Health inspection·February 4, 2026

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide an inner canula to the tracheostomy for one resident (R6) during tracheostomy care. This failure affected one (R6) of three residents reviewed for tracheostomy care.Findings include:R6 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to cardiac arrest with anoxic brain injury, chronic respiratory failure with hypoxia, tracheostomy and gastrostomy tube, and heart failure. On the (MDS) Minimal Data Set assessment of section C on 01/18/2026, the BIMS (Brief Interviewed Mental Status) section C1000, Cognitive Skills for Daily Decision Making, shows R6 is severely impaired. MDS section GG of 1/18/2026 GG, R6 is dependent care - Helper does all the effort. Residents do none of the effort to complete the activity. The assistance of 2 or more helpers is required for the residents to complete the activity. R6's physician order dated 1/16/2026 reads in part, change inner cannula twice daily every day and night shift, and Trach: Shiley- Size: 8 FLEXES. On 2/3/2026 at 09:40 AM, the surveyor observed the tracheostomy without the inner canula and requested V7 (Respiratory Therapist) remove the tracheostomy mask and check the tracheostomy. V7 said, I do not see an inner canula inside the tracheostomy and (R6) is supposed to have one. I will call another respiratory therapist to help me. When questioned, V7 said, I rounded on (R6) around 8:00-8:30 AM when I gave her breathing treatment earlier today. V7 could not say why the inner canula was not there. At 10:07 AM V6 (Respiratory Therapist) came into the room to assess the tracheostomy and checked for the inner canula and said, I do not see one and (R6) should have an inner cannula with the trach. I usually assess the resident first thing in the morning by auscultating, checking lung sounds, oxygen saturation, heart rate and swap dressing, ties twice a week or as needed and the inner canula should be changed twice a day. The inner cannula is a safe feature that allows the quick removal of a mucus plug and removes any obstruction. If a mucus plug occurs without an inner cannula, the whole trach needs to be removed and replaced. 2/3/2026 at 12:33 PM, V12 (Respiratory Therapist Director) said, I expect the staff to change the inner cannula during tracheostomy care every shift or as needed. (R6) is expected to have an inner cannula in place, and the respiratory therapist is expected to assess during initial rounds and make sure it is in place. The inner cannula helps to avoid a mucus plug, and when there is one, just pick it up and remove the cannula and remove the plug. We can do lavage if there is a mucus plug, and we use aerosol, which prevents it. On 2/3/2026 at 4:37 PM, V3 (Director of Nursing) provided facility policy Title Tracheostomy Care Policy revised 10/2024. Which reads in part (but not limited to):PURPOSE: To provide guidelines for maintaining an unobstructed airway and preventing infection in residents with a tracheostomy.POLICY: It is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway, that aseptic technique is used during dressing changes until the tracheostomy is healed, and a physician's order is obtained for tracheostomy care.EQUIPMENT: Tracheostomy care kit, Sterile water (if not in kit), Inner cannula if disposable, Suction kit or Residents Affected - Few Page 1 of 2 145650 145650 02/04/2026 Nexus at Palos 10426 South Roberts Palos Hills, IL 60465

F 0695 Level of Harm - Minimal harm or potential for actual harm closed suction catheter, Tracheostomy tube holder.G. With clean hand, remove the inner cannula1. For disposable cannula, insert new inner cannula and lock it into place; maintain sterility2. For reusable cannula, reapply tracheostomy collar over outer cannula to provide oxygenation during cleaning; cleanse secretions from outside and inside of inner cannula and rinse in sterile saline; gently reinsert cannula and lock into place; maintain sterility (may use solution supplied in the tracheostomy care kit) Residents Affected - Few 145650 Page 2 of 2