Deficiencies in Respiratory Care Administration and Documentation
Summary
Surveyors identified multiple deficiencies in the provision and documentation of respiratory care, including oxygen therapy, nebulizer treatments, and BIPAP equipment maintenance for several residents. In several cases, oxygen was not administered according to physician orders, and there was a lack of documentation regarding the administration and reasons for PRN oxygen use. For example, one resident received continuous oxygen therapy at varying rates without documentation of the reason for administration or the specific amount delivered, despite having a physician order specifying PRN use and titration parameters. Another resident received oxygen at a rate exceeding both the physician's order and the facility's policy for nasal cannula use, with no attempt to titrate the oxygen to the lowest effective rate as required. Additional deficiencies were observed in the handling and maintenance of respiratory equipment. One resident's oxygen tubing was found touching the floor, and another's oxygen tubing was not labeled or dated as required by facility policy. A resident's nebulizer machine, mask, and tubing remained at the bedside undated and not stored in a clear plastic bag after the physician's order for nebulizer treatments had been discontinued. For a resident using a BIPAP device, there was no documentation that the tubing assembly, water tub, and mask were regularly cleaned as recommended by the manufacturer's user guide and facility policy, and the available logs did not specify when cleaning occurred. Surveyors also found that physician orders for oxygen therapy were not consistently followed. In one case, a resident was observed receiving oxygen at a higher rate than ordered, and in another, a resident had an active order for oxygen therapy that was not being implemented or discontinued in a timely manner. Interviews with nursing and respiratory staff confirmed the lack of adherence to orders and documentation requirements, and facility leadership acknowledged these findings during the survey.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 36, 54, 69, 80, 86, 89, 104, 122 were affected by this deficient practice. Immediately, Licensed nurse updated the plan of care for residents 36, 86, 89, 104, 122. Licensed nurse immediately replaced oxygen tubing that was touching the floor for resident 69 and replaced tubing of 80 with no label. On 7/18/2025, Respiratory Therapist supervisor reviewed the BIPAP user guide manual and provided 1:1 education to RT 1 about BIPAP cleaning guidelines and documentation. On 7/16/2025, DON provided 1:1 education to LVN 2 and 12 regarding oxygen administration and making sure to document when providing PRN order. On 8/5/2025-8/8/2025, DON in-serviced all Licensed Nurses about facility policy and procedure of developing a comprehensive care plan for each resident, in particular the care plan for oxygen administration. DON in-serviced also about policy and procedure for assessing residents' medical needs to make sure the plan of care was updated and documenting when providing oxygen as needed. DON also in-serviced about oxygen setting monitoring and following physician orders. On 8/5/2025-8/8/2025, RT supervisor in-serviced all Licensed Nurses about facility policy and procedure for managing and maintaining BIPAP machine which included cleaning schedule and making sure it was documented when cleaning and replacing parts of the BIPAP, such as tubings and mask. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents receiving oxygen could potentially be affected by this deficient practice. DON and Unit managers audited all residents' care plans who were receiving oxygen and found no other issues. DON will provide ongoing education and training to Licensed nurses about developing comprehensive care plans for individual residents. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. DON or designee will review all new admissions and re-admissions for oxygen orders and will make sure comprehensive care plans are developed to include oxygen parameters, especially for residents receiving oxygen. Any findings will be reviewed and reported during clinical meetings. Department Heads and designee will do daily room rounds to ensure all oxygen tubings are labeled and not touching the floor. Any issues will be addressed immediately and reported to the morning meeting for three months. Medical record audits will be conducted to ensure oxygen orders reflect residents' oxygen administration parameters every three months, with reports to the DON for any non-compliance. The Respiratory Therapist will review BIPAP cleaning and maintenance logs monthly to ensure RTs are following the user guide manual for cleaning and maintenance of BIPAP. Any non-compliance will be reported to the DON for three months. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON and Administrator will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented at the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- F0698 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 9 was affected by this deficient practice. Immediately on 7/23/2025, RN Supervisor assessed Resident 9's dialysis access site and found it to be in working order with no issues noted—bruit and thrill were present on assessment. Resident 9's plan of care was updated by RN supervisor to ensure dialysis access site was being assessed every shift. On 7/23/2025, DON provided 1:1 education to LVN 8 about facility policy and procedure for assessing dialysis access site and to ensure it was being documented in the resident's medical record. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All dialysis residents were potentially affected by this deficient practice. RN supervisor and Unit managers reviewed all dialysis residents and found no other issues. From 8/5/2025-8/8/2025, DON in-serviced all Licensed nurses about facility policy and procedure for assessing dialysis access sites, ensuring they are assessed every shift and as needed for functionality, and reporting any issues to the primary physician. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. RN supervisor or designee will review all new dialysis residents to ensure dialysis access sites are assessed every shift. The IDT team will review during clinical meetings to ensure the plan of care is being followed. Medical record audits will be conducted to review care plans and MAR for assessing dialysis access sites, with any non-compliance reported to the DON for three months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
A resident with COPD and dementia, receiving scheduled nebulizer treatments, was found on multiple occasions to have a nebulizer mask stored on top of the machine rather than in a sanitary manner. A CNA and a nurse aide in training confirmed the mask’s placement, and an LPN reported that masks were routinely cleaned, dried, and then stored on top of the machine. The DON later acknowledged that masks should be washed, dried, and placed on a clean surface, and facility policy required oxygen and respiratory supplies to be stored in a plastic bag when not in use.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Improper Storage of Nebulizer Mask and Respiratory Supplies
Penalty
Summary
Surveyors identified a deficiency in the sanitary storage of respiratory equipment for one resident receiving respiratory care. The resident was admitted with COPD and unspecified dementia and had care plan focuses for terminal prognosis due to COPD and shortness of breath, with interventions including administration of inhalers and nebulized medications as ordered. Physician orders included scheduled ipratropium-albuterol nebulizer treatments twice daily for COPD. During multiple observations in the resident’s shared room, the nebulizer mask was seen lying on top of the nebulizer machine rather than being stored in a sanitary manner. Staff interviews confirmed the observed storage practice. A CNA and a nurse aide in training each verified that the nebulizer mask was lying on top of the machine at the times of observation. An LPN stated that masks were cleaned after use, dried, and then stored on top of the machine, and acknowledged this could be an infection control issue. During a later observation, the LPN again confirmed the mask was on top of the machine. In an interview, the DON, with the Administrator present, stated the mask should be washed, dried, and placed on a clean surface and acknowledged it could be an infection control issue, and the facility’s written policy specified that oxygen and respiratory supplies were to be stored in a plastic bag when not in use.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
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