**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure 3 of 3 residents (R) reviewed, (R1, R2, and R3) who required oxygen with ventilator (Vent) and respiratory care were provided such services consistent with professional standards of practice, the resident's comprehensive person-centered care plan, and physician orders on the ventilator unit. R1 is ventilator dependent and requires oxygen continuously via the ventilator to maintain oxygen levels above 90% saturation. On [DATE], when R1 was put to bed, staff did not connect R1 to the stationary liquid oxygen tank, but left R1 connected to a portable oxygen tank that runs out of oxygen within 3-4 hours. Respiratory Therapist (RT) skipped ventilator spot checks for R1 at 2:00 AM on [DATE]. R1 was found at 6:00 AM on [DATE] with low saturations, no pulse, and died. The facility's failure to ensure R1 had oxygen supply during the night of [DATE] and respiratory therapy check at 2:00 AM, created a reasonable likelihood for serious harm and death which created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on [DATE] at 12:10 PM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as evidenced by the following examples. R2 and R3 are ventilator dependent with oxygen. RT spot checks were not documented as completed on several dates. Findings include: Facility policy titled, Oxygen Administration, dated reviewed on [DATE] states in part: .Procedure: 7. Residents receiving oxygen will be hooked up to the stationary liquid oxygen tank when they are in bed. Facility policy titled, Ventilator Checks, dated reviewed on 06/2024 states in part: .Procedure: 7. Verify the vent is connected to an appropriate source of power. 9. Document the ventilator settings. 10. Document the residents measured parameters. 11. Document the residents pulse oximeter reading. 12. Document the residents heart rate. 13. If applicable, verify the amount of oxygen in the oxygen tank and switch over to a new source if necessary. 14. If resident is receiving oxygen verify the following: a. The oxygen tank is set to the appropriate setting and chart the LPM. 19. Document the number of minutes spent with resident . R1 was admitted on [DATE] with chronic respiratory failure with hypoxia, cardiac arrest due to other underlying condition, respiratory arrest, ventilator associated pneumonia, spontaneous pneumothorax, anoxic brain damage, dependence on respirator (ventilator) status, anxiety disorder, chronic obstructive pulmonary disease, paranoid schizophrenia, and tracheostomy. R1's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 00 which indicated facility could not determine BIMS for R1 due to R1 was rarely/never understood. MDS indicated that R1 is totally dependent on staff for all cares. R1's care plan, dated [DATE], indicates: -Dependent on others for all cares. Needs assistance of 2 staff members to reposition every 2 hours and as needed. Assist 2 with Hoyer lift for transfers. -Trach in place and dependent on vent. Order to titrate oxygen as needed to keep my O2 greater than 89%. Surveyor reviewed R1's physician orders: -[DATE]-Respiratory Therapy standing orders have been approved for use. -[DATE]: *Initiate O2 to maintain SpO2>90%. *Refill portable unit every 4 hours when in use 9:30 am, 1:30 pm, and 5:30 pm. Progress notes: On [DATE], notes in part, .-11:26 am-Spot checks: 95% O2 on 4L, Resps-18 -1:49 pm-Lungs auscultated anterior bilaterally clear. -4:53 pm- 92% O2 on 4L . No further documentation in nurse notes. On [DATE]: Documentation indicates at: .-3:42 am-Length of tube 4 -6:02 am-Heels intact and elevated . Treatment Administration Record (TAR) indicated: -On [DATE], portable O2 tank refilled at 9:30 AM and 1:30 PM. Surveyor did not locate documentation for portable oxygen tank refilled at 5:30 PM on [DATE], as ordered. Respiratory spot checks indicated: On [DATE] at 11:26 am: 95 % on 4L, HR-85, Resp-18. On [DATE] at 3:56 PM, no spot check documentation. Oxygen checks indicated: On [DATE] in AM- 92%, PM- 92%, NOC-92%. Progress notes continued, [DATE] -11:06 AM - late entry - On [DATE], Writer RN was summoned to resident's room at approximately 6:08 am by RT. When writer entered resident's room two RT's were bagging resident due to low oxygen saturations. Resident had two pulse oximeters on right and left hand and they both indicated no pulse or O2 saturation present. Resident was unresponsive at this time and writer performed sternal rub and verbal command with no response from resident. RTs continued to bag resident while writer confirmed code status. Writer code status was confirmed DNR [do not resuscitate]. At approximately 6:12 am writer then felt popliteal, femoral, radial, and carotid pulse and no pulses were palpable. Writer then auscultated for heart sounds and agreed with writer's assessment. Bagging was stopped at 6:14 am. MD updated on resident's overall condition and no signs of life. See MD update note. -Call placed to DON at 6:20 am and updated. Writer called provider approximately 6:30 am to update of resident's condition change and not having a pulse or oxygen saturations. NP answered and suggested to call medical director. DON called Medical Director and orders given at 6:35 am, provider gave orders for time for time of death, release body to funeral home and to remove the ventilator . Interviews On [DATE] at 1:26 PM, Surveyor interviewed Medication Aide (MA) E. MA E indicated MA E worked on [DATE] from 6-10 PM on another hall but then started cares for R1 at 10 PM to 6 AM. MA E indicated that MA E saw the other two CNAs that were on night shift walk into R1's room to lay her down around 7:30 PM on [DATE]. MA E indicated that MA E observed R1's big liquid oxygen tank outside of R1's room and not in room where it should be. MA E indicated that MA E liked that it wasn't in the room because resident's room is always so cluttered and crowded. MA E indicated that through the night resident was fine and had checked and changed her at 11:30 PM, 1:30 AM, and 3:45 AM. MA E noted that the small portable tank was hanging on resident's ventilator. Surveyor asked MA E how long small portable tank lasts. MA E indicated it depends on how high the flow in liters is for oxygen, but resident should have been connected to the big liquid oxygen tank. Surveyor asked MA E if she was present for the events that happened at 6:00 AM. MA E indicated that MA E was clocking out and looked over and saw RT bagging resident. On [DATE] at 1:36 PM, Surveyor interviewed Certified Nursing Assistant (CNA) F who put R1 to bed on [DATE]. CNA F indicated that CNA F gathered all of R1's equipment in the common area such as continued tube feeding pump and vent and took R1 into room to lay down to bed. Surveyor asked if CNA F had brought the big liquid oxygen tank in resident's room and hooked R1 to it. CNA F indicated that CNA F did not hook big liquid oxygen tank up and left it outside the door. CNA F indicated that R1 had a small portable oxygen tank hanging on vent, so CNA F thought it was fine. Surveyor asked CNA F if CNA F checked the small portable oxygen tank to see how much oxygen was left in the tank. CNA F indicated that CNA F did not check the small portable oxygen tank. Surveyor asked whose job is it to check the small portable oxygen tanks. CNA F indicated it is everyone's job to check the portable tanks. Surveyor asked CNA F why the big liquid oxygen tank was in the hallway in the common area and not in R1's room. CNA F indicated that sometimes R1 will sit in common area to socialize and so the facility brings the big liquid oxygen tank outside the room to connect to R1 if resident is going to be a while in the common area. Surveyor asked CNA F if it is the process to bring the big liquid oxygen tank back in the room once resident is laid down for the night. CNA F indicated that is required. We bring big liquid oxygen tank back into room and connect resident once lying in bed. CNA F indicated that she did not do this. Surveyor asked CNA F if facility debriefed or educated CNA F on proper oxygen use after R1 passed away. CNA F indicated CNA F did not receive any training on the matter. On [DATE] at 9:25 AM, Surveyor interviewed CNA D, who was on the [DATE] day shift and found R1 in an unconscious state. Surveyor asked CNA D to walk Surveyor through the events on [DATE]. CNA D indicated that CNA D came on shift and entered R1's room. CNA D observed that the big liquid oxygen tank was outside R1's room. CNA D could see R1 was not herself, just lying there. CNA D quickly ran to RT G who was clocking out for the day, and RT G quickly ran to R1's room and started bagging R1. Surveyor observed CNA D crying, and CNA D indicated the big liquid oxygen tank should have been attached to R1 while resident was in bed. On [DATE] at 1:50 PM, Surveyor interviewed RT G who was on night shift on [DATE]. RT G indicated that RT G saw aides going in resident's room on [DATE] around 7:00 PM and laying resident down for the night. RT G noticed the big liquid oxygen tank outside resident's room and didn't think anything of it. RT G indicated that RT G heard R1's vent alarm going off around 10 PM. RT G went into R1's room and found the vent was unplugged from the wall. RT G connected vent back into the wall and walked out of R1's room. Of note, the vent does operate on battery for a period of time and was functioning properly on battery. Surveyor asked RT G why RT G did not hook resident up to big liquid oxygen tank. RT G indicated that RT G did not think anything of it at the time. RT G indicated that RT G did not see R1 for the rest of the night. RT G indicated that it was unusual that R1's vent did not alarm at all for rest of night. RT G indicated that R1 always has alarms going off every night, and RT G is usually in there periodically. Surveyor asked if RT G completed 2:00 AM spot checks. RT G indicated that RT G did not go back into R1's room and skipped 2:00 AM spot checks. Surveyor asked RT G what the correct process is for spot checks. RT G indicated that RT G completes spot checks at least every night at 2:00 AM but really RTs are supposed to be in rooms every 4 hours to complete spot checks for the ventilator. Surveyor asked RT G to explain what spot checks consist of. RT G indicated that spot checks are assessing heart rate (HR), O2 saturation, how many liters of oxygen resident is on, and checking ventilator settings. This is documented every time spot checks are completed. RT G indicated that RT G went to clock out at 6:04 AM when an aide stopped RT G and asked RT G to come to R1's room as something was wrong and R1 was not connected to big liquid oxygen tank. RT G entered R1's room and could see something was wrong. RT G grabbed big liquid oxygen tank and began bagging R1 and placed R1 on 10 liters of oxygen. RT G instructed CNA D to go get help from other RT on duty. RT G indicated that R1 had no pulse and found out resident was a DNR, so RT G stopped bagging R1. After nurse assessed for pulse and found no pulse, R1 was pronounced dead. Surveyor asked RT G if RT G was debriefed on the situation that occurred, trained or educated on the events and if administration concluded an investigation into the matter. RT G indicated that nothing was ever completed. RT G did not get debriefed on anything in particular. On [DATE] at 2:04 PM, Surveyor interviewed RT I, who was on day shift of [DATE]. RT I indicated that around 6:00 AM, CNA D came and grabbed RT I frantically to come assist in R1's room. RT I indicated that day shift CNA D had found R1 on small portable oxygen tank and immediately knew something was wrong. RT I indicated that RT I saw RT G bagging R1. RT I performed a sternum rub, and R1 did not respond. RT I checked pulses and no pulse was found. At that point RT I instructed CNA D to go get AED and code status. RT I indicated that shortly after RN C came back in and stated code status was DNR and bagging was stopped. Surveyor asked RT I what the process is for spot checks for residents on ventilators. RT I indicated that RT I can't speak for night shift but day shift RTs are supposed to do spot checks every 4 hours and spot checks consist of HR, resp rate, O2 flow, and ventilator settings. RT I indicated this is documented in the resident's chart right away and for each time performed. On [DATE] at 2:00 PM, Surveyor interviewed Registered Nurse (RN) C, who came on day shift on [DATE] at 6:00 AM. RN C indicated that RN C came in around 5:53AM. RN C indicated this was her first day on the floor by herself, and RN C noticed a big liquid oxygen tank outside R1's room and thought that was odd. RN C indicated that shortly after the start of her shift, RN C observed RT G in R1's room and CNA D run out of resident's room yelling for help. RN C ran into R1's room and observed both RTs bagging R1. RN C immediately observed a small portable oxygen tank hanging from the vent. RN C checked it to see how much oxygen was in the small tank, and RN C indicated it was empty. RN C observed RTs instruct to grab AED and find out R1's code status immediately. RTs were still bagging when RN C exited resident's room. RN C found that R1 was a DNR and immediately told RTs. RN C checked popliteal, femoral, radial, and carotid pulse and no pulses were palpable. RN C assessed no saturations for oxygen. RN C indicated RTs stopped bagging and started making phone calls to appropriate people such as DON B and provider. RN C indicated that DON B told RN C to leave everything as is until DON B arrived at facility. Surveyor asked RN C if RN C was educated or debriefed about the death of R1. RN C indicated that RN C was not educated or debriefed, and this has impacted RN C tremendously. Surveyor observed RN C crying, and RN C stated, I feel so bad for her. The facility failed her in more ways than one, and the facility has done nothing to fix the issue or investigate it. On [DATE] at 2:27 PM, Surveyor interviewed NHA A and Director of Nursing (DON) B and asked about the event with R1 on [DATE] into [DATE]. NHA A indicated that two CNAs put R1 down to bed around 7:30 PM and R1 was fine. Then on [DATE] the next morning, R1 passed away around 6:30 AM. and DON B was notified. DON B then notified NHA A. DON B arrived onsite around 7:15 AM and began creating timeline and gathering statements. NHA A indicated that CNA D on day shift observed something wrong with R1. RT G responded but R1 was still alive at that point and heart rate was in the 40s, which is low. NHA A indicated that RT then pulled big liquid concentrator into room and began bagging and had oxygen at 10 liters flow as per policy. R1 then had no pulse and was a DNR status. R1 passed away and appropriate calls were made. Surveyor asked NHA A and DON B if they completed a thorough investigation of the incident and what led to the events proceeding R1's death on [DATE]. NHA A indicated that facility did investigate and NHA A will gather the report to give to Surveyor. NHA A indicated that education and training was completed by the RT Director for RTs. NHA A admitted there has been lack of documentation that spot checks have been being completed as they should be, and they are aware of this issue. Surveyor asked NHA A and DON B what the facility process is for spot checks performed by RTs. NHA A indicated that spot checks should be completed regularly and would have to look at facility policy on spot checks. NHA A indicated that NHA A understands there was a system failure, and everyone has been educated on importance of spot checks. NHA A also indicated that NHA A and DON B educated aides and nurses about the correct use of the smaller portable oxygen tanks and the big liquid oxygen tanks. NHA A indicated that through their investigation of R1's death, the facility did not find that the RT not completing the spot check or the aides not connecting the big liquid oxygen tank was the cause of R1's death. NHA A indicated that NHA A and DON B have talked with Medical Director (MD) H and R1 most likely had a cardiac arrest event and died from that. Surveyor asked NHA A how NHA A can determine that was the cause of death. NHA A indicated that R1 was fine all night long and then suddenly wasn't fine with pulse down in the 40s. NHA A indicated that R1 has a history of cardiac arrest where R1 desats and that's how R1 had an anoxic brain injury months ago when she ended up here at the facility on ventilator and trach. Surveyor asked NHA A and DON B where the documentation was in the electronic health record (EHR) for R1's condition documenting a heart rate was present and in the 40s, when CNA D found the resident. NHA A and DON B indicated there is not much documentation in the EHR. NHA A indicated there is work to be done with educating staff on documenting more. On [DATE] at 8:43 AM, Surveyor interviewed MD H and asked MD H to recap the events that led to R1's death on [DATE]. MD H indicated that the facility called MD H that morning after R1 had passed. Facility completed an evaluation and investigation of the matter and then updated MD H that following Wednesday during rounds. MD H indicated that the facility made MD H aware that staff did not connect R1 to the stand-alone liquid oxygen tank when R1 was put to bed as per facility protocol and staff had kept R1 on small portable tank which only lasts roughly 4 hours depending on flow of oxygen. MD H indicated this resulted in R1 dying the morning of [DATE]. MD H indicated that since the death of R1, the facility has educated and trained staff on facility policy. On [DATE] at 8:57 AM, Surveyor interviewed NHA A and DON B and asked about the lack of signatures on the education that was given to Surveyor yesterday on [DATE]. NHA A and DON B indicated they had verbally educated staff back in February right after R1's death, but no one signed. NHA A indicated that NHA A and DON B stayed late last night to obtain employee signatures for the education on oxygen use. Surveyor asked for all signatures and education. NHA A indicated that NHA A is still trying to complete all education at this time. On [DATE] at 9:12 AM, Surveyor interviewed RN C and asked to clarify that education was not given to RN C as RN C stated yesterday on [DATE]. RN C indicated that staff were not educated, and administration pumped out education and signs to be placed throughout as reminders to connect big liquid oxygen tank yesterday during day when Surveyor was present and this morning as well. Surveyor reviewed the facility's investigation file. Surveyor could not confirm the accuracy of the statements due to lack of documentation in the EHR and investigation file. Surveyor did not find signatures from staff that they were educated as NHA A indicated. Surveyor did not find any documentation about R1 having a heart rate in the 40s when RT G entered resident's room. The failure to provide needed respiratory services of ongoing oxygen resulted in the reasonable likelihood for serious harm and death for R1 and led to a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it completed the following: RTs educated on expectation of completing oxygen checks and documentation/refusals of the 2am spot checks. CNAs educated on expectation of putting residents on stationary liquid tank when transferring to bed. Clinical staff educated on ensuring proper oxygen source prior to start of their next shift. Clinical staff educated on facility policy on oxygen administration prior to start of their next shift. Clinical staff educated on facility procedure for oxygen source switching prior to start of their next shift. Clinical staff educated on completing oxygen checks and completion of documentation/refusals as designated in the TAR. Clinical staff educated on oxygen safety check signs placed in resident rooms prior to start of next shift. On [DATE], facility reviewed policy and procedure of oxygen administration and updated to include the use of stationary liquid tanks when oxygen dependent residents are in bed. On [DATE], facility created a procedure for Oxygen Source Switching. On [DATE], facility updated Liquid Oxygen Portable Fill policy to reference source switching procedure. Clinical Managers will conduct audits on oxygen checks daily x 4 weeks, weekly x 4 weeks, bimonthly x 2 months Clinical Managers will conduct audits on appropriate oxygen source connection Monday-Friday x 4 weeks, weekly x 4 weeks, and bimonthly x2 months Results of the audits will be reviewed at QAPI meetings for further recommendations. The deficient practice continues at a scope/severity of D (potential for harm/isolated) as evidencd by: Example 2 On [DATE], Surveyor reviewed R2's medical record. R2 was admitted on [DATE] with diastolic heart failure with atrial fibrillation, chronic respiratory failure with vent status, tracheostomy, anxiety disorder, and major depressive disorder. Surveyor reviewed R2's respiratory spot checks that indicated: On [DATE]-[DATE]: No spot checks were documented for 2:00 AM. On [DATE]-[DATE]: No spot checks were documented for 2:00 AM. On [DATE]-[DATE]: No spot checks were documented for 2:00 AM. Example 3 On [DATE], Surveyor reviewed R3's medical record. R3 was admitted on [DATE] with chronic respiratory failure with vent status, anxiety disorder, and tracheostomy. Surveyor reviewed R3's respiratory spot checks that indicated: On [DATE]: No spot checks were documented for 2:00 AM, 11:00 AM, and 3:00 PM. On [DATE]: No spot checks were documented for 2:00 AM and 3:00 PM. On [DATE]-[DATE]: No spot checks were documented for 2:00 AM. On 02/25-[DATE]: No spot checks were documented for 2:00 AM. On [DATE] at 2:27 PM, Surveyor interviewed NHA A and NHA A admitted there has been lack of documentation that spot checks have been being completed by RTs as they should be, and they are aware of this issue. NHA A indicated that spot checks should be completed regularly as per facility policy. NHA A indicated that NHA A understands there was a system failure, and everyone has been educated on importance of spot checks.