**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficient practice has two Deficient Practice Statements A. Based on observations, record reviews, interviews, and policy review, the facility failed to ensure that 2 of 2 residents (Residents (R) 14 and R32) reviewed for tracheostomy (trach) care in the sample of 23 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 [DATE] at 9:05 PM, the Administrator and the Regional Director of Operations were informed of an Immediate Jeopardy (IJ) at F695-J: Respiratory/Tracheostomy Care and Suctioning. The Immediate Jeopardy began on [DATE] when the survey team identified the concerns related to the facility not having readily available emergency tracheostomy supplies and the facility failed to train staff on what to do in the event the resident's trach was dislodges from the airways for R14 and R32. The facility provided an acceptable removal plan on [DATE] at 1:15 PM. On [DATE] at 05:20 PM, the Administrator was notified that the IJ was removed but the deficient practice existed at F695-D. Findings include: Review of the facility's policy titled, Skills and Techniques Evaluation revised 10/21 revealed .The Skills and Techniques Evaluation is completed during job-specific orientation revalidated annually .documents skill validation and or return demonstration of skills and techniques identified as necessary to care for patient' needs . Reviewed of an untitled binder provided by the Administrator for clinical staff competencies for 08/22 revealed there were no training or return demonstrations of emergency tracheostomy care in the event the tracheostomy tube was dislodged provided by the facility. Review of the facility's policy titled, Tracheostomy tube cannula and stoma care dated [DATE] revealed, .To prevent infection, perform tracheostomy care using sterile technique .unintentional decannulation Be prepared for emergency replacement by keeping at the bedside a new tracheostomy tube with obturator that is the same size as originally placed tube and a new tracheostomy tube with an obturator that's one size smaller . replace the tube .follow .steps .start with the same size tracheostomy tube .If you encounter problems with reinserting switch to a tube that is one size smaller .using sterile technique . Review of the facility's policy titled, Laryngectomy stoma and tube care dated 12/22 revealed, .It is important to know what type of laryngectomy, particularly if the resident requires emergency care or an airway intervention. Patients who have undergone total laryngectomy require bag-mask ventilation over the stoma .because there is no communication between the trachea and upper airway . surgeon .bringing the trachea to the opening created in the neck .When the stoma heals, the patient can use a baseplate or laryngectomy tube .Coughing up or clearing mucous must occur through the stoma . Proper laryngectomy stoma care is crucial to maintain stoma patency and prevent complications, such as fistula, stomal stenosis, peristomal skin irritation, stomal crusting, and airway obstruction . Inspect all equipment and supplies. If a product is expired is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility . verify the practitioner's order . 1. Review of R14's undated admission Record Report, located in the hard chart, revealed R14 was admitted to the facility on [DATE] with a trach and a diagnosis of brain damage. Review of R14's annual Minimum Data Set (MDS), located in the EMR, under the MDS tab, with an Assessment Reference Date (ARD) of [DATE], revealed the Brief Interview for Mental Status (BIMS) was incomplete. The MDS revealed R14 had a trach. Review of R14's comprehensive Care Plan, under the Care Plan tab located in the EMR and revised on [DATE], revealed .Has/At risk for respiratory impairment related to tracheostomy . Further review of the care plan revealed no information for emergency management of tracheostomy, no style, size, or cuff or uncuffed tracheostomy information, and no intervention related to emergency management of R14's tracheostomy. Review of R14's Order Summary Report, dated [DATE], located in the EMR under the Orders revealed the following: .Change trach collar weekly and as needed . dated [DATE]. .Change Trach Inner Canula . dated [DATE] without specific information about the inner cannula [it should be noted that there can be significant differences between the different manufacturer's tubes]. Suction PRN or ___ (frequency) every day shift for Maintain patent airway . .Trach care daily and PRN [as needed]: For disposable: remove and dispose of inner cannula. Replace with new inner cannula. every day shift for Reduce risk of infection . dated [DATE] and without specific information about the inner cannula [it should be noted that there can be significant differences between the different manufacturer's tubes]. Further review of the physician orders in the EMR under the Orders tab revealed no order for an emergency tracheostomy kit at the bedside. The orders did not include patient specific tracheostomy details (brand, style, cuffed or uncuffed). Review of R14's Treatment Administration Record (TAR), located in the EMR under the Orders tab and dated 02/23, revealed: .Suction PRN or ___ (frequency) every day shift for Maintain patent airway . staff's initials documented the procedure was performed from [DATE] through [DATE]. .Trach care daily and PRN: For disposable: remove and dispose of inner cannula. Replace with new inner cannula . with no specific direction for cleaning the skin around the stoma and assessing for complications. Review of the TAR revealed staff initials documented for [DATE] through [DATE] indicating care was provided. During an interview on [DATE] at 8:05 PM, Licensed Practical Nurse (LPN)1 verified R14's physician orders did not include patient specific tracheostomy details. During an observation on [DATE] at 12:20 PM, R14 was lying in bed with a suction machine at her bedside. Emergency tracheostomy supplies were not visible at her bedside. R14 did not have an ambu bag or replacement tracheostomy tube at her bedside. During an observation on [DATE] at 1:53 PM, R14 did not have an ambu bag, a visible spare tracheostomy or an emergency kit at her bedside. R14 had a suction catheter machine at her bedside. During an interview on [DATE] at 3:40 PM, Certified Nurse Aide (CNA)1 stated that she assisted with R14's care. She stated the facility had not provided training for trach or any emergency trach management training. CNA1 stated if R14's trach came out it was her responsibility to notify the charge nurse. During an observation and interview on [DATE] at 3:47 PM, LPN1 verified R14 did not have an ambu bag or emergency trach kit at R14's bedside. LPN1 pointed at R14's supply of inner cannulas and identified them as R14's replacement tracheostomy tube. She said her responsibility was to replace the trach if it came out. LPN1 stated that she was not sure what size trach R14 required or had in her stoma. LPN1 looked at R14's trach and stated she could not see the brand, type or size. She stated R14 had an order to receive suction as needed. She stated the facility had not provided training for trach or any emergency trach management training and had not been asked to show skills or knowledge with emergency management of a trach or any trach care. During an observation and interview on [DATE] at 4:03 PM, the MDS Coordinator verified R14 did not have an ambu bag at her bedside and stated she did not understand what an emergency trach care kit included. The MDS Coordinator stated it was her responsibility to put R14's trach back in if it came out. The MDS Coordinator identified R14's supply of inner cannulas as R14's replacement tracheostomy tube. She said she was not sure what size trach R14 required or had in her stoma. The MDS Coordinator looked at R14's trach and stated she could not see the brand, type or size. She stated R14 had an order to receive suction as needed. She stated the facility had not provided training for trach or any emergency trach management training. During an observation and interview on [DATE] at 4:11 PM, Registered Nurse (RN)1 verified R14 did not have an ambu bag, replacement trach or emergency trach kit at her bedside. RN1 identified a bag that read manual emergency resuscitator she verified the bag was empty and stated an ambu bag should be in that bag. RN1 stated it was the nurses' responsibility to replace R14's trach immediately if it came out. She said the trach should be replaced with the same size trach or one smaller. RN1 stated replacement trachs were kept in the storage room on 300. During an observation of the 300-hall storage room on [DATE] at 4:30 PM, RN1 verified there were no replacement tracheostomy tubes in the storage room. RN1 stated she had not received training regarding trach care or emergency management of a tracheostomy. Review of Basic Crash Cart Checklist located on the 100 hallway (provided by LPN1) and 200 hallway (provided by RN2) revealed no tracheostomy supplies listed. During an interview on [DATE] at 8:00 PM with LPN1 and on [DATE] at 8:05 PM with RN2, both stated trach supplies were not on the crash cart. During an observation and interview on [DATE] at 4:21 PM, the Unit Manager-RN (UM-RN) stated if R14's trach came out the nurse would attempt to reinsert it. The UM-RN identified R14's supply of inner cannulas as R14's spare trach. She said the ambu bag was down the hallway on the crash cart. The UM-RN stated she thought R14's trach tube was an uncuffed Shiley brand but did not know the size. The UM-RN verified trach sizes were specific to each resident. The UM-RN stated R14's trach dislodging would be an emergency. The UM-RN stated she had not received training regarding emergency trach care and had not been required to demonstrate trach competencies. During an interview on [DATE] at 6:03 PM, the Medical Director stated she expected nurses to be trained, be able to identify emergency situations and have equipment to address emergency situations at the bedside of a resident with a trach. She stated she expected the facility should follow their policy regarding emergency supplies needed at the bedside. 2. Review of R32's undated admission Record located in the EMR revealed R32 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses to include malignant neoplasm of larynx and, chronic obstructive pulmonary disease. Review of R32's admission MDS with an ARD of [DATE] revealed a BIMS score of 14 out of 15 indicating she was cognitively intact. The MDS indicated that R32 was not provided tracheostomy care or suctioning. Review of R32's Physician's Orders under Orders tab located in the EMR revealed .Laryngeal [Laryngectomy stomas are formed following excision of the larynx, usually for the treatment of an underlying malignancy. This is a permanent stoma in which the trachea is separated from the esophagus and brought to an opening in the neck] tube care BID [twice a day] Cleanse with soap and water pat dry . dated [DATE]. There was no order for emergency management of laryngeal tube (trach stoma), no suctioning information and no specific information for brand, type, or size of laryngeal tube. Review of R32's TAR dated 02/23 revealed .Laryngeal tube care BID Cleanse with soap and water pat dry . [DATE]. There was no order for emergency management of laryngeal tube (trach stoma), no suctioning information and no specific information for brand, type, or size of laryngeal tube. Review of R32's comprehensive Care Plan revealed .Maintain and use artificial larynx .Maintain patent airway Date Initiated: [DATE] . Maintain replacement laryngeal tube and Ambu [A 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. It consists of a self-inflating bag, one-way valve, mask, and an oxygen reservoir] bag at bedside Date Initiated: [DATE] . The Care Plan did not indicated emergency management of trach/laryngeal tube, no suctioning intervention, and no patient specific information of laryngeal tube replacement (brand, type or size). During an observation on [DATE] at 12:36 PM, R32 was sitting on the bed and did not have an emergency kit, laryngeal replacement tube or ambu bag at her bedside. During an observation on [DATE] at 2:03 PM, R32 still had no emergency trach kit, no laryngeal replacement tube, and no ambu bag was at her bedside. During an observation and interview on [DATE] at 4:32 PM, R32 was in her room with UM1. The UM1 stated R32 had a [NAME] [laryngeal] tube and it was rubber material and was clean. The UM1 stated R32 had facial paralysis and the [NAME] tube maintained her airway. The UM1 stated R32 did not have a spare laryngeal tube at her bedside and should have. UM1 stated she expected the nurses to replace R32's laryngeal tube. UM1 stated R32 did not have an emergency kit at her bedside or an Ambu bag. UM1 stated she could not remember when the last training for tracheostomies was provided by the facility, but knew it was over a year ago. During an observation and interview on [DATE] at 4:34 PM, R32 was in her room with RN2 who stated he provided care for R32, and she had a [NAME] tube. RN2 stated R32's [NAME] tube was used for breathing. RN2 stated he did not provide a demonstration of his competency skills or knowledge of how to care for a resident with a [NAME] tube to the facility. RN2 stated R32 did not have an ambu bag or emergency kit trach tube, replacement laryngeal tube, or sterile kit for suctioning at her bedside. RN2 stated if R32's laryngeal tube came out it was an immediate life situation for R32. RN2 stated he would put R32's laryngeal tube in with whatever supplies that were readily available even the used one that was dislodged. RN2 stated he would clean it up and put it back in. RN2 stated if R32's same size laryngeal tube would not go back in her stoma, he would attempt to reinsert a smaller size. RN2 stated residents with a trach or laryngeal tube required two replacement trachs, one the same size and one smaller at the bedside. RN2 stated he didn't know where the facility stored the replacement trachs or laryngeal supplies. During an interview on [DATE] at 4:44 PM, CNA3 stated if a resident's decannulated or dislodged tracheostomy/laryngeal tube occurred was to get the nurse. CNA3 stated a resident's trach/laryngeal tube dislodgement was an emergency. CNA3 stated she was not provided training for trach/laryngeal tube emergency management by the facility. During an interview on [DATE] at 4:54 PM, CNA6 stated she was not responsible for trach care. CNA6 stated she doesn't remember if the facility had provided her with training for trach care. CNA6 stated she was not sure what to do for a resident with a trach/laryngeal tube while providing the resident with a shower. CNA6 stated the facility should have provided her trach/laryngeal tube training. During an interview on [DATE] at 5:22 PM, LPN2 stated the facility had not provided any training for suctioning, trach care, replacing a trach, or any emergency trach care. LPN2 stated if a resident's trach came out, she would use sterile technique to reinsert it. LPN2 stated it would be considered an emergency if a resident's trach came out. During an interview on [DATE] at 6:01 PM, the Administrator confirmed the facility used [NAME] hospital procedures for their resource for policies and procedures. The Administrator confirmed the DON was responsible for ensuring the clinical staff were competent with trach care. During an interview on [DATE] at 6:32 PM, the Administrator stated it was leadership's (Administrator and the DON) responsibility to ensure the facility central supply clerk and unit managers ordered and provided resident's medical supplies at the facility. During an interview on [DATE] at 6:21 PM, the DON verified R32 did not have a physician's order to suction her laryngeal tube and should have had an order. The removal plan included physician order revisions, placing tracheostomy supplies at the bedside in each resident's room, in-servicing nursing staff regarding tracheostomy care, revising residents' care plans and physician order revisions, placement of emergency supplies in the supply room. 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 [DATE] at 5:18 PM. B. Based on observation, record review, interview and policy review, the facility failed to ensure oxygen concentrators currently used by residents, had clean filters for 2 of 2 Residents (R17 and R49) reviewed for oxygen use. Findings include: Review of the facility's policy, Oxygen Administration dated 06/2021 indicated, .Preparation of Equipment .2. For oxygen concentrator . If using concentrator: Clean filter weekly: Remove filter from back or sides of concentrator Rinse filter with water Shake off excess water. Air dry. Replace filter . 1. Review of the EMR revealed R17 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, heart disease and pulmonary hypertension Review of R17's EMR under the Orders tab revealed a Physician's order dated [DATE], which indicated, Oxygen via nasal cannula 2 LM [Liters per minute] every shift for hypoxia to keep O2 [oxygen] over 90%. During an observation on [DATE] at 12:20 PM, R17 was in her bed wearing a nasal cannula attached to the oxygen concentrator. The filter on the side of the machine was coated with an off-white layer of dust. Review of the EMR under Face Sheet, revealed R49 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, chronic and obstructive pulmonary disease, 2. Review of R49's EMR under the Orders tab revealed a Physician's order dated [DATE], which indicated, Oxygen 3 LM via nasal cannula to keep O2 sat greater than 92%. During an observation on [DATE] at 1:05 PM, R49 was in her bed wearing a nasal cannula attached to the oxygen concentrator. The filter on the back of the machine was coated with a thick layer of off-white dust. During an interview on [DATE] at 12:50 PM, the Administrator was shown R17 and R49's oxygen concentrator filters. The Administrator agreed the filters were dirty and the expectation was to have a clean filter. The Administrator stated the filters should be cleaned weekly by the nursing staff. During an interview on [DATE] at 3:30 PM, LPN1 stated she thought maintenance was responsible for cleaning the oxygen concentrator filters. During an interview on [DATE] at 3:33 PM, LPN4 stated she thought maintenance was responsible for cleaning the oxygen concentrator filters. During an interview on [DATE] at 3:55 PM with Maintenance Director (MD), he stated he has never been asked to clean the oxygen concentrator filters. MD said he thought cleaning the oxygen concentrator filters was a nursing staff responsibility.