The search began at 9:55 a.m. when Assistant Director of Nursing #364 attempted to locate supplies for Resident #52, who had a Shiley 7.5 tracheostomy tube. The supervisor checked the assessment to confirm what supplies were needed, then wandered through the facility looking for them.
At 10:50 a.m., after Central Supply Personnel #367 entered to direct where the supplies would be located, the nursing supervisor finally found the trach supplies. All necessary items were present except trach ties, which weren't available anywhere in the facility.
The supervisor confirmed the amount of time taken to find the supplies "could have been detrimental to the resident if the supplies were needed in an emergency."
But the emergency supply problem was just the beginning. Resident #52 revealed his inner cannula hadn't been changed for weeks, despite requiring daily replacement. He told inspectors he had made the nursing staff aware of this issue.
Licensed Practical Nurse #266 admitted she didn't monitor Resident #52 performing his own trach care. "Resident #52 did all of his own trach care and she did not have to do any of it," the inspection report stated.
Another nurse, LPN #233, revealed her approach was simply asking the resident if he had completed his care, then signing orders confirming the treatment was completed without actually observing the procedure.
The facility's respiratory therapist, who visited twice weekly, explained why supplies weren't kept in Resident #52's room. "Resident #52 did not keep trach supplies in his room because he goes through them and would use them all," she said during a phone interview.
She confirmed that nursing staff should provide supplies when trach care is due, but this wasn't happening consistently. The respiratory therapist usually checked Resident #52's supplies and ordered them during her visits.
According to the facility's Infection Preventionist and Director of Nursing, proper trach care requires supplies to be readily available at the bedside. Trach ties should be changed weekly and when visibly soiled. The inner cannula needs daily cleaning or replacement, and nurses should be performing this care according to physician orders.
The respiratory therapist confirmed these standards, stating trach ties should be changed at least once weekly and as needed, while the disposable inner cannula should be changed daily. Trach care should occur twice daily.
LPN #292 confirmed that Resident #52 kept trach supplies in his room and performed his own care. However, LPN #233 revealed that supplies were actually kept in the treatment or medication cart, contradicting other accounts of where supplies were located.
The confusion over supply locations became apparent during the inspection when the nursing supervisor had to search multiple areas before finding them. A spare tracheostomy tube should have been kept with nursing staff, but the respiratory therapist noted it might not be kept at the bedside if the resident had behavioral issues.
The facility's own tracheostomy care policy required staff to verify physician orders, gather assembled supplies, assess the stoma condition, remove the inner cannula, cleanse around the stoma, place a new inner cannula inside the tracheostomy tube, and replace trach ties if soiled.
None of these steps were being properly followed. Nurses were signing off on completed treatments without performing or observing the care. Critical supplies weren't readily available. The resident's inner cannula went unchanged for weeks.
For someone with a tracheostomy, the inner cannula serves as a crucial barrier against infection and blockage. Daily replacement prevents buildup of secretions that could obstruct breathing. Weekly trach tie changes prevent skin breakdown and ensure the tube remains properly secured.
The violations were investigated under two separate complaint numbers, suggesting multiple concerns had been raised about the facility's tracheostomy care practices.
Resident #52 continued managing his own care while nursing staff signed documents claiming they had provided treatment they never performed or monitored.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wickliffe Country Place from 2025-11-17 including all violations, facility responses, and corrective action plans.