the 100 hall, 13 new positive residents on the 200 hall, five positive residents on the 300 hall, and one new positive resident on the 400 hall. Outbreak testing was conducted for all staff on all halls. PP. Review of the facility's 06/07/21 COVID-19 policy revealed, Follow the process in the COVID-19 Outbreak Management Tiers for patients or employees with confirmed COVID-19 . Perform contact tracing for both suspected and confirmed cases . Centers will have a plan based on CDC/CMS/state/local recommendations to prevent transmission, such as having a dedicated space in the facility for cohorting and managing care for patients with COVID-19. Per the CDC 09/23/22 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#:~:text=in%20the%20facility.-,Duration%20of%20Transmission-Based%20Precautions,-The%20following%20are, Place a patient with suspected or confirmed SARS-CoV-2 [COVID-19] infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room . Facilities could consider designating entire units within the facility, with dedicated HCP [health care professionals], to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts . Limit transport and movement of the patient outside of the room to medically essential purposes . Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel. QQ. Failed Infection Control Practices Observation in the 200 hall on 12/12/22 at from 9:57 AM to 11:20 AM revealed a large red pitcher with a black lid sitting on top of the clean Personal Protective Equipment (PPE) cart that was holding clean gloves and hand sanitizer. The pitcher was visibly soiled with liquid stains on the lid. At 11:20 AM, Certified Nurse Aide (CNA) 1 picked up the pitcher, refilled it, and delivered it to R18, who was COVID-19 positive. CNA1 did not sanitize the PPE cart where the pitcher had been. RR. Observation in the 200 hall on 12/12/22 at 11:01 AM revealed five bins marked clean gowns that were set at intervals in the hallway. A bin outside of room [ROOM NUMBER] contained two loose disposable gloves mixed in with the clean gowns. A bin outside of room [ROOM NUMBER] to the right had a loose disposable glove mixed in with the clean gowns. A second bin near room [ROOM NUMBER] contained three loose disposable gloves mixed in with the clean gowns. SS. Observation in the 200 hall on 12/12/22 at 11:19 AM revealed R74 walking out of her room, which had a transmission-based precautions sign on the door and a COVID-19 positive roommate. The resident had a cloth mask tied around her neck, but it was dangling from her neck and not covering her nose or mouth. From 11:19 AM to 12:45 PM, R74 continued to ambulate up and down the hallway without any encouragement from staff to put on her mask. Review of R74's 07/09/22 Care Plan, located in the Care Plan tab of the EMR, revealed R74 had impaired cognition and impaired safety awareness. The Care Plan did not address any refusals or inability to wear a mask. TT. Observation on 12/12/22 at 11:25 AM revealed Certified Nursing Assistant (CNA)1 went into R18's room which was a COVID positive room. The CNA wore goggles and a mask, however, did not have a gown on. UU. Continued observation on 12/12/22 at 11:34 AM revealed CNA1 went into room [ROOM NUMBER] without wearing a gown. She was observed to lower her mask and kiss and hug the resident in the room. CNA6 came into room wearing full PPE. CNA1 then stated she didn't know the resident in room [ROOM NUMBER] was on quarantine and then stated, The door was open, so I did not see the sign on the door .actually it is his fault (points to CNA6) because he did not close the door and I did not see it. There was a second sign noted outside the door by the resident names to the left of the door documenting covid precautions. VV. Observation in the 400 hall on 12/12/22 at 11:53 PM revealed CNA5 entered R79's room, who had COVID-19, wearing a gown, gloves and an N-95 mask. The CNA did not have on eye protection, though a pair of goggles were resting on top of the CNA's head. WW. Observation in the 200 hall on 12/12/22 at 1:00 PM revealed an empty clean gown bin with two loose disposable gloves on the bottom. At 1:03 PM, the IP was observed to bring a bag of clean gowns to the hall and put the clean gowns in the bin on top of the gloves. XX. Observation in the 200 hall on 12/12/22 at 1:11 PM revealed Nurse Aide (NA) 1 was preparing to deliver a meal tray to R19, who was COVID-19 positive. Though NA1 was wearing an N-95 mask and eye protection, she did not don a gown and gloves, and was told to enter the room without her PPE on by CNA6. Upon exiting the room, NA1 did not wash or sanitize her hands, then went directly to the meal cart and handled another room tray. In an interview on 12/12/22 at 1:17 PM, NA1 stated she did not typically work on the 200 hall and had not been told which residents on the hall were on transmission-based precautions for COVID-19 or given directions on donning the appropriate PPE. The NA stated gown and gloves should be worn in rooms on transmission-based precautions, but she did not know where the clean gowns were kept. YY. During an interview on 12/12/22 at 7:30 PM with the Administrator and DON, the staff were alerted to the above observations. The DON stated staff were expected to wear all PPE when caring for a resident with COVID-19, including gown and gloves in addition to the N-95 mask and eye protection. The Administrator stated these observations were concerning, and she needed to follow up with some of the staff related to potential COVID-19 exposures. ZZ. Observation in the 200 hall on 12/13/22 at 12:09 PM revealed a bin without a lid with clean gowns inside. The bin also contained two loose disposable gloves and a crumpled-up plastic bag. LPN3 stated the bin was supposed to contain only clean gowns, but staff may have mistaken the bin for a trash can as it did not have a lid. LPN3 removed the bin from the hallway. AAA. Observation in the 200 hall on 12/13/22 at 12:11 PM revealed a second bin, with the lid closed and labeled, Clean Gowns, with a loose disposable glove and a resident's sock inside. LPN3 stated it looked to her as if the glove and sock came with the gowns from the laundry, but she could not be sure that the glove and sock were clean. LPN3 removed the bin from the hallway. BBB. Observation in the 200 hall on 12/13/22 at 12:48 PM revealed the Recreation Assistant (RA) had donned an N-95 mask, gown, eye protection, and gloves to visit with R1, who was positive for COVID-19. The RA doffed her gown and gloves before exiting the room, then exited into the hallway without performing hand hygiene. She then walked off the 200 hall to the facility's common area, where she adjusted another resident's mask, touching the resident's mask and face without first sanitizing her hands. In an interview with the RA on 12/13/22 at 12:57 PM, she verified she did not wash or sanitize her hands when leaving R1's room or before touching another resident in the common area. The RA stated she had not been instructed in the proper procedure for donning and doffing PPE and performing hand hygiene. CCC. Observation on the 200 hall on 12/14/22 at 12:26 PM revealed a closed bin labeled Clean Gowns outside of room [ROOM NUMBER]. There were three loose disposable gloves lying on top of the gowns. Interview with CNA9 at 12:30 PM revealed she thought that the gloves had been through the laundry with the gowns and that most likely, the gloves were clean. When asked if she would continue to use gowns from the bin, she stated, Yes, the bin says the gowns are clean. The CNA did not remove the bin from the floor. DDD. In an interview on 12/15/22 at 10:30 AM, the IP stated the staff on the 100 hall were used to having COVID-19 positive residents and using PPE because it was the post-acute unit. He stated the staff in the 200 hall were not used to using PPE and dealing with COVID-19, so they had a harder time dealing with the influx of COVID-19 positive residents. The IP stated he had not provided any additional education on COVID-19 or PPE use to the staff in the 200 hall, as he had focused all of his training efforts in the 100 hall. The IP stated all staff received training through a monthly All Staff Meeting. The IP stated staff that did not attend the monthly meetings received the information via email to read independently. He said there was a way to track whether or not the staff had viewed the training materials, but he had not been tracking whether or not all staff reviewed the training materials. The IP provided training materials, which included training on use of Contact plus airborne precautions for care of residents with COVID-19, which included hand hygiene, an N-95 mask, gown, eye protection, and gloves. The material also documented, Patient must wear a face mask when out of room and maintain social distancing . Please do not remove dedicated or single use disposable equipment from this room . when dedicated equipment is not possible, disinfect shared equipment. EEE. Review of the facility's 10/18/22 and 10/20/22 In-Service Sign-In Sheets, provided on paper by the IP, revealed education was provided on COVID-19 and isolation. The staff in attendance included LPN3. There was no evidence that CNA6, NA1, CNA9 or the RA had received the training. FFF. Review of the facility's 09/06/22 In-Service Sign-In Sheet documented education was provided on COVID-19. The staff in attendance included LPN3 and CNA6. There was no evidence CNA9, NA1, or the RA had received the training. GGG. Review of the facility's 06/07/21 COVID-19 policy revealed, In addition to Standard Precautions, Contact and Airborne Precautions will be implemented for patients suspected or confirmed to have COVID-19 based on the Centers for Disease Prevention & Control (CDC) guidance. For the purpose of this policy, Airborne Precautions is defined as wearing an N95/approved KN95 respirator upon entry to the patient's room, in addition to the recommended Personal Protective Equipment (PPE), keeping the door to the patient's room closed and no negative pressure room required . Implement universal use of facemasks/respirators and eye protection while in the Center . Clean and disinfect the environment, especially high touch surfaces, using an EPA approved . hospital grade disinfectant . Patients on Transmission-Based Precautions are restricted to their room except for medically necessary purposes . If a patient has to leave his/her room, he/she must wear a facemask or cloth face covering, perform hand hygiene, limit movement in the Center, and perform social distancing . When possible, all patients, whether they have COVID-19 symptoms or not, should cover their noses and mouths with tissue when staff are in their rooms . Provide COVID-19 education as indicated to employees, patients, and visitors. HHH. Per the CDC 09/23/22 Interim Infection Prevention and Control Recommendations for Hea[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that nursing staff were properly trained and had the appropriate competencies on Tracheotomy (a small surgical opening that is made through the front of the neck into the windpipe allowing air to flow in and out) care/showering for 1 ( R #1) of 3 ( R #1, 2 and 3) residents. This deficient practice resulted in R #1 becoming unresponsive requiring immediate intervention when a plastic trash bag was used to cover R #1's airway during a shower so water would not get into the trach. The findings are: A. Record review of R #1's medical record revealed that resident had a diagnoses of Acute Respiratory Failure with Hypoxia (results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels), Tracheostomy, Neuromuscular Dysfunction of Bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination), Degenerative Nervous System Disease (disorder of the central nervous system characterized by gradual and progressive loss of neural tissue and neurologic function), Amyotrophic Lateral Sclerosis ALS is a progressive neurological disorder which results in weakened muscles and deformity), Hypertension (high blood pressure) and Dysphagia (difficulty swallowing). B. Record review of a facility reported incident on [DATE], complaint intake #63126 indicated that on [DATE] R #1 was receiving a shower and a plastic trash bag had been placed over the trach so no water would get into the trach during the shower. This caused the resident to become unconscious due to a lack of air. The following was taken from the the facility report: CNA (Certified Nursing Assistant) reported that (name of R #1) became unresponsive and she immediately called out for help. Respiratory Therapist (RT) responded immediately and noted that (name of R #1) was not breathing. RT provided ventilation via ambu bag (rescue breathing provided through the trach by ambu bag instead of doing CPR). Two additional nurses also responded and assisted with removing (name of R #1) from the shower room to his bed. Nurse noted (name of R #1) was pale with shallow breathing. RT placed resident on oxygen via tracheostomy. (name of R #1) started to respond to verbal stimuli (a lethargic patient often needs a gentle touch or verbal stimulation to initiate a response). Attending Physician was in the Center and also was called to assess (name of R #1). Education provided to CNA to keep the tracheostomy airway free and clear. Education will be provided to all staff to keep the airway free and clear during all care tasks . C. On [DATE] at 2:55 pm, during an interview with CNA #5, she stated that she was washing R #1 and noticed that his eyes started rolling back. She called out for help and a staff member came and brought the Ambu bag and started pumping air through the trach. She stated that she had covered the top part of the trach with plastic and that is how she always did it. They (staff) said that was probably why he lost consciousness. CNA #5 stated that she had not received any special training to work on that unit. CNA #5 said that R #1 wasn't able to assist her with the shower and that he can move his hands a little bit but he isn't strong enough to assist or help. D. Record review of a note dated [DATE] indicated the following: CNA (Certified Nurse Assistant) was giving resident (R #1) shower when resident became unresponsive. CNA called out to RT and nurse for assistance. RT provided resident with breathing via ambu bag (self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately). Nurse and staff (CNA) removed the resident from shower room and transferred the resident to bed via shower chair and mechanical lift (are devices designed to help caregivers move a person from a sitting to standing position and from one place to another). Nurse noted resident pale. RT applied oxygen via trach. Resident increased alertness. Resident was evaluated by (name of physician). Resident with no known history of unresponsive episodes. Suctioning of phlegm (is mucus produced by the respiratory system) and secretions provided by RT. Noted o2 (Oxygen) saturation increased from 85% to 90% with o2 and suctioning. CNA reported resident cough up lots of phlegm secretion during shower prior to unresponsive episode . E. On [DATE] at 10:00 am, during interview with CNA #3, she stated she had been working on the 400 unit (primary unit for the Tracheostomy residents). CNA #3 stated that the responsibilities for working the 400 unit are basically the same as working on any unit. She stated that she had not received any training recently and wasn't really trained to work that unit. She stated that when giving a shower to a trach resident you have to be careful because you don't want the trach to get wet or get water in it. She stated that she would cover it. She stated that she had only given bed baths to the trach residents and had not done a shower. She stated that she had not gotten any recent or specific training on how to give a shower to a trach resident. F. On [DATE] at 10:14 am, during an interview with CNA #4, she stated that she had been working on that unit for two or three months. She works on 300 and 400 primarily. She stated that CNA #3 helped her to get familiar on the floor. She stated that with the trach residents you need to have more caution with them. CNA #4 stated that she had only showered R #3, but R #3 is basically independent and she only needs help with washing her hair. CNA #4 stated that R #3 will cover her trach herself during showers. CNA #4 said that if she were going to do it (cover the trach), she would use a towel or a plastic trash bag. She stated that she has learned from the other CNA's and was only told to not get it wet. She stated that she had not received any recent or specific training around showering a resident with a trach. G. On [DATE] at 11:38 am, during an interview with Respiratory Therapist (RT), she stated that she is not aware of any specific training around showers and trach residents. She stated that the main thing to always know is that the trach is unobstructed (not blocked, clear and open). She stated that with R #1 she wasn't working the day the incident happened but what she was told is that plastic was put over the trach so water wouldn't get into it. She stated that R #1 would probably deteriorate (becoming progressively worse) faster than others if he wasn't getting enough air, because he is very weak. A couple of minutes. She stated that the safest thing to do would be to not cover it with anything. She stated that she was not sure how the CNA's are trained when they are hired, or before working on this unit. H. On [DATE] at 12:36 pm, during an interview with Respiratory Therapist Director, he stated that he had no direct training with the CNA's. He had done a few training's with the nurses. He stated that after the incident when R #1 was already back in his room, that is when he saw R #1. When asked if R #1 had passed out or had stopped breathing, he stated that he wasn't sure if R #1 passed out or stopped breathing. He stated his understanding is the RT that was working at the time of the incident grabbed the Amub bag (manual resuscitator force-feeds air or oxygen into the lungs in order to inflate them under pressure) and started to give him air and he (R #1)came back quickly. He stated that he heard that a plastic trashcan bag had been used to cover the trach during the shower. He stated that nothing should be wrapped around the trach. I. On [DATE] at 2:00 pm during an interview with the Nurse Educator, she stated that she had done some training since the incident about how to shower a resident with a trach with the CNA's, but not all of them. She stated that they only focused on the showering part for the training because they wanted to make it simple and to the point, so the message didn't get lost. She stated that they have been tag teaming the training trying to get everyone, but they have focused on the 400 hall. She stated that not everyone has been trained. The Nurse Educator provided a list of all the staff members that had been trained so far. J. Record review of the training sheets provided by the Nurse Educator indicated the following, on [DATE] after the incident and [DATE], 12 staff members were trained on trachs and showering. On [DATE] and [DATE] three more staff members were trained on showering trach residents. K. Record review of the staffing sheets that were provided by the facility revealed the following: 1. the time of interview with both CNA #3 and #4 who were working on the 400 hall on [DATE] (date of their interviews) neither had received the training for showering a resident with a trach. 2. Three other CNA's (#5, #6 and #7) had also worked the 400 hall without training from the date of the first training on [DATE] to [DATE]. L. On [DATE] at 10:45 am, during an interview with Center Nursing Executive (CNE), she stated that the 400 hall staff are being trained. She stated that she and nurse educator are doing the trainings on how to shower a resident who has a trach.The CNE stated that the training started the day of the incident [DATE] and the next day. She stated that they focused on those staff that work 400 hall because not everyone in the facility works on that hall. The CNE did agree that any new staff member (CNA) should be trained before working that hall. She stated that with agency staff they get an onboarding packet. During a follow-up conversation with CNE she stated that for the nurses there is a training in vital learn that covers suctioning, breathing treatments, and changing the stoma cloth, but there was nothing for the CNA's. The CNE stated that she checked if the agency onboarding packet contained the training sheet on showering a resident with a trach and she stated no, it wasn't put in there, but she will make sure that it is now. She stated that the training sheet is in the new hire packet. M. On [DATE] at 2:02 pm, during an interview with the Pulmonologist (specialize in the respiratory system and treat breathing-related conditions), when asked what his expectation was for staff being trained to work on the trach unit he stated that he isn't' in charge of this unit. He stated that every staff member working on this unit should have some basic training. He stated that he thinks there should be specific training protocol of steps, one for CNA and one for Licensed Practical Nurse (LPN)/Registered Nurse (RN). He said even Respiratory could use one. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J [Isolated Jeopardy] to resident health and safety being identified on [DATE] at 1:20 pm. The facility took corrective action by implementing an acceptable Plan of Removal on [DATE] at 12:30 pm which was verified onsite and the scope and severity was lowered to a G. Based on the Plan of Removal, the interventions included: 1. All tracheostomy residents have been identified and reviewed for bathing and the care plan/[NAME] has been updated to reflect safety instructions related to not covering or obstructing the airway at any time, including during showers. 2. A nurse must check with the CNA prior to any shower to ensure they understand the airway, and not to get water in the trach, or cover the trach at any time before/during/after the shower. The airway must remain unobstructed at all times. Both signatures are needed to ensure training and understanding of the training. 3. The Director of Nursing (DON/CNE)/designee will begin education [DATE] and continue until all staff have been educated prior to their next shift. Any direct care staff member on leave of absence (FMLA) (Family Medical Leave Act), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires and agency staff will be educated prior to their first shift. 4. The Center Nurse Executive/designee will review all new admission for tracheostomy needs in clinical meetings to ensure that shower preferences are noted, safety needs have been reviewed, shower resources are available, care plan/[NAME] is updated, and check offs for the nurse/CNA for shower is implemented . 5. DON/(CNE) and/or designee will observe 3 showers a week to ensure process is being followed, as well as interview 5 direct care staff to ensure they can speak to the process x (times) 3 months. DON will bring results of audits to the QAPI (Quality Assurance Performance Improvement) committee for further recommendations based on tracking and trending presented monthly for the next 3 months or until ongoing compliance is achieved.