**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident goals and preference for 1 (Resident #81) of 1 reviewed for tracheostomy care. -LVN A failed to reconnect Resident #81's trach to oxygen after removing it to gather trach supplies. -LVN A failed to properly secure Resident #81's trach when removing the trach tie. -LVN A failed to clean Resident #81's trach stoma to prevent infection. An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 5:44PM. While the IJ was removed on 02/19/2024 at 10:55AM, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not an immediate jeopardy because all staff had not been trained on tracheostomy care. The failures has the potential to place resident(s) with tracheostomies at risk of not receiving the necessary care and services needed to meet their medical goals resulting in a decline in health or harm. Findings included : Record review of Resident #81's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses that included: intracranial hemorrhage (bleeding on the brain), respiratory failure (serious condition making it difficult to breathe), encephalopathy (brain disease that alters the way the brain function), tracheostomy (procedure to help air and oxygen reach the lungs by creating a surgical opening in the neck), dysphagia (difficulty swallowing), narcolepsy (condition that cause one to fall asleep suddenly without warning), hypertension (elevated blood pressure), epilepsy (temporary uncontrolled stiffening and jerking of arms and legs or loss of awareness), and dependence on supplemental oxygen ( oxygen therapy that provides one with extra oxygen to breathe). Record review of Resident #81's physician's orders for the month of February 2024 revealed the following orders: -Dated 02/14/2024 Ambu bag (device used to provide respiratory support to an individual), extra trach tube and O2 tank at the bedside. -Dated 02/14/2024 Change disposable inner cannula daily and PRN. -Dated 02/14/2024 Change trach tubing collar weekly and PRN, date all pieces of tubing. -Dated 02/14/2024 Oxygen via tracheostomy collar at 35% (4L) every shift. -Dated 02/14/2024 Suction tracheostomy q shift and PRN. -Dated 02/14/2024 Trach care every shift and PRN -Dated 02/15/2024 Tracheostomy cuff Shiley size 6 in place. Record review of Resident #81's Baseline Care Plan dated 02/14/2024 revealed special treatment that included oxygen therapy and tracheostomy care. Observation on 02/16/24 at 10:35 AM revealed Resident #81 was resting in bed with the head of bed elevated, receiving continuous feedings via a gastrostomy tube (insertion of a surgical tube in the stomach to provide nutrition). The resident's tracheostomy was connected to oxygen at 4 liters per minute. The resident had a fenestrated (having one or more openings) gauze around the trach site that appeared clean and dry. Resident trach was secured with a trach tie. Further observation was made of the resident having respiratory/trach supplies in the room at the bed side that included suctioning kits, inner cannulas, an Ambu bag, etc. Further observation was done with LVN A preparing to provide trach care for the resident. LVN A disinfected the resident's bedside table and placed the trach supplies on the bedside table and washed her hands. LVN A told the surveyor that Resident #81 had already been suctioned and did not need to be suctioned at this time. The surveyor told the nurse that she could proceed with care. LVN A proceeded to check the resident's pulse oximetry that was at 96%. At 10:36AM LVN A proceeded with care by removing the oxygen from the resident's trach and placing the oxygen mask on the resident's chest. LVN A then completely removed the trach tie from around the resident's neck along with the dressing to the trach site, disposing of materials in a trash can at the resident's' bedside. At this time the resident coughed with the trach moving. LVN A placed her fingers at the trach site to prevent the trach from dislodging while proceeding to clean around the resident's trach site, not starting at the stoma (surgery to create an opening from an area inside the body to the outside) site and moving away from the stoma, instead using the same wipe to clean more than one time near the stoma site. Further observation was made of the resident beginning to move her left hand toward the trach site. Resident oxygen was still resting on her chest. The surveyor asked LVN A at 10:39AM to check the resident's oxygen saturation. Resident oxygen saturation was 90%. The surveyor asked the nurse to place the resident back on her oxygen and secure the trach with trach tie to prevent further decrease in resident oxygen level . Resident oxygen saturation had increase to 94%. Resident call light was alarmed by LVN A for the ADON to come to room. Further observation was made of the resident's physician entering the resident room with a student. The physician began to assess the resident and observed that the resident was not wearing a trach tie and told the nurse to put a trach tie on Resident #81. LVN A proceeded to place a trach tie on the resident but did not secure the right side of resident the trach tie. LVN A applied a 4 x 4 gauze that was not fenestrated gauze to the resident's stoma site. The 4 x 4 gauze was not neatly placed around the trach stoma site. Observation was made of Resident #81 beginning to cough. The surveyor asked LVN A to secure the right side of the resident's trach tie and if she could place a fenestrated gauze (gauze with an opening through which secretions can drain). After LVN A placed a fenestrated gauze around the resident's stoma site, and secured the trach tie, the resident stopped coughing. Interview on 02/16/24 at 11:00AM LVN A said the last time she had worked at facility with residents that had tracheostomies was about 7-8 years ago. LVN A said she had been a nurse for 40 years and had been working at the facility for 2 years. LVN A said she had not been in-serviced on trach care while working at the facility. Interview on 02/16/24 at 11:08AM the ADON and DON said the last training that the facility had done on trach care was about 6 months ago but would have to check to be certain. The ADON and DON said Resident #81 had arrive at the NF about 2 days ago. Further interview, with the DON and ADON said they were not at the facility when Resident #81 arrived at the facility because Resident #81 was admitted to the facility on the night shift. The ADON said the facility had not admitted any residents (s) with a tracheostomy in a long time. The ADON said Resident #81 should have never been admitted to the facility because the facility had not admitted a resident with a trach in a long time. Interview on 02/16/2024 at 4:00PM the DON said he and the ADON had not in-serviced the staff on trach care and that the facility Respiratory Therapist would be coming to the facility on [DATE] to in-service the staff on tracheostomy care. The DON said he had given the nursing staff the facility policy on tracheostomy care after Resident #81 was admitted to the facility. Further interview the DON said he had asked LVN A after Resident #81 was admitted to the facility if she was comfortable in providing trach care. The DON said LVN A said she was comfortable with caring for residents with a trach. The DON said he gave a trach training last year sometime and that LVA A should have received the training. The DON was not able to produce documentation that an in-service was done with the nursing staff on tracheostomy care in 2022. Interview on 02/19/2024 at 1:03PM the Respiratory Therapist said the last time she had come to the facility was sometime in 2023. The Respiratory Therapist said when she came to the facility in 2023, she was following up with the facility to see if she could be of service and at that time, the facility did not have any residents with tracheostomies. The Respiratory Therapist said she was contracted with the facility and came to the facility on an as needed basis. The Respiratory Therapist said she preferred to be called in advance prior to a new admission so that she could educate the staff and provide guidance for the facility. The Respiratory Therapist said the reason staff should be using a spilt gauze to place around the trach stoma after cleaning was to help absorb any secretions around the stoma. Interview on 02/22/2024 at 2:00PM the Administrator said the last time the NF had admitted a resident with a tracheostomy was in 2022. The Administrator said he started working at the facility in August of 2022 and the DON began working at the facility in September of 2022. The Administrator said whenever a resident was considered for admission to the facility, the marketing team would send the referral to the facility that included the business office as well as the DON and ADON. The Administratorion said the DON and ADON reviewed the residents' medical records and acknowledged they receive the referral. The Administrator said no one in administration was caught off guard on any new admission. The Administrator said the facility knew that Resident #81 was going to be admitted to the facility but did not know the exact day that resident was going to be admitted . Record review of the facility last in-service on tracheostomy care revealed it was done in 2022 . Record review of the facility policy on Tracheostomy Care revised October 2023 revealed in part: .With moistened gauze starting at the 12 o'clock position of the stoma, wipe toward the 3 o'clock position. Begin again with a new gauze square at 12 o'clock and clean toward 9 o'clock. To clean the lower half of the site, start at the 3 o'clock position and clean toward 6 o'clock; then wipe from 9 o'clock to 6 o'clock, using a clean moistened square for each wipe. Continue this pattern on the surrounding skin and tube flange (projecting flat rim, collar that maintain position) .Apply fenestrated gauze pad around the insertion skite, touching only outer edges .Replace neck ties: A two person technique is recommended, with one person holding the tracheostomy tube in place while the other secures the ties .If resident's condition is unstable, or if the stoma is less than two weeks old, apply new ties before removing old ties . The Administrator and DON were notified on 02/16/23 at 5:44 PM that an IJ situation had been identified due to the above failures. The IJ template was provided. The following plan of removal was submitted by the facility on 02/17/2024 and accepted on 02/17/2023 at 11:08AM. PLAN OF REMOVAL Date: 2/16/2024 The facility failed to ensure that Resident #81 who required respiratory care, including tracheostomy care was provided such care consistent with professional standards of practice when the facility failed to provide adequate care and in service staff on tracheostomy care prior to and after resident was admitted to the facility on [DATE]. Immediate action: LVN A was removed from providing care to Resident #1 on 2/16/2024 and would not be permitted to work until trained and return demonstration is complete. On 2/16/2024 an AdHoc QAPI meeting was held with the Director of Nursing, Executive Director, Medical Director, and Co-Medical Director. Reviewed: IJ Template, Resident #1's chart, and plan of removal. The policy on tracheostomy care in-service was initiated by the DON and will run concurrent with training provided by Respiratory Therapist. Respiratory Therapist initiated training on 2/16/2024 on Respiratory Assessments, O2 Therapy, Nebulizer Therapy, Suctioning, Tracheotomy Training & Emergency Procedures. Nursing staff caring for Resident #1 will be trained prior to next working shift. New hires (licensed nurses) will receive education before working. Licensed Nurses will not be able to work until training is completed. Training and competency checks will be completed by 2/18/2024. No other residents are affected as this is the only resident admitted to the facility . Assessment was completed on Resident #1 by an RN with no adverse findings on 2/16/2024. The DON/Designee will make random rounds on all patients requiring tracheostomy care to ensure staff competency initiated on 2/17/2024. The DON/Designee will ensure that staff is trained prior to the admission of any patients that require tracheostomy care by reviewing referrals prior to admission. The DON or designee will review clinicals for new admissions to identify any specialized needs initiated on 2/16/2024. The Admissions Director was educated on process of reviewing referrals by the DON or designee prior to admissions on 2/17/2024. The Administrator will review education records of staff to ensure they are properly trained in specialized areas to be implemented on 2/16/2024. ________________________________________________________________________ The surveyor confirmed the plan of removal had been implemented sufficiently to remove IJ by the following: Interview on 02/17/2024 at 11:48AM LVN C said she worked at the facility PRN on all shifts. LVN C said she had been in- serviced on tracheostomy care and that the skill was a sterile procedure when performing trach suctioning and cleaning around the stoma site. LVN C said the trach had to always be secured when providing care. LVN C said prior to suctioning the resident she was supposed to assess the resident's lung sounds and check the resident's oxygen saturation by placing the pulse oximetry on the resident's finger and to not remove the pulse oximetry until trach suction had been completed. LVN C said when cleaning the trach stoma site, she had to clean starting at the site moving away from the stoma, one wipe at a time. Interview on 02/17/2024 at 1:06PM LVN D said she worked on the weekends double shift from 6AM-10PM full time. LVN D said she had been in-serviced on tracheotomy care to assess the lung sounds prior to and after suctioning along with checking the resident's pulse oximetry. LVN D said she was also in-serviced to always ensure that the trach was secured. LVN D said when cleaning around the stoma she was supposed to clean starting near the stoma site, moving away from the stoma and being careful to not introduce bacteria to the stoma site, one wipe at time. LVN D said she was in-serviced that when she had to replace or change the tie around the trach to untie one string at a time to prevent the trach from dislodging. LVN D said she was to apply a split gauze to the stoma site after cleaning around the stoma site to better absorb any moisture. LVN D said she was in-serviced that when suctioning the resident or cleaning the stoma, it was a sterile technique. Interview on 02/17/2024 at 1:12PM LVN E said she worked the weekend shift form 6AM-10PM full time. LVN E said she had been in-serviced on trach care regarding suctioning, cleaning of the stoma site, assessing the resident's lung sounds prior to and after suctioning, checking the oxygen saturation before, during, and after suctioning the resident. LVN E said if the resident's trach dislodged, she was in-serviced to place a new trach immediately and if met with resistance to down size with a smaller trach reassessing the resident and informing the physician what took place. LVN E said when cleaning the stoma to clean at the stoma, moving away one wipe at a time, going in a clock motion to prevent infection. LVN E said she was in-service to always make sure resident trach was secure during care and afterwards and only loosen one tie at a time when changing or having to clean the stoma site. Interview on 02/18/2024 at 1:30PM LVN F said she worked at the facility full time from 6:00AM to 10PM and had been in- serviced on the following regarding tracheostomy care: trach suctioning and stoma care was a sterile procedure, assessing the resident prior, during, and after trach suctioning by observing respirations, oxygen saturation, and lung sounds, cleaning of the stoma, how to remove the trach tie without dislodging the trach, what to do if a trach dislodged (replace immediately with the same size trach, if meet resistance to downsize to a small trach size), assess the resident for any distress, notify the physician of happenings, and how to dispose of soiled material placing in a red biohazard bag. Interview on 02/18/2024 at 1:38PM RN G said he worked at the facility PRN on various shifts. RN G said he had been in-serviced on how to care for a resident with a tracheostomy. RN G said when performing trach suctioning and cleaning the stoma was a sterile technique. RN G said before performing suctioning, the lung sounds, and oxygen saturation should be assessed prior leaving the pulse oximeter on the resident to monitor the oxygen saturation throughout the procedure. RN G said before starting the procedure, the workspace should be disinfected. RN G said once he placed on his sterile gloves, the dominant hand should be establish being careful not to break sterile procedure. RN G said when cleaning the stoma, he was in-serviced to clean the stoma site one wipe at a time moving away from the stoma. RN G said when cleaning the stoma, the trach did not have to be removed but loosened enough to clean around the site and that the nurse should use a split gauze to apply around the stoma site. RN G said when changing the trach tie. oOne tie should be removed at a time to prevent the trach from dislodging. RN G said if the trach dislodged, he would replace with a new trach same size and if he could not get the trach back in, he would get a smaller size to reinsert. RN G said the same size trach should always be kept at the bedside along with a smaller one size down. Interview on 02/18/2024 at 2:12PM LVN H said she worked at the facility on the weekends from 2PM-6AM. LVN H said she had been in-serviced on trach care, that it was a sterile procedure to prevent infections. LVN H said before suctioning the resident, she was in-serviced to disinfect her workspace, wash her hands prior to the procedure, and then assess the resident's lung sounds and oxygen saturation. LVN H said when not suctioning the resident, the oxygen needed to be connected to the resident. LVN H said the pulse oximeter needed to be kept on the resident's finger so the nurse could monitor the resident's oxygen saturation throughout the procedure. LVN H said she was also in-service that the resident head of bed was elevated when suctioning the resident and to always know what hand her dominant hand was to suction the resident, so she did not contaminate the procedure. LVN H said when cleaning the resident's stoma, she had to make sure that resident's trach tie was secured enough in case the resident coughed to prevent the trach from dislodging. LVN H said when cleaning the trach stoma, she would start clockwise at the 12:00 o'clock position cleaning the stoma moving outward one wipe at a time to avoid reintroducing bacteria to the stoma site and when done would apply a split gauze to the stoma site. LVN H said when changing the trach tie she would remove one tie at a time always keeping one tie in place. LVN H said if the trach came out and she could not insert a new trach the same size, she would insert the next trach size down from the original size. LVN H said she would also provide the resident with oxygen if needed and call the doctor. Interview on 02/18/2024 at 7:00PMvia phone RN I said he was working the 2PM-10AM and had been in-serviced on tracheostomy care on how to perform sterile technique when suctioning, changing the inner cannula, and cleaning the stoma. RN I said he had to check the resident oxygen saturation and listen to the lung sounds before suctioning, oxygenate the resident in between suction, when changing the trach tie, untie one side at a time to prevent the risk of the trach coming out. RN I said if the trach dislodged, he would reinsert immediately and if he had to would insert a smaller size trach if met resistance. RN I said he would then assess the resident and oxygenate as needed. RN I said he would send the resident out if unstable and call the physician. Interview on 02/18/2024 at 7:27PM via phone LVN B said she worked every weekend shift from 2PM-6AM. LVN B said she had received an in-service on how to care for a resident with a tracheostomy. LVN B said trach suctioning was a sterile technique to prevent resident from getting an infection. LVN B said resident oxygen level had to be taken before suctioning incase the resident needed to be oxygenated as well as assessing the lung sounds. LVN B said when changing resident trach tie, only remove one tie at a time to prevent the trach from coming out. LVN B said if the resident's trach came out, she would try and insert the trach immediately or get a smaller size if could not reinsert the original size trach. LVN B said she would continue to assess the resident and if the resident was unstable, she would call 911 right away, notify the doctor, continue to observe the resident and administer further care, one being oxygen, if needed. Observation on 02/19/2024 at 9:56AM revealed tracheostomy care on Resident #81 (who was resting in bed with head of bed elevated receiving continuous gastrostomy feedings) by LVN J. LVN J washed his hands, disinfected his workspace/bedside table, and placed the trach supplies (normal saline, suction kit with sterile gloves) on his workspace/bedside table. LVN J paused the resident's continuous gastrostomy feedings, washed his hands again, listened to the resident's lung sounds and checked the resident's oxygen saturation which was 98% and left the pulse oximetry on the resident's finger. LVN J then put on a pair of clean gloves after sanitizing his hands and began to open the suction kit and normal saline container without contaminating his sterile field. LVN J placed on his sterile gloves confirming that his right hand would be his dominant hand and suctioned the resident intermittently pulling the suction catheter out of the trach with no concerns identified. Resident #81 tolerated the procedure with minimum reaction or distress noted. Interview on 02/19/2024 at 10:15AM LVN J said he had been in-serviced that when he provide trach suctioning, or changing out the inner cannula the procedure was invasive, and therefore was a sterile procedure to prevent infections. LVN J said he was also in-serviced that if the trach came out, he was to get a new trach the same size and put it back in. LVN J said if he was unable to get the same size trach back in, he would get the next size down to insert. LVN J said he was in-serviced to the keep trach supplies at the bedside including a smaller trach size for emergency purposes. LVN J said if he had to change the trach ties, he was in-serviced to change one tie at time to keep the trach from coming out. On 2/19/2024 at 10:55AM the Administrator was informed the IJ was removed, however, the facility remained out of compliance at a scope of isolation and severity of harm that is not an immediate jeopardy the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the nursing staff were able to demonstrate competency in skills and techniques necessary to provide tracheostomy care for 1 (Resident #81) of 1 resident reviewed for tracheostomy care. -LVN A failed to reconnect Resident #81's trach to oxygen after removing to gather trach supplies. -LVN A failed to properly secure Resident #81's trach when removing the trach tie. -LVN A failed to clean Resident #81's trach stoma to prevent introducing micro-organism (bacteria) inside of tracheostomy. An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 5:44PM. While the IJ was removed on 02/19/2024 at 10:55AM, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not an immediate jeopardy because all staff had not been trained on tracheostomy care. This failure has the potential to place resident(s) with tracheostomies at risk of not receiving the necessary care and services needed to meet their medical goals resulting in a decline in health or harm. Findings included: Record review of Resident #81 face sheet revealed a 77year old female admitted to the facility on [DATE] with the following diagnoses that included: intracranial hemorrhage (bleeding on the brain), respiratory failure (serious condition making it difficult to breathe), encephalopathy (brain disease that alters the way the brain function), tracheostomy (procedure to help air and oxygen reach the lungs by creating a surgical opening in the neck), dysphagia (difficulty swallowing), narcolepsy (condition that cause one to fall asleep suddenly without warning), hypertension (elevated blood pressure), epilepsy (temporary uncontrolled stiffening and jerking of arms and legs or loss of awareness), and dependence on supplemental oxygen ( oxygen therapy that provides one with extra oxygen to breathe). Record review of Resident #81's physician orders for the month of February 2024 revealed the following orders: -Dated 02/14/2024 Ambu bag (device used to provide respiratory support to an individual), extra trach tube and O2 tank at the bedside -Dated 02/14/2024 Change disposable inner cannula daily and PRN -Dated 02/14/2024 Change trach tubing collar weekly and PRN date all pieces of tubing -Dated 02/14/2024 oxygen via tracheostomy collar at 35% (4L) every shift -Dated 02/14/2024 Suction tracheostomy q shift and PRN -Dated 02/14/2024 trach care every shift and PRN -Dated 02/15/2024 tracheostomy cuff Shiley size 6 in place Record review of Resident #81's Baseline Care Plan dated 02/14/2024 revealed special treatment that included oxygen therapy and tracheostomy care. Observation on 02/16/24 at 10:35 AM Resident #81 was resting in bed with head of bed elevated receiving continuous feedings via gastrostomy tube. Resident tracheostomy was connected to oxygen at 4 liters. Resident had a fenestrated gauze around trach site that appeared clean and dry. Resident trach was secured with a trach tie. Further observation was made of resident having respiratory/trach supplies in room at the bed side that included suctioning kits, inner cannulas, Ambu bag, etc. Further observation was done with LVN A preparing to provide trach care for resident. LVN A disinfected resident bedside table and placed trach supplies on the bedside table and washed her hands. LVN A told the surveyor that Resident #81 had already been suctioned and did not need to be suctioned at this time. The surveyor told the nurse that she could proceed with care. LVN A proceeded to check resident pulse oximetry that was at 96%. At 10:36AM LVN A proceeded with care by removing the oxygen from resident trach and placing on resident's chest. LVN A then completely removed the trach tie from around resident neck along with the dressing to trach site disposing of materials in a trash can at residents' bedside. At this time resident coughed with the trach moving. LVN A placed her fingers at the trach site to prevent the trach from dislodging while proceeding to clean around resident trach site, not starting at the stoma site and moving away from the stoma, instead using the same wipe to clean more than one time near the stoma site. Further Observation was made of resident beginning to move her left hand toward trach site. Resident oxygen was still resting on her chest. The surveyor asked LVN A at 10:39AM to check resident oxygen saturation. Resident oxygen saturation was 90%. The surveyor asked the nurse to place resident back on her oxygen and secure trach with trach tie. Resident oxygen saturation had increase to 94%. Resident call light was alarmed for the ADON to come to room. Further observation was made of resident physician entering resident room with a student. The physician began to assess resident and observed that resident was not wearing a trach tie and told the nurse to put a trach tie on Resident #81. LVN A proceeded to place a trach tie on resident but did not secure the right side of resident trach tie and applied a 4 x 4 gauze and not fenestrated gauze to resident stoma site. The 4 x 4 gauze was not neatly gathered around the trach stoma site with observations made of resident appearing to be comfortable beginning to cough. The surveyor asked LVN A to secure the right side of resident trach tie and if she could place a fenestrated gauze (gauze with an opening through which secretions can drain). After LVN A placed a fenestrated gauze around resident stoma site, and secured the trach tie, resident stopped coughing and appeared comfortable. Interview on 02/16/24 at 11:00AM LVN A said the last time she had worked at facility with residents that had tracheostomies was about 7-8 years ago. LVN A said she had been working at the facility for 2 years and had never received in-service on tracheostomy care. Interview on 02/16/24 at 11:08AM the ADON and DON said the last training that the facility had done on trach care was about 6 months ago but would have to check to be certain. The DON and ADON said they were unaware that Resident #81 was being admitted to the facility and that resident was admitted after they had left the faciity on the night shift. Further interview on 02/16/2024 at 4:00PM the DON said he and the ADON had not in-serviced the staff on trach care and that the facility Respiratory Therapist would be coming to the facility on [DATE] to in-service the staff on tracheostomy care. The DON said he had given the nursing staff the facility policy on tracheostomy care. Further interview with the DON said LVN A said she was comfortable with caring for residents with a trach. The DON said he gave a trach training last year sometime and that LVA A should have received the training. The DON was not able to produce documentation that in-service was done with the nursing staff on tracheostomy care in 2022. Record review on 02/16/2024 of the facility last in-service on tracheostomy care was in 2022. 02/19/2024 at 12:30PM Interview with the Administrator said he did not know if the facility had a skills competency check list for the nurses and would have to ask the DON. The Administrator said he did know that the facility gave a 3-day orientation for all new hires. The Administrator said he did not know in detail what was done in the 3-day orientation with new employees. Interview on 02/19/2024 at 1:03PM the Respiratory Therapist said the last time she had come to the facility was sometime in 2023. The Respiratory Therapist said when she came to the facility in 2023, she was following up with the facility to see if she could be of service and at that time, the facility did not have any resident (s) with tracheostomies. The Respiratory Therapist said she was contracted with the facility and came to the facility on an as needed basis. The Respiratory Therapist said she preferred to be called in advance prior to a new admission so that she could educate the staff and provide guidance for the facility. The Respiratory Therapist said the reason staff should be using a spilt gauze to place around the trach stoma after cleaning was to help absorb any secretions around the stoma. The Respiratory Therapist said she assessed Resident #81, and the resident was stable, not having in copious secretions from her tracheostomy. The Respiratory Therapist said she had also assessed the facility respiratory/tracheostomy supplies and that the facility had adequate supplies. The Respiratory Therapist said after assessing the nursing staff skills in trach care, the in-service was much needed. The Respiratory Therapist said because the facility had a resident at the facility with a tracheostomy, she would be coming to the facility on a weekly basis. Interview on 02/19/2024 at 1:30PM the DON said new nurses got at least a 3-day orientation that consisted of going over the facility's policy and procedures, medication pass, electronic medical record/PCC. The DON said the facility did not have a written skills competency check off list that he was aware of and if they did, the facility was not utilizing the competency check off list. The DON said when the facility hired a nurse, they just asked if the nurse was competent in doing certain skills . The DON said since the facility had incurred an IJ in the area of trach care, the facility was discussing on potentially setting up a skills area for new hires to demonstrate their skills or pairing them with a chosen preceptor. 02/19/2024 at 2:00PM Interview with the Administrator said he just learned on 02/18/2024 that the NF did have a Nursing Competency Skills Checklist, but the facility was just not using the form and could not provide a reason why the facility was not using the form. The Administrator said moving forward the facility would be utilizing the Nursing Competency Skills Checklist. The Administratorion said the DON and ADON reviewed each resident admission referral and must acknowledge they receive the referral and therefore no one in administration was caught off guard on any new admission. The Administrator said the facility knew that Resident #81 was going to be admitted to the facility just did not know the exact day that resident was going to be admitted . The Administrator said the facility did not have a specific policy on staff training. Record review of the facility policy for the Director of Nursing Job Description revealed in part: .The DON is a registered nurse who oversees and supervises the care of the residents. The DON also provides direct resident/patient care .Develop and conduct in-services for the clinical staff . The Administrator and DON were notified on 02/16/23 at 5:44 PM that an IJ situation had been identified due to the above failures. The IJ template was provided. The following plan of removal was submitted by the facility on 02/17/2024 and accepted on 02/17/2023 at 11:08AM. PLAN OF REMOVAL Date: 2/16/2024 The facility failed to ensure that Resident #81 who required respiratory care, including tracheostomy care was provided such care consistent with professional standards of practice when the facility failed to provide adequate care and in service staff on tracheostomy care prior to and after resident was admitted to the facility on [DATE]. Immediate action: LVN A was removed from providing care to Resident #1 on 2/16/2024 and would not be permitted to work until trained and return demonstration is complete. On 2/16/2024 an AdHoc QAPI meeting was held with the Director of Nursing, Executive Director, Medical Director, and Co-Medical Director. Reviewed: IJ Template, Resident #1's chart, and plan of removal. The policy on tracheostomy care in-service was initiated by the DON and will run concurrent with training provided by Respiratory Therapist. Respiratory Therapist initiated training on 2/16/2024 on Respiratory Assessments, O2 Therapy, Nebulizer Therapy, Suctioning, Tracheotomy Training & Emergency Procedures. Nursing staff caring for Resident #1 will be trained prior to next working shift. New hires (licensed nurses) will receive education before working. Licensed Nurses will not be able to work until training is completed. Training and competency checks will be completed by 2/18/2024. No other residents are affected as this is the only resident admitted to the facility . Assessment was completed on Resident #1 by an RN with no adverse findings on 2/16/2024. The DON/Designee will make random rounds on all patients requiring tracheostomy care to ensure staff competency initiated on 2/17/2024. The DON/Designee will ensure that staff is trained prior to the admission of any patients that require tracheostomy care by reviewing referrals prior to admission. The DON or designee will review clinicals for new admissions to identify any specialized needs initiated on 2/16/2024. The Admissions Director was educated on process of reviewing referrals by the DON or designee prior to admissions on 2/17/2024. The Administrator will review education records of staff to ensure they are properly trained in specialized areas to be implemented on 2/16/2024. ________________________________________________________________________ The surveyor confirmed the plan of removal had been implemented sufficiently to remove IJ by the following: Interview on 02/17/2024 at 11:48AM LVN C said she worked at the facility PRN on all shifts. LVN C said she had been in- serviced on tracheostomy care and that the skill was a sterile procedure when performing trach suctioning and cleaning around the stoma site. LVN C said the trach had to always be secured when providing care. LVN C said prior to suctioning the resident she was supposed to assess the resident's lung sounds and check the resident's oxygen saturation by placing the pulse oximetry on the resident's finger and to not remove the pulse oximetry until trach suction had been completed. LVN C said when cleaning the trach stoma site, she had to clean starting at the site moving away from the stoma, one wipe at a time. Interview on 02/17/2024 at 1:06PM LVN D said she worked on the weekends double shift from 6AM-10PM full time. LVN D said she had been in-serviced on tracheotomy care to assess the lung sounds prior to and after suctioning along with checking the resident's pulse oximetry. LVN D said she was also in-serviced to always ensure that the trach was secured. LVN D said when cleaning around the stoma she was supposed to clean starting near the stoma site, moving away from the stoma and being careful to not introduce bacteria to the stoma site, one wipe at time. LVN D said she was in-serviced that when she had to replace or change the tie around the trach to untie one string at a time to prevent the trach from dislodging. LVN D said she was to apply a split gauze to the stoma site after cleaning around the stoma site to better absorb any moisture. LVN D said she was in-serviced that when suctioning the resident or cleaning the stoma, it was a sterile technique. Interview on 02/17/2024 at 1:12PM LVN E said she worked the weekend shift form 6AM-10PM full time. LVN E said she had been in-serviced on trach care regarding suctioning, cleaning of the stoma site, assessing the resident's lung sounds prior to and after suctioning, checking the oxygen saturation before, during, and after suctioning the resident. LVN E said if the resident's trach dislodged, she was in-serviced to place a new trach immediately and if met with resistance to down size with a smaller trach reassessing the resident and informing the physician what took place. LVN E said when cleaning the stoma to clean at the stoma, moving away one wipe at a time, going in a clock motion to prevent infection. LVN E said she was in-service to always make sure resident trach was secure during care and afterwards and only loosen one tie at a time when changing or having to clean the stoma site. Interview on 02/18/2024 at 1:30PM LVN F said she worked at the facility full time from 6:00AM to 10PM and had been in- serviced on the following regarding tracheostomy care: trach suctioning and stoma care was a sterile procedure, assessing the resident prior, during, and after trach suctioning by observing respirations, oxygen saturation, and lung sounds, cleaning of the stoma, how to remove the trach tie without dislodging the trach, what to do if a trach dislodged (replace immediately with the same size trach, if meet resistance to downsize to a small trach size), assess the resident for any distress, notify the physician of happenings, and how to dispose of soiled material placing in a red biohazard bag. Interview on 02/18/2024 at 1:38PM RN G said he worked at the facility PRN on various shifts. RN G said he had been in-serviced on how to care for a resident with a tracheostomy. RN G said when performing trach suctioning and cleaning the stoma was a sterile technique. RN G said before performing suctioning, the lung sounds, and oxygen saturation should be assessed prior leaving the pulse oximeter on the resident to monitor the oxygen saturation throughout the procedure. RN G said before starting the procedure, the workspace should be disinfected. RN G said once he placed on his sterile gloves, the dominant hand should be establish being careful not to break sterile procedure. RN G said when cleaning the stoma, he was in-serviced to clean the stoma site one wipe at a time moving away from the stoma. RN G said when cleaning the stoma, the trach did not have to be removed but loosened enough to clean around the site and that the nurse should use a split gauze to apply around the stoma site. RN G said when changing the trach tie. oOne tie should be removed at a time to prevent the trach from dislodging. RN G said if the trach dislodged, he would replace with a new trach same size and if he could not get the trach back in, he would get a smaller size to reinsert. RN G said the same size trach should always be kept at the bedside along with a smaller one size down. Interview on 02/18/2024 at 2:12PM LVN H said she worked at the facility on the weekends from 2PM-6AM. LVN H said she had been in-serviced on trach care, that it was a sterile procedure to prevent infections. LVN H said before suctioning the resident, she was in-serviced to disinfect her workspace, wash her hands prior to the procedure, and then assess the resident's lung sounds and oxygen saturation. LVN H said when not suctioning the resident, the oxygen needed to be connected to the resident. LVN H said the pulse oximeter needed to be kept on the resident's finger so the nurse could monitor the resident's oxygen saturation throughout the procedure. LVN H said she was also in-service that the resident head of bed was elevated when suctioning the resident and to always know what hand her dominant hand was to suction the resident, so she did not contaminate the procedure. LVN H said when cleaning the resident's stoma, she had to make sure that resident's trach tie was secured enough in case the resident coughed to prevent the trach from dislodging. LVN H said when cleaning the trach stoma, she would start clockwise at the 12:00 o'clock position cleaning the stoma moving outward one wipe at a time to avoid reintroducing bacteria to the stoma site and when done would apply a split gauze to the stoma site. LVN H said when changing the trach tie she would remove one tie at a time always keeping one tie in place. LVN H said if the trach came out and she could not insert a new trach the same size, she would insert the next trach size down from the original size. LVN H said she would also provide the resident with oxygen if needed and call the doctor. Interview on 02/18/2024 at 7:00PMvia phone RN I said he was working the 2PM-10AM and had been in-serviced on tracheostomy care on how to perform sterile technique when suctioning, changing the inner cannula, and cleaning the stoma. RN I said he had to check the resident oxygen saturation and listen to the lung sounds before suctioning, oxygenate the resident in between suction, when changing the trach tie, untie one side at a time to prevent the risk of the trach coming out. RN I said if the trach dislodged, he would reinsert immediately and if he had to would insert a smaller size trach if met resistance. RN I said he would then assess the resident and oxygenate as needed. RN I said he would send the resident out if unstable and call the physician. Interview on 02/18/2024 at 7:27PM via phone LVN B said she worked every weekend shift from 2PM-6AM. LVN B said she had received an in-service on how to care for a resident with a tracheostomy. LVN B said trach suctioning was a sterile technique to prevent resident from getting an infection. LVN B said resident oxygen level had to be taken before suctioning incase the resident needed to be oxygenated as well as assessing the lung sounds. LVN B said when changing resident trach tie, only remove one tie at a time to prevent the trach from coming out. LVN B said if the resident's trach came out, she would try and insert the trach immediately or get a smaller size if could not reinsert the original size trach. LVN B said she would continue to assess the resident and if the resident was unstable, she would call 911 right away, notify the doctor, continue to observe the resident and administer further care, one being oxygen, if needed. Observation on 02/19/2024 at 9:56AM revealed tracheostomy care on Resident #81 (who was resting in bed with head of bed elevated receiving continuous gastrostomy feedings) by LVN J. LVN J washed his hands, disinfected his workspace/bedside table, and placed the trach supplies (normal saline, suction kit with sterile gloves) on his workspace/bedside table. LVN J paused the resident's continuous gastrostomy feedings, washed his hands again, listened to the resident's lung sounds and checked the resident's oxygen saturation which was 98% and left the pulse oximetry on the resident's finger. LVN J then put on a pair of clean gloves after sanitizing his hands and began to open the suction kit and normal saline container without contaminating his sterile field. LVN J placed on his sterile gloves confirming that his right hand would be his dominant hand and suctioned the resident intermittently pulling the suction catheter out of the trach with no concerns identified. Resident #81 tolerated the procedure with minimum reaction or distress noted. Interview on 02/19/2024 at 10:15AM LVN J said he had been in-serviced that when he provide trach suctioning, or changing out the inner cannula the procedure was invasive, and therefore was a sterile procedure to prevent infections. LVN J said he was also in-serviced that if the trach came out, he was to get a new trach the same size and put it back in. LVN J said if he was unable to get the same size trach back in, he would get the next size down to insert. LVN J said he was in-serviced to the keep trach supplies at the bedside including a smaller trach size for emergency purposes. LVN J said if he had to change the trach ties, he was in-serviced to change one tie at time to keep the trach from coming out. On 2/19/2024 at 10:55AM the Administrator was informed the IJ was removed, however, the facility remained out of compliance at a scope of isolation and severity of harm that is not an immediate jeopardy the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for 1of 5 residents (CR#1) reviewed for physician notification. The facility failed to notify the physician of Resident #1's continued change in condition, including low blood pressure and high pulse rate, for approximately 12 hours. After approximately 12 hours Resident #1 was sent to the hospital via emergency transport and was admitted with Pneumonia, Acute Kidney Failure, and Septic Shock and was placed on life-support. An IJ was identified on 11/6/2023. The IJ template was provided to the facility on [DATE] at 4:13pm. While the IJ was removed on 11/8/2023, the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. This failure could affect residents by placing them at risk of delayed treatment that has the propensity to lead to death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year-old female admitted to the NF on 10/26/2023. CR#1 diagnoses included the following: chronic respiratory failure with hypercapnia (occurs when the respiratory system cannot adequately remove carbon dioxide), candida esophagitis (weakened immune system), sickle-cell trait (inherited blood disorder), demyelinating disease of central nervous system (central nervous system disorder), chronic inflammatory demyelinating polyneuritis (Progressive weakness and reduced senses in the arms and legs), Congestive heart failure (A chronic condition that prevent the heart from pumping blood as well as it should). Record review of CR#1's MDS dated [DATE] did not reveal a BIMS score. Record review of CR#1's baseline care plan dated 10/26/23 and revised on 10/30/23 revealed allowing residents to make decision regarding treatment, care and provide opportunities for resident to make choices. Record review of CR#1's Physician Orders revealed the following orders: - Start Date-10/26/23 2200-D/C Date 11/2/23 1639 HydrAlazine HCI Oral Tablet 50 MG (Hydralazine)-Give 1 tablet by mouth every 8 hours for High blood Pressure Hold for BP<110/60 or HR <60 - Start Date-11/01/2023 1400-D/C Date-11/01/2023 1907 revealed an order for NS via IV Perlpheral (3L) at 75cc r/t dehydration every shift for fluids - Start Date-11/01/23 2200-D/C Date 11/02/2023 1639-NS via Clysis (introducing large amount of fluids into the body) (3L) at 75cc r/t dehydration every shifter for fluids - Start Date-11/01/2023 2200 - D/C Date-11/02/2023-Sodium Chloride Intravenous 0.9% (Sodium Chloride)- Use 75 ml/hr ml/hr Intravenously every shift for dehydration until 11/3/23 23:59 3L via Clysis Record Review of CR#1's Progress Notes revealed the following: Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:34am - blood pressure 90/68 Pulse 74 Record review of vitals revealed blood pressure completed on 11/1/2023 at 1:54pm- blood pressure 86/56 Pulse 65 Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:28pm -blood pressure 75/55 Pulse 120 Record review of vitals revealed blood pressure completed on 11/2/2023 at 5:20am - blood pressure 102/57 Pulse 130 Record review of vitals revealed blood pressure completed on 11/2/2023 at 7:00am - blood pressure 63/48 Pulse 136 Record review of the SBAR summary Late Entry, created by LVN A on 11/2/23 at 10:23pm effective 11/1/23 at 7:20pm on 11/1/2023 at 12:02 revealed a change in condition: Temp: T 97.9 - 11/1/2023 3:54 Route: Forehead (non-contact) Weight: W 176.8 lb - 11/2/2023 10:52 Scale: Mechanical Lift Pulse Oximetry: O2 92.0% - 11/1/2023 13:54 Method: Room Air Blood Glucose: BS 113.0 - 11/1/2023 11:23 In an interview with FM A on 11/2/2023 at 12:25pm revealed a concern with CR#1 vitals since the early morning of 11/1/2023. The concerns were based on her level of care and her current health condition. FM A stated CR#1 had not eaten or had any fluids by mouth in 4 days and was severely dehydrated. There was a concern by the RP that nursing personnel showed no urgency in attending to CR#1's medical needs. FM A was informed on 11/1/2023 at or close to 10:00am, by the SW, that the nursing staff had ordered a doppler from the pharmacy due to nursing staff having a difficult time locating a vein. It would take at least 4 hours for the doppler to arrive to the facility. After 8 hours without follow up from the social worker or nursing staff, RP A asked RN A what was the status of the doppler. RN A informed RP A that they were changing directions because the doppler had not arrived. Interview with LVN A on 11/2/23 at 1:55pm revealed received information from LVN B about 6:30am on 11/2/23. was that CR# 1 was trending low blood pressure. LVN A was given an order to do a straight catheter (tube inserted through a narrow opening into a body cavity)and start resident on 3 liters saline 75cc hourly until her scheduled transportation arrived between 7:00 AM and 9:00 AM this morning. However, CNA A checked CR#1's vitals on her initial rounds and immediately reported blood pressure 55 / 44 and pulse was high as it was between 136 and 140. LVN A confirmed what she was told by CNA A by taking CR#1's vitals again. This time the resident bp was 63/48 and showed signs of Tachycardia (elevated heart rate). The DON contacted and permission given to send CR#1 out 911. Interview on 11/2/23 at 3:54pm with CNA A revealed she took CR#1 vitals at the beginning of her shift 6a-2p). She stated she took CR#1 blood pressure, and it was low, but her pulse was high and breathing through her mouth appearing to need oxygen, which none was in the vicinity. She stated she immediately reported this to LVN A. CNA A was informed, by LVN A to get CR#1 ready because she (CR#1) was going out 911. Telephone interview with LVN B on 11/2/23 at 4:14pm revealed on 11/1/23 at approximately 10:00pm they met with RN A for shift change briefing. LVN B was informed by RN A that there was a lot going on with CR#1and FM. FM's has requested a pain pump and RN A informed FM that is not a procedure they did at the facility. LVN B informed him the family wanted CR#1 transferred to a pnotes/dx?referred hospital for a G-Tube (tube placed in stomach). LVN B stated there was no clear instructions and was unsure what was really going on. LVN B was getting ready to administer CR#1's blood pressure medication. The blood pressure as 88/61 blood pressure, which was too low. No medication was given based on the orders to hold if bp was less than 110/60. Instead, he propped her legs up because she had an IV running sodium chloride at about 0.9% running at 75 milliliters' an hour. LVN B stated RN A directed him to follow-up with transportation that was reserved for CR#1 to be picked-up between 7am-9am and taken to the hospital of choice for the FM. LVN B spoke with FM around 11:00pm on 11/1/2023 with the confirmation. Also, LNV B stated he took CR#1's vitals around 5:00am on 11/2/2023. Prior to administering CR#1's blood pressure medication, the blood pressure read 106/54 and heart rate was around 120. Because the blood pressure was out of parameters of the doctors' orders, he did not administer. LVN B also stated CR#1 responded to him calling her name. Observation of CR#1 on 11/3/23 at 9:00am at hospital revealedCR#1 was highly sedated; eyes closed no distress noted and non-interviewable. Her RP was at her bedside. RP stated she was waiting on her siblings to get to the hospital as the doctor(s) wanted to have a consultation with all of the family members. Interview with ER physician on 11/3/2023 at 9:30am revealed CR#1 arrived yesterday (11/2/2023), via, ambulance and had to be placed immediately on ventilator (Breathing machine). He stated, CR#1 is in critical condition and is not going to make it. In fact, is dying. Further stated, CR#1's current diagnosis is Pneumonia, Acute Kidney Failure and Septic Shock. In a telephone interview with Facility Physician on 11/3/23 at 1:29pm- He stated he completed his rounds on 11/1/23 at 5:00am. During his assessment of CR#1 the blood pressure was 90/68 and pulse 74. An IV for fluids was ordered at that time. Later in the afternoon toward evening hours, Physician A received a telephone call and was informed that CR#1 was dehydrated, and access needed changing (change the entrance of fluid in the body). An order was completed to change access and start clysis to LLA, d/t DVT in bilateral upper extremities. NS %0.9 running at 75 cc/hr via gravity. Further interview with the Facility Physician stated neither he or his NP were ever notified of the changes in CR#1's vitals. Also Stated, based on CR#1's medical history when admitted into the facility, if he had known of the low blood pressure, he would have ordered CR#1 transferred to the hospital via EMS 911. In a telephone interview with the NP on 11/3/23 at 2:04pm. it was revealed she was notified by RN A on 11/1/23 at 9:39pm that CR#1's condition had changed, and the FM had requested CR#1 be transferred, via, transportation back to the hospital. The NP stated if the FM wanted CR#1 to go to hospital then send her out. On 11/2/23 NP received a text message from LVN A that CR#1 went to the hospital, via, 911 ambulance. NP stated at no time was she informed by the nursing staff of the decrease in vitals or the increase in pulse rate. During a telephone interview with RN A on 11/3/23 at 2:39PM- revealed CR#1 was a little responsive with yes or no questions asked throughout the evening of 11/1/2023. When touched or moved CR#1 would groan as if she was in a lot of pain. During this time, RN A stated she did not call the doctor to tell of the declining blood pressure because she felt the doctor already had been notified of the low blood pressure and she was waiting for IV rehydration that was ordered from the pharmacy. RN A stated she took CR#1's blood pressure earlier in the afternoon, stated it was low, but did not notate it nor can she remember what it was. RN A took the blood pressure again and it was 75/55 and pulse 120. CR#1 was not responding verbally at this time. When asked, why she didn't call the doctor when the vitals were 75/55 and pulse 120, RN A stated she is not sure what she was wondering at the time. RN A stated the doctor should have been called. An interview with the DON on 11/3/23 at 3:37pm - revealed he was notified on 11/2/2023 by LVN A of CR#1's declining vitals and S-Bar and that they RP wanted to wait for transportation to a hospital of choice. The DON informed LVN A to use her nursing skills and if the CR#1 needed to go 911 then call 911. The DON was not notified that CR#1's vitals were declining; but notified the resident was having a change in condition on 11/1/23 at 1:00pm. Based on the CR#1 blood pressure going from 102/57 (130) to 63/48 (136) the call to 911 should have been made. During a telephone interview with the pharmacist on 11/7/2023 at 11:16am it was revealed a verbal order for CR#1 and was called in on 11/1/23 at or around 6:22pm. The prescription was filled and went out during the 8:00pm delivery. There were no other orders. Received an email from the pharmacist on 11/7/2023 at 11:45am - that revealed an email of the fax that was sent to the pharmacy for an order of Sodium Chloride Hydration (3bags). The order was called in on 11/1/23 at 1816 (6:16pm) by RN A. A Policy Review of the Significant Change in Condition revised February 2021, The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. The following Plan of Removal submitted by the facility was accepted on 11/7/2023 at 9:31am., after multiple revisions. FACILITY'S PLAN OF REMOVAL DATED 11/06/23. Immediate action: CR # 1 was sent to the emergency room on [DATE] via 911 services. On 11/6/2023 an ADHOC QAPI meeting was held with the Director of Nursing, Executive Director, Medical Director and Co-Medical Director. Reviewed: IJ Template, CR #1's chart, and Plan of Removal. Director of Nursing initiated in-service on 11/6/2023 with all nursing staff changes of condition. Topics included: assessing resident blood pressure, respirations, and pulse, reporting abnormal vital signs to the physician upon identification of the abnormality, reporting abnormal vital sign trends to the Physician upon identification of the abnormality, notify the Physician of delays in care to include: unable to obtain iv access and delays in pharmacy delivery, and ensuring residents are sent to the emergency room for emergent conditions (such as severe hypotension) upon identification of the emergent condition. All nursing staff will be trained before working their next shift. New hires (licensed nurses) will receive education in orientation. Licensed Nurses will not be able to work until training is completed. Training will be completed by 11/7/2023. The Director of Nursing initiated in-service with CNAs on 11/6/23 regarding vital signs. Topics included assessing the resident's blood pressure and reporting abnormal vital signs to the charge nurse immediately. All CNAs will be trained before working their next shift. New hires (CNAs) will receive education in orientation. CNAs will not be able to work until training is completed. Training will be completed by 11/7/2023. On 11/6/23 the Director of Nursing completed a 100% audit of residents' vital signs and physician orders from 11/1/23 to present. The audit included reviewing residents' vital signs for abnormalities or abnormal trends and ensuring these were communicated with the physician timely. The audit also included reviewing new physician orders from 11/1/23 to current to ensure implementation and no delays of care. No adverse findings were noted. The DON/Designee will review Point Click Care vitals report daily to audit abnormalities in residents' vitals to include blood pressure, pulse and respirations to ensure that at the sign of abnormalities physician is promptly notified. Monitoring Review of the Plan of Removal revealed each medical staff member (RN's, LVN's and CNA's) were in-serviced, between 11/6/2023 and 11/8/2023 on Urgency in the notifications when resident vitals are abnormal, any changes in resident conditions, if blood pressure and heart rate are out of the normal parameters an immediate notification to nursing and physician is required and documentation of date, time of the occurrence. Monitoring interviews on 11/7/2023 through 11/8/2023 with 39 staff across three shifts to include 6AM-2PM, 2PM-10PM & 10PM-6AM (RN's, LVN's, CNA's) indicated they had been in-serviced on Urgency, Changes in Conditions, assessing blood pressure parameters and how to identify and who to immediately report changes to and the importance of documentation in the system immediately. During the interviews each staff member were asked to provide an example of what they felt was urgency and what they would do. All CNA's interviewed indicated they would immediately contact the RN or LVN if the vitals are too low, or the resident has a change in condition. They also indicated if necessary and they are unable to contact the RN/LVN/DON or anyone else and the need occurs they would call 911 then complete the appropriate documentation afterwards. The RN and LVN indicated the same. They also indicated that it was imperative for them not to wait to document, but to document all occurrences. The DON will closely monitor changes in conditions with patients by completing an audit daily and reviewing all new physician orders from 11/1/23 to present and foregoing. He stated prior to the IJ he was auditing bi-weekly; however, feels it is more important to complete the audits daily. The Executive Director was notified the IJ lowered on 11/8/2023 at 11:05am and the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 5 residents (CR# 1) reviewed for quality of care. The facility failed to ensure that CR #1 received treatment and care in accordance with professional standards of practice. The facility failed to call 911 services to transport CR#1 to a higher level of care, instead, attempted to use their non-emergency transportation to send resident to the hospital when CR #1 ' s blood pressure was extremely low and pulse extremely high. The facility failed to transfer CR #1 to the hospital in a timely manner when resident ' s vitals began to decline. The facility initially became aware of CR#1 ' s declining vitals 11/1/23 at 5:34am and 911 was called 11/2/23 at 7:00am, 24 hours after the facility was made aware of CR#1 ' s condition. An IJ was identified on 11/6/2023. The IJ template was provided to the facility on [DATE] at 4:13pm. While the IJ was removed on 11/8/2023, the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. This failure could affect residents by placing them at risk of delayed treatment that has the propensity to lead to death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year-old female admitted to the NF on 10/26/2023. CR#1 diagnoses included the following: chronic respiratory failure with hypercapnia (occurs when the respiratory system cannot adequately remove carbon dioxide), candida esophagitis (weakened immune system), sickle-cell trait (inherited blood disorder), demyelinating disease of central nervous system (central nervous system disorder), chronic inflammatory demyelinating polyneuritis (Progressive weakness and reduced senses in the arms and legs), Congestive heart failure (A chronic condition that prevent the heart from pumping blood as well as it should). Record review of CR#1's MDS dated [DATE] did not reveal a BIMS score. Record review of CR#1's baseline care plan dated 10/26/23 and revised on 10/30/23 revealed allowing residents to make decision regarding treatment, care and provide opportunities for resident to make choices. Record review of CR#1's Physician Orders revealed the following orders: - Start Date-10/26/23 2200-D/C Date 11/2/23 1639 HydrAlazine HCI Oral Tablet 50 MG (Hydralazine)-Give 1 tablet by mouth every 8 hours for High blood Pressure Hold for BP<110/60 or HR <60 - Start Date-11/01/2023 1400-D/C Date-11/01/2023 1907 revealed an order for NS via IV Perlpheral (3L) at 75cc r/t dehydration every shift for fluids - Start Date-11/01/23 2200-D/C Date 11/02/2023 1639-NS via Clysis (introducing large amount of fluids into the body) (3L) at 75cc r/t dehydration every shifter for fluids - Start Date-11/01/2023 2200 - D/C Date-11/02/2023-Sodium Chloride Intravenous 0.9% (Sodium Chloride)- Use 75 ml/hr ml/hr Intravenously every shift for dehydration until 11/3/23 23:59 3L via Clysis Record Review of CR#1's Progress Notes revealed the following: Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:34am - blood pressure 90/68 Pulse 74 Record review of vitals revealed blood pressure completed on 11/1/2023 at 1:54pm- blood pressure 86/56 Pulse 65 Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:28pm -blood pressure 75/55 Pulse 120 Record review of vitals revealed blood pressure completed on 11/2/2023 at 5:20am - blood pressure 102/57 Pulse 130 Record review of vitals revealed blood pressure completed on 11/2/2023 at 7:00am - blood pressure 63/48 Pulse 136 Record review of the SBAR summary Late Entry, created by LVN A on 11/2/23 at 10:23pm effective 11/1/23 at 7:20pm on 11/1/2023 at 12:02 revealed a change in condition: Temp: T 97.9 - 11/1/2023 3:54 Route: Forehead (non-contact) Weight: W 176.8 lb - 11/2/2023 10:52 Scale: Mechanical Lift Pulse Oximetry: O2 92.0% - 11/1/2023 13:54 Method: Room Air Blood Glucose: BS 113.0 - 11/1/2023 11:23 In an interview with FM A on 11/2/2023 at 12:25pm revealed a concern with CR#1 vitals since the early morning of 11/1/2023. The concerns were based on her level of care and her current health condition. FM A stated CR#1 had not eaten or had any fluids by mouth in 4 days and was severely dehydrated. There was a concern by the RP that nursing personnel showed no urgency in attending to CR#1's medical needs. FM A was informed on 11/1/2023 at or close to 10:00am, by the SW, that the nursing staff had ordered a doppler from the pharmacy due to nursing staff having a difficult time locating a vein. It would take at least 4 hours for the doppler to arrive to the facility. After 8 hours without follow up from the social worker or nursing staff, RP A asked RN A what was the status of the doppler. RN A informed RP A that they were changing directions because the doppler had not arrived. Interview with LVN A on 11/2/23 at 1:55pm revealed received information from LVN B about 6:30am on 11/2/23. was that CR# 1 was trending low blood pressure. LVN A was given an order to do a straight catheter (tube inserted through a narrow opening into a body cavity)and start resident on 3 liters saline 75cc hourly until her scheduled transportation arrived between 7:00 AM and 9:00 AM this morning. However, CNA A checked CR#1's vitals on her initial rounds and immediately reported blood pressure 55 / 44 and pulse was high as it was between 136 and 140. LVN A confirmed what she was told by CNA A by taking CR#1's vitals again. This time the resident bp was 63/48 and showed signs of Tachycardia (elevated heart rate). The DON contacted and permission given to send CR#1 out 911. Interview on 11/2/23 at 3:54pm with CNA A revealed she took CR#1 vitals at the beginning of her shift 6a-2p). She stated she took CR#1 blood pressure, and it was low, but her pulse was high and breathing through her mouth appearing to need oxygen, which none was in the vicinity. She stated she immediately reported this to LVN A. CNA A was informed, by LVN A to get CR#1 ready because she (CR#1) was going out 911. Telephone interview with LVN B on 11/2/23 at 4:14pm revealed on 11/1/23 at approximately 10:00pm they met with RN A for shift change briefing. LVN B was informed by RN A that there was a lot going on with CR#1and FM. FM's has requested a pain pump and RN A informed FM that is not a procedure they did at the facility. LVN B informed him the family wanted CR#1 transferred to a pnotes/dx?referred hospital for a G-Tube (tube placed in stomach). LVN B stated there was no clear instructions and was unsure what was really going on. LVN B was getting ready to administer CR#1's blood pressure medication. The blood pressure as 88/61 blood pressure, which was too low. No medication was given based on the orders to hold if bp was less than 110/60. Instead, he propped her legs up because she had an IV running sodium chloride at about 0.9% running at 75 milliliters' an hour. LVN B stated RN A directed him to follow-up with transportation that was reserved for CR#1 to be picked-up between 7am-9am and taken to the hospital of choice for the FM. LVN B spoke with FM around 11:00pm on 11/1/2023 with the confirmation. Also, LNV B stated he took CR#1's vitals around 5:00am on 11/2/2023. Prior to administering CR#1's blood pressure medication, the blood pressure read 106/54 and heart rate was around 120. Because the blood pressure was out of parameters of the doctors' orders, he did not administer. LVN B also stated CR#1 responded to him calling her name. Observation of CR#1 on 11/3/23 at 9:00am at hospital revealedCR#1 was highly sedated; eyes closed no distress noted and non-interviewable. Her RP was at her bedside. RP stated she was waiting on her siblings to get to the hospital as the doctor(s) wanted to have a consultation with all of the family members. Interview with ER physician on 11/3/2023 at 9:30am revealed CR#1 arrived yesterday (11/2/2023), via, ambulance and had to be placed immediately on ventilator (Breathing machine). He stated, CR#1 is in critical condition and is not going to make it. In fact, is dying. Further stated, CR#1's current diagnosis is Pneumonia, Acute Kidney Failure and Septic Shock. In a telephone interview with Facility Physician on 11/3/23 at 1:29pm- He stated he completed his rounds on 11/1/23 at 5:00am. During his assessment of CR#1 the blood pressure was 90/68 and pulse 74. An IV for fluids was ordered at that time. Later in the afternoon toward evening hours, Physician A received a telephone call and was informed that CR#1 was dehydrated, and access needed changing (change the entrance of fluid in the body). An order was completed to change access and start clysis to LLA, d/t DVT in bilateral upper extremities. NS %0.9 running at 75 cc/hr via gravity. Further interview with the Facility Physician stated neither he or his NP were ever notified of the changes in CR#1's vitals. Also Stated, based on CR#1's medical history when admitted into the facility, if he had known of the low blood pressure, he would have ordered CR#1 transferred to the hospital via EMS 911. In a telephone interview with the NP on 11/3/23 at 2:04pm. it was revealed she was notified by RN A on 11/1/23 at 9:39pm that CR#1's condition had changed, and the FM had requested CR#1 be transferred, via, transportation back to the hospital. The NP stated if the FM wanted CR#1 to go to hospital then send her out. On 11/2/23 NP received a text message from LVN A that CR#1 went to the hospital, via, 911 ambulance. NP stated at no time was she informed by the nursing staff of the decrease in vitals or the increase in pulse rate. During a telephone interview with RN A on 11/3/23 at 2:39PM- revealed CR#1 was a little responsive with yes or no questions asked throughout the evening of 11/1/2023. When touched or moved CR#1 would groan as if she was in a lot of pain. During this time, RN A stated she did not call the doctor to tell of the declining blood pressure because she felt the doctor already had been notified of the low blood pressure and she was waiting for IV rehydration that was ordered from the pharmacy. RN A stated she took CR#1's blood pressure earlier in the afternoon, stated it was low, but did not notate it nor can she remember what it was. RN A took the blood pressure again and it was 75/55 and pulse 120. CR#1 was not responding verbally at this time. When asked, why she didn't call the doctor when the vitals were 75/55 and pulse 120, RN A stated she is not sure what she was wondering at the time. RN A stated the doctor should have been called. An interview with the DON on 11/3/23 at 3:37pm - revealed he was notified on 11/2/2023 by LVN A of CR#1's declining vitals and S-Bar and that they RP wanted to wait for transportation to a hospital of choice. The DON informed LVN A to use her nursing skills and if the CR#1 needed to go 911 then call 911. The DON was not notified that CR#1's vitals were declining; but notified the resident was having a change in condition on 11/1/23 at 1:00pm. Based on the CR#1 blood pressure going from 102/57 (130) to 63/48 (136) the call to 911 should have been made. During a telephone interview with the pharmacist on 11/7/2023 at 11:16am it was revealed a verbal order for CR#1 and was called in on 11/1/23 at or around 6:22pm. The prescription was filled and went out during the 8:00pm delivery. There were no other orders. Received an email from the pharmacist on 11/7/2023 at 11:45am - that revealed an email of the fax that was sent to the pharmacy for an order of Sodium Chloride Hydration (3bags). The order was called in on 11/1/23 at 1816 (6:16pm) by RN A. A Policy Review of the Significant Change in Condition revised February 2021, The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. The following Plan of Removal submitted by the facility was accepted on 11/7/2023 at 9:31am., after multiple revisions. FACILITY'S PLAN OF REMOVAL DATED 11/06/23. Immediate action: CR # 1 was sent to the emergency room on [DATE] via 911 services. On 11/6/2023 an ADHOC QAPI meeting was held with the Director of Nursing, Executive Director, Medical Director and Co-Medical Director. Reviewed: IJ Template, CR #1's chart, and Plan of Removal. Director of Nursing initiated in-service on 11/6/2023 with all nursing staff changes of condition. Topics included: assessing resident blood pressure, respirations, and pulse, reporting abnormal vital signs to the physician upon identification of the abnormality, reporting abnormal vital sign trends to the Physician upon identification of the abnormality, notify the Physician of delays in care to include: unable to obtain iv access and delays in pharmacy delivery, and ensuring residents are sent to the emergency room for emergent conditions (such as severe hypotension) upon identification of the emergent condition. All nursing staff will be trained before working their next shift. New hires (licensed nurses) will receive education in orientation. Licensed Nurses will not be able to work until training is completed. Training will be completed by 11/7/2023. The Director of Nursing initiated in-service with CNAs on 11/6/23 regarding vital signs. Topics included assessing the resident's blood pressure and reporting abnormal vital signs to the charge nurse immediately. All CNAs will be trained before working their next shift. New hires (CNAs) will receive education in orientation. CNAs will not be able to work until training is completed. Training will be completed by 11/7/2023. On 11/6/23 the Director of Nursing completed a 100% audit of residents' vital signs and physician orders from 11/1/23 to present. The audit included reviewing residents' vital signs for abnormalities or abnormal trends and ensuring these were communicated with the physician timely. The audit also included reviewing new physician orders from 11/1/23 to current to ensure implementation and no delays of care. No adverse findings were noted. The DON/Designee will review Point Click Care vitals report daily to audit abnormalities in residents' vitals to include blood pressure, pulse and respirations to ensure that at the sign of abnormalities physician is promptly notified. Monitoring Review of the Plan of Removal revealed each medical staff member (RN's, LVN's and CNA's) were in-serviced, between 11/6/2023 and 11/8/2023 on Urgency in the notifications when resident vitals are abnormal, any changes in resident conditions, if blood pressure and heart rate are out of the normal parameters an immediate notification to nursing and physician is required and documentation of date, time of the occurrence. Monitoring interviews on 11/7/2023 through 11/8/2023 with 39 staff across three shifts to include 6AM-2PM, 2PM-10PM & 10PM-6AM (RN's, LVN's, CNA's) indicated they had been in-serviced on Urgency, Changes in Conditions, assessing blood pressure parameters and how to identify and who to immediately report changes to and the importance of documentation in the system immediately. During the interviews each staff member were asked to provide an example of what they felt was urgency and what they would do. All CNA's interviewed indicated they would immediately contact the RN or LVN if the vitals are too low, or the resident has a change in condition. They also indicated if necessary and they are unable to contact the RN/LVN/DON or anyone else and the need occurs they would call 911 then complete the appropriate documentation afterwards. The RN and LVN indicated the same. They also indicated that it was imperative for them not to wait to document, but to document all occurrences. The DON will closely monitor changes in conditions with patients by completing an audit daily and reviewing all new physician orders from 11/1/23 to present and foregoing. He stated prior to the IJ he was auditing bi-weekly; however, feels it is more important to complete the audits daily. The Executive Director was notified the IJ lowered on 11/8/2023 at 11:05am and the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan.