Failure to Provide Required Respiratory Care Leads to Resident's Death
Summary
The facility failed to provide appropriate respiratory care for a resident who required a Bi-level Positive Airway Pressure (Bi-pap) machine upon readmission. The resident, admitted for rehabilitation after a spinal fracture, had a physician's order for continuous oxygen at five liters per minute. However, the resident was found with a low oxygen saturation level of 41% while on only two liters per minute of oxygen, leading to a hospital readmission for hypercapnic respiratory failure. Upon readmission to the facility, there was no documentation that the necessary Bi-pap machine was obtained, nor was the physician notified of its unavailability. The resident was readmitted to the facility without the required Bi-pap machine, despite the hospital discharge summary indicating its necessity. The facility's staff, including the Licensed Practical Nurse (LPN) on duty, failed to ensure the Bi-pap machine was available and did not notify the physician about the equipment's absence. The resident was found unresponsive and without respirations or a pulse, leading to their death shortly after readmission. The facility's investigation revealed that the respiratory supply company failed to deliver the Bi-pap machine, and the LPN did not follow the physician's order or notify the physician of the equipment's absence. Interviews with facility staff, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Medical Director, highlighted a lack of communication and adherence to protocols. The facility's policy required notifying the physician if necessary equipment was unavailable, which was not done. The Medical Director and the resident's long-term physician were not informed of the situation, and the resident was admitted under the care of the Medical Director without proper notification. The failure to provide the ordered respiratory care and notify the physician of the equipment's absence contributed to the resident's death.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Oxygen Order and Improper Nebulizer Storage: A resident receiving oxygen for sleep apnea had no physician order specifying the oxygen delivery rate, even though staff were setting the rate. In a separate observation, a resident’s nebulizer mask was left unbagged on the nightstand while not in use. An LPN and the DON both stated respiratory equipment should be stored in a bag when not in use, and the facility policy required bagged storage between uses.
Respiratory care was not provided in accordance with standards for several residents receiving oxygen and nebulizer treatments. Staff observed outdated oxygen tubing and humidification equipment, a nebulizer mouthpiece left out with tubing touching the floor, and oxygen supplies not stored properly. One resident’s oxygen was running at a higher flow than ordered, and staff confirmed the tubing and humidification items should be changed weekly and documented.
Improper Storage and Dating of Oxygen and CPAP Equipment: Two residents had oxygen equipment and CPAP items observed out of proper storage, including nasal cannula tubing on the floor, undated or empty humidifiers, and a CPAP mask on the floor. One resident had OSA with an order for oxygen at bedtime and as needed, and the other had COPD with orders for nightly CPAP and continuous oxygen. Staff stated the tubing, humidifier, and CPAP mask should be stored and dated per facility practice, and the facility policy required weekly changes and dating of oxygen equipment.
A resident receiving continuous O2 via nasal cannula had the cannula found on the floor while the concentrator was running. A CNA placed the cannula back on the resident’s face before an LVN identified it as contaminated and replaced the cannula and tubing. The resident had diagnoses including hypertensive heart disease and atherosclerotic heart disease, and the care plan called for O2 at 2 L/min to maintain O2 sats above 92%.
A resident with COPD, a respiratory infection, continuous O2, and CPAP therapy had CPAP and nasal cannula tubing observed lying on the bed and the CPAP mask draped over the machine instead of being stored in a sanitary container. Staff interviews showed inconsistent understanding of how to store the respiratory equipment, and the facility did not provide the requested storage of the equipment when not in use.
Respiratory equipment was not properly changed, labeled, or stored for a resident receiving nebulizer treatment. An undated aerosol mask attached to a nebulizer was observed on the resident’s nightstand, open to air, and remained there on a later observation. An LPN confirmed the mask was open to air and not stored properly, and the DON confirmed the mask and tubing had not been dated or stored properly.
Missing Oxygen Order and Improper Nebulizer Storage
Penalty
Summary
The facility failed to ensure that Resident #11’s oxygen delivery rate was specified in the clinical record. Resident #11 was observed semi reclined in bed receiving oxygen from a concentrator via nasal cannula at 2 liters per minute. The resident’s care plan, initiated 1/2/2026, identified risk for complications related to sleep apnea and included oxygen as needed to promote lung expansion and improve air exchange, with positioning at 45 degrees if tolerated. The physician orders included oxygen-related maintenance and respiratory orders for oxygen at night for sleep apnea, but the clinical record did not contain a physician’s order establishing the ordered oxygen delivery rate. An LPN confirmed the record did not show an ordered delivery rate, and the DON agreed the oxygen delivery rate should be included as a physician’s order. The facility also failed to ensure nebulizer equipment was properly stored for Resident #85. During observations, a nebulizer mask was seen lying on top of the nightstand and was not bagged while the resident was sitting in a wheelchair and later while lying in bed with eyes closed. Resident #85 had physician orders for levalbuterol nebulization every 8 hours and ipratropium-albuterol inhalation solution every 6 hours as needed for shortness of breath. An LPN stated the nebulizer mask and oxygen tubing should be stored in a bag when not in use, and the DON stated the nebulizer mask and tubing should be stored in a dated bag when not in use. The facility policy stated oxygen cannula and tubing used PRN should be kept in a plastic bag when not in use, and nebulizer circuits should be stored in a plastic bag marked with the date and resident’s name between uses.
Respiratory equipment was not maintained and stored per standards
Penalty
Summary
The facility failed to follow professional standards of practice for oxygen and nebulizer treatments for four residents receiving respiratory services. During observations, Resident #56 was receiving continuous oxygen at 4 liters per minute by nasal cannula, and the tubing was dated 5/22 even though staff stated the tubing should be changed weekly on Thursdays. The DON confirmed oxygen tubing is changed weekly. Resident #56’s physician order dated 4/2/2026 ordered continuous oxygen at 4 liters nasal cannula. Resident #29 was observed with oxygen via nasal cannula connected to an oxygen concentrator with a humidification/water bottle dated 5/17/26, and the same date was observed again the next day. Her orders included continuous oxygen at 2 liters and weekly change of tubing, mask, and/or nasal cannula, but there was no order for humidification related to her oxygen and no MAR/TAR entry for humidification. Staff stated the humidification bottles should be changed weekly and at the same time as the tubing, and the DON stated there should be an order for humidification and that tubing and humidification bottles should be documented on the TAR. Resident #55’s nebulizer setup was observed with inhalation tubing hanging from the machine, with the distal tip touching the floor, and the mouthpiece sitting on the bedside table instead of in a plastic storage container. Resident #88 was observed with an oxygen concentrator running at 4.5 liters per minute, while the physician order was for 2 liters continuous; the oxygen cannula was wrapped around the bedside rail and not stored in a bag. The unit manager stated oxygen supplies should be stored in a dated plastic bag and the mouthpiece should not be left on the bedside table.
Improper Storage and Dating of Oxygen and CPAP Equipment
Penalty
Summary
The provider failed to ensure infection control practices were followed for oxygen equipment for two residents. One resident had obstructive sleep apnea and an order for oxygen at 3 L by nasal cannula at bedtime and as needed; observations showed the nasal cannula tubing on the floor and not dated, and the pre-filled humidifier was not dated. The resident’s June 2026 TAR did not indicate when the nurse was to change the oxygen tubing. Another resident had COPD and orders for nightly CPAP use and continuous oxygen at 2 L. Observations showed the oxygen concentrator in the room, the nasal cannula tubing dated but later found on the floor, the pre-filled humidifier empty and not dated, and the CPAP mask on the floor between the bed and nightstand. Staff interviews stated the oxygen tubing should be stored in a bag or in the bedside table drawer when not in use, the CPAP mask should be stored on the CPAP machine, and the tubing and humidifier should be dated when changed. The facility policies stated oxygen tubing and nasal cannula/mask were to be changed weekly, the tubing should be changed when found lying on the floor, and the humidifier bottle should be replaced weekly and as needed with date and initials.
Contaminated oxygen tubing was placed back on a resident
Penalty
Summary
Resident #7, a female admitted on 05/14/2026 with diagnoses including hypertensive heart disease and atherosclerotic heart disease, was ordered to receive oxygen at 2 L/min via nasal cannula continuously every shift. Her MDS indicated that she was rarely/never understood and received oxygen therapy, and her care plan addressed impaired gas exchange related to respiratory failure with oxygen at 2 L/min via nasal cannula to maintain O2 saturations above 92%. During observation on 06/01/2026, Resident #7 was in bed with the head of bed elevated about 30 degrees. The oxygen concentrator was running at 2 L/min, but the tubing was above her head and the nasal cannula was lying on the floor. CNA C picked up the cannula from the floor and placed it back on the resident’s face. LVN A then entered the room and stated the cannula was contaminated and immediately changed it out. CNA C stated she had put the cannula back on because she did not think it had touched the floor, but also acknowledged that it could be contaminated and cause infection if it touched the floor. LVN A stated the cannula and tubing were changed because they had touched the floor and were contaminated. The DON stated the expectation was that tubing or a nasal cannula on the floor are to be changed out to prevent infection.
Respiratory Equipment Not Stored Sanitarily
Penalty
Summary
The facility failed to provide adequate respiratory care and services for a resident with COPD, diabetes mellitus, major depressive disorder, and neuromuscular dysfunction of the bladder who also had a respiratory infection and was receiving continuous oxygen and CPAP therapy. The resident’s MDS documented intact cognition, lower-body extremity impairment, and dependence on staff for toileting, bathing, and dressing, with setup or cleanup assistance needed for eating and oral hygiene. The care plan and physician orders directed staff to assist with CPAP application every bedtime, ensure oxygen was connected at 3 L/min, clean the CPAP mask daily, and store the CPAP equipment in a bag or enclosed storage when not in use. During observations, the resident’s CPAP and nasal oxygen tubing were found laid on the bed, and the CPAP mask was observed draped over the CPAP machine on the bedside table, with the respiratory equipment not stored in a sanitary container. A CNA stated the equipment should be stored in a bag and pulled shut, while an LPN stated she was unsure how the equipment should be stored and said respiratory staff handled respiratory issues during the day. An administrative nurse stated all respiratory equipment should be placed in a bag when not in use and that all staff could place the equipment in the bags. The facility did not provide storage of respiratory equipment as requested.
Respiratory Equipment Not Properly Labeled or Stored
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident by not ensuring respiratory equipment was properly changed, labeled, and stored. The resident had an admission date of 04/20/2023 and diagnoses including iron deficiency anemia, morbid obesity, diffuse traumatic brain injury with loss of consciousness, and unspecified convulsions. On 06/01/2026, an undated aerosol mask attached to a nebulizer machine was observed on the resident’s nightstand, open to air. The resident had an order for ipratropium-albuterol solution, 1 vial inhaled orally four times a day for wheezing and cough for 5 days, with a start date of 05/28/2026. On 06/02/2026, the same aerosol mask remained on the nightstand, open to air. An LPN confirmed the mask was open to air and not labeled or stored properly, and the DON confirmed the aerosol mask and tubing had not been dated or stored properly.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.