**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and family interviews, review of audio and video recordings, and review of the facility policy titled Abuse Prohibition, the facility failed to ensure one resident (R) (R#1) was protected from neglect from licensed nursing staff, by failing to promptly assess a decline in respiratory status. Specifically, R#1 exhibited symptoms of respiratory distress, became hypoxic and unresponsive, and required emergency intubation by the Emergency Medical Services (EMS) prior to transport to the hospital. R#1 required a tracheostomy for breathing and insertion of a gastrostomy tube for nutrition. On 4/4/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility Administrator, Director of Nursing (DON), and the Regional Nurse Consultant were informed of Immediate Jeopardy on 4/4/2023, at 10:07 a.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 1/15/2023. At the time of exit on 4/6/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings include: Review of the policy titled Abuse Prohibition reviewed 12/30/2022 revealed the intent is to preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of property. Neglect is defined as the absence or omission of services to the degree that it harms or threatens with harm the physical or emotional health of a disabled adult or elder person. The center will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of patient property is more likely to occur. This will include an analysis of the deployment of staff on each shift in sufficient numbers to meet the needs of the patients, and assure the staff assigned has knowledge of individual patient's needs. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of left femur, pneumonitis, chronic diastolic (congestive) heart failure, hypertensive chronic kidney disease, encephalopathy, dysphagia, diabetes, atrial fibrillation, and epilepsy. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment. Section G revealed resident required extensive assistance with all activities of daily living. Section O revealed resident received Respiratory Therapy (RT) for five days during the seven day look back period. Review of the care plan dated 1/4/2023 revealed there is no evidence that a care area or problem addressing residents' respiratory status was developed. The resident was admitted with a diagnosis of pneumonitis and congestive heart failure. Further review revealed resident was a Full Code. Review of December Physician Orders (PO) dated 12/28/2022, revealed an admitting diagnosis of aspiration pneumonia, with a custom order for swallowing precaution-high risk for aspirations. Review of Nurses Note dated 1/15/2023 at 2:27 p.m. written by the DON revealed assessment noted fluid filled lungs with cough that he was unable to produce and spit out. Eyes were closed and he was unresponsive to verbal stimuli. The DON notified Nurse Practitioner (NP) WW and ordered to send R#1 to the ER for evaluation. Review of Nurses Note dated 1/15/2023 at 2:52 p.m. written by the DON revealed report called to Registered Nurse at {hospital} emergency room (ER) and arranged transportation via {provider} Ambulance Service. Review of Nurses Notes dated 1/15/2023 at 5:22 p.m. written by Licensed Practical Nurse (LPN) CC revealed resident had a sudden decline since the beginning of her shift. Resident was unresponsive to verbal stimuli and several attempts to arouse with sternal rub, were unsuccessful. The Director of Nursing (DON) was called to the residents' room to further assess his decline. Addendum was added at 5:27 p.m. for vital signs were blood pressure 142/72, pulse 79, temperature 97.0 degrees Fahrenheit (F), respirations 20, oxygen saturation (O2 Sat) 94% on room air. Review of Nurses Note dated 1/15/2023 at 5:25 p.m. written by LPN CC revealed resident sent to {hospital} per wife's request. He remains unresponsive to verbal stimuli. Further review of the note revealed the family had removed his belongings earlier in the shift and was overheard stating he won't be back. Review of Resident/Patient Transfer Form dated 1/15/2023 revealed reason for transfer documented shortness of breath/respiratory changes and altered mental status/change in cognitive status. Vital signs included a B/P of 142/72, pulse 79, temperature 97.0 degrees F, respirations 20, and an O2 Sat 94% on room air. Review of video recording provided by family member of R#1 revealed the video shows family member sitting outside of his room. The family member asked an unidentified staff member why the DON had not come back to check on him. The unidentified staff member stated the DON was notified and will be in to see him when she is finished with wound care on another resident. The family member indicated she had asked for oxygen to be placed on him because his oxygen level is low. The family member used her personal pulse oximeter to check his oxygen level. At 1.32 seconds into the video, LPN CC was seen slowly bringing in an oxygen concentrator and supplies into the room. R#1 was visible on the video and was noted to be in respiratory distress, with an audible wet cough with grunting sounds. LPN CC removed the plastic bag from the oxygen concentrator and was heard telling receptionist MM to bring her another concentrator, due to the knob coming off. She proceeded to open the oxygen supplies, without noted urgency. There was no evidence on the video that LPN CC assessed the resident nor obtained vital signs or oxygen saturation level. During further review of the video at 4.20 seconds, the DON arrived outside of the residents' room and began to argue back and forth with the family member of R#1. The DON indicated she was going to call the police and asked the family member to leave. Continued review of the video does not show the DON enter the room to assess the resident or speak to LPN CC about her concerns. At 10.9 seconds into the video, First Responders arrived at the facility. The video ended at 10 minutes and 37 seconds. During the 10 minute 37 second length of the video, there was no evidence that R#1 was assessed by the DON, or the LPN and no evidence oxygen was administered. The video is not time stamped. Review of a second video recording provided by family member of R#1 revealed family member sitting outside of R#1's room. Resident could be heard on the video making grunting sounds and when family member entered room and asked him what was wrong, the resident did not respond. The length of the video was one minute 4 seconds. The video is not time stamped. Review of a picture provided by family member of R#1 time stamped 1/15/2023 at 3:47 p.m. revealed a pulse oximeter (device used to measure the proportion of oxygenated hemoglobin in the blood) attached to the finger indicated a pulse of 97 and oxygen saturation of 67 percent (%). Review of the Fire Department's Prehospital Care Report dated 1/15/2023 revealed at 3: 41 p.m. 911 dispatch was notified of male in respiratory distress/altered mental status. The Fire Unit/First Responders were dispatched to the facility at 3:47 p.m. and enroute at 3:49 p.m. At 3:56 p.m., Fire Unit/First Responders arrived on scene and to resident at 4:04 p.m. The First Responder Narrative Summary revealed upon arrival at the scene, family and facility staff were having a dispute. Upon arrival to resident in room [ROOM NUMBER], the resident was laying in the bed unresponsive with a non-rebreather mask on. The non-rebreather bag was not inflated and not being used at the appropriate liter per minute (LPM) flow rate and the resident's oxygen saturation was at 79%. First Responders personnel changed the resident to portable oxygen cylinder at 15 LPM and resident's oxygen saturation slowly increased. Further review of the report revealed blood pressure was 90/60, pulse was 91 and respiration was 20. Glasgow Coma Scale (GCS) was three with no eye movement, no motor movement, and no verbal response. The resident's wife indicated he has been unresponsive and not at his baseline for two days. Attempt was made to decrease oxygen from 15 LPM to 10 LPM, but saturation slowly decreased, and oxygen was reset to 15 LPM. First Responders personnel monitored the resident until emergency medical services (EMS) arrived. Review of the Call for Service Detail Report created 1/15/2023 at 3:41 p.m. revealed nature of the call was male patient with trouble breathing. At 3:47 p.m. unit recommended Police and Fire/First Responders. Fire/First Responders were en route at 3:49 p.m. Fire/First Responders arrived on scene at 3:56 p.m. Additional request for estimated time of arrival (ETA) for EMS was made at 3:59 p.m. EMS arrived on scene at 4:27 p.m. Review of the ER report dated 1/15/2023 revealed resident arrived at the ER via ambulance at 4:59 p.m. He was unresponsive and hypotensive. He was intubated in the field. His oxygen saturation rate was at 100% and his blood pressure was 85/61 and was febrile. He had a GCS of three. Chest x-ray indicated a right lower lobe infiltrate. Labs were consistent with severe dehydration. Other concerns included acute and chronic renal failure, septic shock, and dehydration. He remained intubated, and a central line was inserted in the ER. He was admitted to the hospital intensive care unit (ICU). Review of the hospital Discharge Summary dated 2/3/2023 revealed discharge diagnoses include septic shock due to klebsiella pneumonia, respiratory failure, and metabolic encephalopathy. Patient presented to the ER brought in by EMS unresponsive and hypoxic. He was intubated in the field. Chest x-ray showed a right lower lobe infiltrate. Labs were consistent with dehydration. COVID-19 test was positive but not likely shedding virus. admission condition was critical. He was unable to be extubated and received a tracheostomy on 2/1/2023 and had a feeding tube placed on 2/2/2023. His hospital course was complicated by persistent encephalopathy and sepsis. His discharge condition was serious and was discharged to a Long-Term Acute Care Center (LTAC) on 2/3/2023 for further management and his anticipated prolonged ventilator requirements. Review of a Facility Reported Incident (FRI) dated 1/17/2023 revealed the facility received a complaint through the facility Compliance Line related to concerns with care for R#1. The facility initiated an investigation related to alleged patient care concerns. Steps taken by the facility to prevent further occurrences included education with staff related to alleged concerns. Review of a statement written by the DON dated 1/15/2023 revealed she was asked at 1:30 p.m. to assess R#1 due to being unresponsive and unable to accept medications. His family was at bedside. She reviewed the vital signs documented in the electronic medical record. The statement did not indicate she took his vital signs or O2 saturation herself. She assessed his lung sounds and heard crackles and indicated his lungs were fluid filled. The DON indicated she called the NP at 2:13 p.m. and received an order to send him to the ER for evaluation. The DON returned to his room and informed the family at 2:27 p.m. of order to send him to the hospital. The DON left the room to get his paperwork ready. According to the statement, the DON called the ambulance service between 2:30 p.m. and 2:45 p.m. to arrange transport for resident and called report to the hospital. Further review of the statement indicated she was downstairs doing wound care when she received three back-to-back calls from LPN CC at 3:40 p.m., 3:41 p.m. and 3:45 pm. She did not indicate she responded to any of the calls. The DON revealed she received a text message from receptionist MM at 3:52 p.m. indicating R#1's family member was recording LPN CC. The text did not indicate R#1 was in distress. The DON finished wound care and went upstairs to R#1's room. According to the DON statement she arrived at R#1's room and was confronted by the family member. An argument ensued, and the DON left to call the police. She did not indicate she went in to assess the resident or have a conversation with LPN CC about the resident's condition. Review of a statement dated 1/15/2023 and written by LPN CC, revealed she entered R#1's room at 11:40 a.m. and noted he was lethargic, and his wife was trying to feed him. LPN CC attempted to arouse him by rubbing on his sternum and was unsuccessful. The nurse held his medications and removed the food tray from the room. She informed his wife she was going to notify the DON of a change in his condition, since this morning. The statement indicated she notified the DON at 1:25 p.m. (one hour and 45 minutes later) and the DON came to residents' room and performed her assessment and found his lungs were full of fluid. LPN CC indicated she then proceeded to finish her medication administration to other residents, as the DON prepared the paperwork for resident to be sent to the hospital. The statement indicated the DON went back downstairs to continue doing wound treatments, after she had called to make transportation arrangements and called report to the hospital ER nurse. The statement does not indicate a time that the transportation arrangements were made, or the report called to the hospital. LPN CC indicated at 3:35 p.m. she was sitting at the nurse's desk when family member of R#1 ran to the nurse's station and yelled you need to get down here and put some oxygen on my daddy. LPN CC indicated she told the family member resident did not have an order for oxygen. Continued review of the statement revealed LPN CC called the DON three times and all three calls were unanswered. She then texted the DON to come upstairs as soon as possible. She indicated the family member was on the phone with receptionist MM stating that her daddy was in respiratory distress and the nurse was saying she needed to get an order for oxygen. The statement revealed the family member never indicated the resident was in distress. LPN CC obtained a pulse oximeter from the medication cart to check his O2 saturation level, which indicated was 94%. LPN CC indicated resident had the family members personal pulse oximeter on his finger and reading was 75%. She left the room and obtained an oxygen concentrator and supplies. When she removed the plastic covering off the oxygen concentrator the knob came off and she asked another staff member to get her another one. At 3:54 p.m., she indicated the DON replied to her earlier text with I'm on my way, I was finishing up wound care. The statement continued by describing an argument between the DON and the family member of R#1. The statement did not indicate he was assessed by the DON or if he received supplemental oxygen. Interview on 3/14/2023 at 11:45 a.m., DON revealed she called for transport for R#1, after Nurse Practitioner (NP) WW ordered for him to be sent to hospital. She indicated the family called 911 too, as he had not been picked up yet. She indicated after the family called 911, the Fire Department and First Responders arrived. During further interview she confirmed R#1 was not placed on oxygen because he was not in respiratory distress and his O2 saturation level was 94%. She indicated oxygen tanks and concentrators are available for use on each floor. Phone interview on 3/20/2023 at 11:00 a.m. R#1's daughter revealed she called her mother who was visiting resident at the facility. Her mother indicated the resident had a decline in his condition since the early morning and was being sent to the hospital. She stated they have been waiting to be picked up by the ambulance. She indicated she tried to talk to her father on the phone but all he did was moan and would not speak. She decided to come to the facility to check on him. She stated when she arrived, she said her father was exhibiting symptoms of respiratory distress and checked his oxygen saturation level with her personal pulse oximeter, and indicated it was low, in the 60's. She stated that the staff did not act like her father was in respiratory distress, so she called 911 and told them to call the Fire Department/First Responders because the facility was trying to kill her father. She confirmed she yelled for the nurse to bring her daddy some oxygen. She stated the nurse was in no hurry to go to his room, to check on her father. She indicated the nurse got an oxygen concentrator and when she was turning it on the knob fell off and she had to get another one. She revealed the DON came to check on her father after finishing wound care. On 3/28/2023 at 1:44 p.m., an attempt to call the Emergency Medical Technician for interview was unsuccessful. A voicemail message was left to return the call. No return call was received. On 4/5/2023 at 3:10 p.m. a second attempt was made to contact the EMS personnel who responded to the call on 1/15/2023 regarding R#1. A message was left to return the surveyor's call. No return call was received. On 4/6/23 at 10:49 a.m. an attempt was made to contact the Fire Department/First Responders and a message was left to return the call to surveyor. No return call was received. Phone interview on 3/28/2023 at 3:23 p.m. R#1's wife revealed she felt like something was wrong with her husband, because he would not eat, drink, or wake up. She stated LPN CC called the DON to come check on him. She stated the DON listened to his lungs but did not check his vital signs or check his oxygen level. The DON told her his lungs sounded wet and stated he needed to go to the hospital. The DON told her she would get the paperwork ready and call the ambulance to take him to the hospital and she never saw the DON again after that. During further interview, she stated LPN CC tried to give R#1 his medications but he could not swallow. She revealed LPN CC did not take his vital signs. During further interview, she indicated her daughter called her after that she told the daughter he was still the same and no one has come to pick him up or come back to check on him. Interview on 3/29/2023 at 8:00 a.m., DON revealed she reviewed the nurse's notes relating to R#1 and realized the times documented were not correct. She stated all notes are time stamped at the time they are entered, and that's why the nurse's should be adding late entry to the notes. She indicated the nurses should be charting in real time and need to add to the note if entered later, the exact date and time incidents happen and notate as late entry. Interview on 3/29/2023 at 12:02 p.m., Certified Nursing Assistant (CNA) BB revealed she was assigned to care for R#1 on 1/15/2023 during the 7:00 a.m. - 3:00 p.m. shift. She stated he did not want to get out of bed, go to the shower, sit in a chair, or want to turn. She indicated he was fine that morning, maybe less alert but he was talking and refusing everything like normal. She stated she did not know about his decline until he was sent out to the hospital. Interview on 3/29/2023 at 12:30 p.m., LPN CC revealed the morning of 1/15/2023, the resident was at his normal baseline. At lunchtime, she attempted to give him his medications. She stated the wife was trying to feed the resident, but he was not swallowing. She held his medications and called the DON who was in the facility, to come assess the resident. She stated she went to get the equipment and pulse oximeter and took his vital signs. The DON assessed the resident and spoke with the wife about sending him to the hospital. She indicated the resident was not in respiratory distress at that time. She stated the DON then left to call the NP about resident needing to go to hospital. During further interview, she revealed the wife called her daughter and the daughter showed up shortly after that and came out of the room yelling to put oxygen on R#1. The daughter did not say or indicate he was in any type of distress. The nurse went to the residents' room and placed a pulse oximeter on his finger to check his oxygen level, and it read 94%. She stated the daughter had put her personal pulse oximeter on his other hand and it was reading in the 60's. She stated she left the room to get an oxygen concentrator and called the DON to come back to the floor. She revealed when she removed the bag covering the concentrator, the knob came off and she told receptionist MM to bring her another one, from the closet downstairs. When the DON arrived on the floor, the daughter began to yell at her. She revealed after Receptionist MM arrived with another concentrator, about five minutes later, she hooked him up to the concentrator using a non-rebreather mask and turned the O2 as high as it would go. She stated shortly after that the First Responders came in and took over. She stated again that the daughter never indicated R#1 was in distress when she came out of the room yelling at her to put oxygen on him. She stated R#1's wife was visiting him and never came out and told her he started to have problems breathing. LPN CC indicated she was checking on him frequently and never saw the resident having signs or symptoms of respiratory distress. Interview on 3/30/2023 at 10:45 a.m. with the Medical Director (MD) revealed he saw the R#1 on 1/13/2023 and had a discussion with his wife regarding a swallow study, but she refused. He indicated he informed residents' wife that he was not going to improve and would eventually need comfort care/hospice. During further interview with the MD about the incident on 1/15/2023 with R#1 experiencing respiratory distress and the facility's delay in assessing and providing emergency care, the MD never responded with an answer. He responded that he had talked with his wife and offered comfort care and stated there was nothing else that could have been done for him. He stated the facility did not notify him of the residents' condition, but the NP notified him. Interview on 4/4/2023 at 11:02 a.m., LPN LL revealed each floor has a storage room where oxygen concentrators, oxygen tanks, and the crash cart are stored. Confirmation of the first floor storage room with LPN LL verified availability of oxygen concentraors and oxygen tanks. Interview on 4/4/2023 at 11:10 a.m., LPN CC revealed there is a crash cart and oxygen storage available on the second floor. Review of the crash cart and oxygen storage closet were confirmed. She confirmed she did not get the crash when R#1 went into distress, but she got an oxygen concentrator from the closet on the same floor. She indicated the knob came off the unit when she was getting it ready, and she sent a staff member to get another one from the closet. Interview 4/5/2023 at 10:00 a.m. the Administrator revealed they have a Regional Certified Respiratory Therapist (CRT) that is available 24 hours a day seven days a week via phone call. She stated the staff have the option to call the CRT if they have questions about respiratory services or equipment issues. Interview on 4/5/2023 at 12:18 p.m. with the CRT OO revealed staff are encouraged to call for residents that are in respiratory distress, or any issues with respiratory equipment, such as BiPap or CPAP machines, or any respiratory questions. She stated she visits the facility monthly for respiratory audits that include infection control, equipment checks, and training if needed. She revealed staff do not have to call the CRT, but confirmed she or another CRT are always available to the facility if needed. She stated that nobody from the facility contacted her regarding R#1 being in respiratory distress. Interview on 4/5/2023 at 1:40 p.m. the DON revealed when a resident has a change in condition she would assess the change, if the change was related to respiratory status, she would reach out to the CRT if needed. She stated the CRT information was not posted prior to today, but revealed it is now located at each nurse's desk, in the med room on each floor, and in the in-service binder located at each nurse's desk. She indicated the CRT comes to the facility quarterly and looks at all the respiratory supplies and looks at all the oxygen tanks and concentrators. The CRT will do in-services with the staff as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of the facility policy titled Patient's Plan of Care, the facility failed to develop a person-centered comprehensive care plan with planned interventions for one resident (R) (R#1) related to respiratory care, who was admitted to the facility with diagnoses of aspiration pneumonia, congestive heart failure (CHF) and Physician's order for inhalers and a high risk for aspiration. The sample size was 12. On 4/4/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility Administrator, Director of Nursing (DON), and the Regional Nurse Consultant were informed of Immediate Jeopardy on 4/4/2023, at 10:07 a.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 1/15/2023. At the time of exit on 4/6/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings include: Review of the policy titled Patient's Plan of Care reviewed 12/30/2022 revealed the guideline is for each patient to have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs. The procedure indicated when developing the comprehensive care plan, facility staff should use the Minimum Data Set (MDS) to assess the patient's clinical condition, cognitive and functional status, and use of service. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of left femur, pneumonitis, chronic diastolic (congestive) heart failure, hypertensive chronic kidney disease, encephalopathy, dysphagia, diabetes, atrial fibrillation, and epilepsy. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment. Section G revealed resident required extensive assistance with bed mobility, eating, and toileting, total dependence with personal hygiene, bathing, and dressing. Section O revealed resident received Respiratory Therapy (RT) for five days during the seven days look back period from 12/28/2022 through 1/3/2023. Review of the care plan dated 1/4/2023 revealed there was no evidence that a care area or problem addressing residents' respiratory status was developed. The resident was admitted with a diagnosis of pneumonitis and congestive heart failure. Further review revealed resident was a Full Code. Review of December 2022 Physician Orders (PO) dated 12/28/2022, revealed an order dated 12/29/2022 for Advair Diskus 250-50 micrograms (mcg) dose powder inhalation, inhale one disk with device two times a day for diagnosis of shortness of breath. Interview on 4/5/2023 at 1:34 p.m., Administrator confirmed the resident did not have a care plan in place that addresses respiratory care. She indicated the MDS coordinator was not available due to scheduled leave time. During further interview, she stated the expectation is that care plans should be person-centered and reflect the resident's current conditions. She stated R#1 should have a care plan in place for the diagnoses of aspiration pneumonia, CHF and Physician's order for inhalers and a high risk for aspiration. Interview on 4/6/2023 at 12:59 p.m. Licensed Practical Nurse (LPN) UU indicated if she has a new resident or a resident she has not cared for before she would review the residents medical record, care plan and get information during report. She confirmed R#1 did not have a care plan addressing his respiratory status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and family interviews, the facility failed to provide respiratory care and services for one resident (R) (R#1) exhibiting signs of respiratory distress. Specifically, R#1 had a rapid decline in respiratory status and staff failed to administer oxygen in an emergent situation, resulting in resident becoming hypoxic and unresponsive. The sample size was 12 residents. On 4/4/2023, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility Administrator, Director of Nursing (DON), and the Regional Nurse Consultant were informed of the Immediate Jeopardy on 4/4/2023, at 10:07 a.m. At the time of exit on 4/6/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings include: Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses including but not limited to pneumonitis due to inhalation of food, dysphagia, altered mental status, and encephalopathy. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status Score of three out of 15, indicating severe cognitive impairment. Section O-Therapies and Special Treatments revealed R#1 received respiratory therapy for five of seven days of the look back period. Review of R#1's medical record revealed on 1/15/2023 at approximately 1:30 p.m. LPN CC assessed R#1 and found there was a sudden decline in condition. R#1 was unresponsive to verbal or physical stimuli (sternal rub). The Director of Nursing (DON) was called to assess resident and found R#1 to have fluid filled lungs with a non-productive cough. Resident remained unresponsive to verbal stimuli. DON notified the Nurse Practitioner of residents decline at approximately 2:13 p.m. and received order to send resident to hospital emergency room (ER) for further evaluation. There is no evidence supplemental oxygen was applied in an emergency situation. Review of video recording provided by family member of R#1 revealed the video shows family member sitting outside of his room. The family member asked an unidentified staff member why the DON had not come back to check on him. The family member indicated she had asked for oxygen to be placed on him because his oxygen level is low. The family member used her personal pulse oximeter to check his oxygen level. At 1.32 seconds into the video, LPN CC was seen leisurely bringing in an oxygen concentrator and supplies into the room. R#1 was visible on the video and was noted to be in respiratory distress, with an audible wet cough with grunting sounds. LPN CC removed the plastic bag from the oxygen concentrator and was heard telling receptionist MM to bring her another concentrator, due to the knob coming off. She proceeded to open the oxygen supplies, without noted urgency. There was no evidence on the video that LPN CC assessed the resident nor obtained vital signs or oxygen saturation level. During the 10 minute 37 second length of the video, there was no evidence that R#1 was assessed by the DON or the LPN and if oxygen was administered. The video is not time stamped. Review of a second video recording provided by family member of R#1 revealed family member sitting outside of R#1's room. Resident could be heard on the video making grunting sounds and when family member entered room and asked him what was wrong, the resident did not respond. The length of the video was one minute 4 seconds. The video is not time stamped. Review of first responders log revealed narrative indicated emergency medical services/first responders responded to a male patient with respiratory distress. Upon arrival at the facility the family was having a dispute with the staff. Upon arrival to R#1's room, vital signs taken by the first responders revealed blood pressure (BP) 90/60, pulse 91 and regular, respirations 20 and an oxygen (O2) saturation of 79%. He was lying in bed unresponsive with a non-rebreather on. The non-rebreather bag was not inflated and not being used at the appropriate liters per minute (LPM) and the patient's oxygen (O2) saturation level was at 79%. He was immediately changed to a portable oxygen cylinder at 15 LPM and after a high concentration of O2, his O2 saturation slowly increased to 96%. First responders continued to monitor resident until an ambulance arrived. Review of the hospital Discharge Summary dated 2/3/2023 revealed R#1 presented to the emergency room (ER) brought in by EMS. Upon EMS arrival he was unresponsive, hypoxic, and hypotensive. He necessitated emergent intubation in the field. Physical exam revealed pupils are pinpoint and eyes are deviated to the right. Glasgow Coma Scale (GSC) of three. Breath sounds with rales and rhonchi present. Chest x-ray showed a right lower lobe infiltrate. Labs were consistent with dehydration. COVID-19 test was positive but not likely shedding virus. admission condition was critical. He was unable to be extubated and received a tracheostomy on 2/1/2023 and had a feeding tube placed on 2/2/2023. His hospital course was complicated by persistent encephalopathy and sepsis. His discharge condition was serious and was discharged to a Long-Term Care Center (LTAC) on 2/3/2023 for further management and his anticipated prolonged ventilator requirements.' Interview on 3/14/2023 at 11:45 a.m. the DON revealed EMS is not fast to respond even if 911 is called. She stated she called 911 for transport, LPN CC called EMS again while the DON was talking to his family. The DON indicated the family called 911 also. She indicated oxygen tanks and concentrators are available for use on each floor. During further interview, she stated R#1 was not placed on oxygen due to resident not being in respiratory distress and his O2 saturation was 94%. Phone interview on 3/20/2023 at 11:00 a.m. with the family of R#1 complainant revealed she called her mother to check on her father due to his decline in condition and to see if he had left the facility to go to the hospital, and her mother indicated he was still there. She stated she decided to go to the facility at that time. When she arrived, she indicated that her father was exhibiting signs of difficulty breathing and she felt like her father was in respiratory distress. She stated she tried to talk to her father and all he did was moan and could not speak. She stated he was gasping for breath. She revealed she went to the door and yelled out for the nurse to come and bring him an oxygen tank. She further stated she had her personal pulse oximeter, and she checked his O2 saturation level and revealed it was low, in the 60's. During further interview, she stated she tried to get the nurses to help her father, but they were just slowly going about caring for him. She indicated the nurse finally went and got an oxygen concentrator and when she was turning it on, the knob fell off and another concentrator had to be retrieved. She stated it seemed like it took forever for another staff member to bring the nurse another concentrator to his room. She further stated she called 911 herself and told them to call the fire department and first responders to come see about her father. She informed the 911 personnel that the facility was trying to kill her father. When asked how long that took she indicated forever. She stated the nurse called the DON to come up and stated she would be there after finishing up her wound care. Phone interview on 3/28/2023 at 3:23 p.m. the spouse of R#1 revealed she felt like her husband wasn't doing well because he would not eat, drink, or wake up the day of incident. She stated the nurse called the DON and she came and listened to his lungs but did not check his vital signs. She stated the DON told her his lungs sounded wet and asked if she wanted him to go to the hospital. She stated she said yes. She revealed the DON told her she would get the paperwork ready for him to go to the hospital and that was the last she saw of her or anyone for a while. During further interview, she stated LPN CC tried to give him medications and realized he could not swallow. She stated LPN CC did not assess his condition or take his vital signs at that time. The wife stated the daughter called her shortly after that and told her he was still the same and no one has come to pick him up or come back to check on him. The wife stated she asked the DON to come back to check on him and was told she was busy doing wound care. The wife stated when the DON finally came up to his room, her daughter had arrived, and the wife indicated the DON wanted to argue with her daughter more than look at her husband. Interview on 3/29/2023 at 12:02 p.m. Certified Medication Aide (CMA) BB revealed she was assigned to the R#1 on 1/15/2023 during the day shift. She stated resident was doing fine that morning, maybe less alert, but he was talking and refusing everything like normal. She stated resident did not eat his lunch. It was after that that he had to go to the hospital. Interview on 3/29/2023 at 12:30 p.m., Licensed Practical Nurse (LPN) CC revealed the resident was at his normal baseline earlier that morning of 1/15/2023. She stated at lunchtime she went to give him some insulin and his medications when she noted the wife force feeding him, and he was not swallowing. She stated she asked residents wife to stop feeding him and removed the tray from the room and called the DON who was in the facility. She stated she went to get the vital sign equipment and pulse oximeter and took his vital signs. She stated the DON came to the room and assessed the resident and spoke with the wife about his condition. She stated the DON left the room to call the Nurse Practitioner (NP). During further interview, she stated the resident did not appear to be in respiratory distress at that time. LPN CC stated the daughter showed up and came out of the room yelling to put oxygen on her daddy. The daughter did not say or indicate the resident was in distress. LPN CC stated she went back to the residents' room and put a pulse oximeter on him, while the daughter was yelling at her. She indicated the pulse oximeter reading was 94%, but she noticed the daughter already had one on his other finger, and that reading was in the 60's. At that point, she stated she went to get an oxygen concentrator and called the DON to come back to the floor. She stated she left the room to get the supplies and another nurse brought her the oxygen concentrator. She stated when she removed the bag that covered the concentrator, the knob came off and she called for another nurse to bring her another concentrator. The DON arrived at residents' room the second time, and the daughter began to yell at her from the doorway of his room, to help her daddy. LPN CC stated another concentrator was brought to R#1's room and she set the O2 setting as high as it would go using a re-breather. LPN CC stated the daughter never said the resident was in respiratory distress when she came out of the room to tell her to put oxygen on him, residents wife was in the room the entire time never came out and told her he started to have problems breathing. During further interview, she stated the First Responders came in and took over. Interview on 3/30/2023 at 10:45 a.m., Medical Director (MD) revealed he saw R#1 on 1/13/2023 and had a discussion with R#1's wife regarding a swallow study, but stated the wife refused the study and refused for resident to get a feeding tube, due to his poor intake. He stated he informed R#1's wife that he was not going to improve and would eventually need comfort care/hospice services. During further interview, the MD indicated he was aware of residents' low hemoglobin (HGB) and indicated resident had a diagnosis of anemia, and replied his levels were low in the hospital. A follow-up interview on 4/4/2023 at 11:10 a.m., LPN CC revealed there is a crash cart and oxygen storage available on each floor. LPN CC confirmed she did not retrieve the crash when R#1 went into respiratory distress. She stated she got an oxygen concentrator from the closet, but the knob came off and she asked someone else to go get another one from the closet. Interview on 4/5/2023 at 10:00 a.m., Administrator stated they have a Regional Certified Respiratory Therapist (RCRT) that is available 24 hours per day and seven days per week via phone call. Interview on 4/5/2023 at 12:18 p.m. Certified Respiratory Therapist (CRT) OO revealed she and one other CRT are always on call. She stated staff are encouraged to call for residents that are in respiratory distress or any respiratory questions related to Bilevel positive airway pressure (BiPap) or Continuous positive airway pressure (C-pap) machines. She stated she visits the facility monthly for respiratory audits that include infection control, equipment checks, and training if needed. She stated the facility does not have any guidance on reaching out to them and stated staff are not required to call them, but they are available by phone if the facility staff need them. Interview on 4/5/2023 at 1:40 p.m., DON revealed when residents have a change in condition, she will assess the resident and if a resident has a change in respiratory condition, she stated she will reach out to the CRT. She indicated the CRT comes in quarterly and looks at all the respiratory supplies and looks at all the oxygen tanks and concentrators. She stated the CRT contact information was not posted prior to today. She indicated it is now located at each nurse's desk, in the med room on each floor and in the education, book located at each nurse's desk. Interview on 4/5/2023 at 2:52 p.m. DON and Central Division Registered Nurse (RN) EE revealed the facility does not have a policy for providing emergent care or standing orders for oxygen use in emergency situations.