On 9/22/13, a resident who suffered from chronic respiratory failure died after pulling out his tracheostomy tube (a tube inserted into his windpipe to enable breathing). Twice in the days before his death, the resident pulled out the tracheostomy tube on 9/17/13 and on 9/18/13. The tube was reinserted each time but the interdisciplinary team did not update the resident's care plan to include interventions, such as properly tying or anchoring the tube, to assure the resident would not be able to remove it. The Respiratory Therapy Director and Director of Nursing stated one-to-one monitoring should have been assigned to the resident after the first incident. The facility was cited because it failed to provide continuous monitoring, to secure the resident's tracheostomy tube and to update his care plan to include necessary interventions. As a result, the resident pulled out the tube three times; the third event resulted in respiratory distress that led to cardiopulmonary arrest and death.