Deficiencies in Emergency Equipment and Oxygen Filter Maintenance
Summary
The facility failed to provide necessary emergency tracheostomy equipment at the bedside for a resident with a tracheostomy, identified as Resident #86. During the survey, it was observed that the required emergency supplies, such as an obturator and appropriately sized inner cannulas, were not available at the resident's bedside or in the supply room. The primary nurses responsible for the care of the resident were not familiar with the obturator or its use, indicating a lack of training and awareness among the staff. Additionally, the facility did not ensure the cleanliness of oxygen concentrator filters for three residents, identified as Resident #33, Resident #44, and Resident #60. Observations revealed that the concentrator inlet filters for these residents were covered with a gray/white substance, indicating they had not been cleaned as required. The Maintenance Director, who was responsible for cleaning the filters, admitted that the filters had not been cleaned until the day of the survey, despite documentation suggesting otherwise. These deficiencies highlight a failure in the facility's processes to ensure the availability of critical medical supplies and the maintenance of equipment necessary for resident care. The lack of emergency tracheostomy equipment and unclean oxygen concentrator filters posed significant risks to the residents' health and safety.
Plan Of Correction
Resident #86 was provided with the proper emergency equipment at his bedside and nursing staff were educated and competencies were completed. Resident #86 is the only resident currently in Alaris Health at Belgrove with [R]. On 12/3/24 upon receiving notification of the Immediate Jeopardy situation, the Director of Nursing in serviced LPN3 and RN1 assigned to work 3-11 shift on the first floor where Resident #86 resides on Trach Care, Emergency Trach Care and identifying supplies needed. Competency and return demonstration was completed. Director of Nursing and/or Infection Preventionist also inserviced the LPN4 and RN2 assigned to the 1st floor for 12/3/24 11-7 shift on Trach Care, Emergency Trach Care and identifying supplies needed. Competency and return demonstration was completed. This was completed prior to start of the shift. Director of Nursing and/or Infection Preventionist repeated this process for RN3, LPN2 and RN4 assigned to the first floor on 7-3 shift 12/4/24 prior to the start of their shift. Starting on 12/4/24, this education and competency will then be completed on all nurses in the facility. Any nurse caring for Resident #86 will be inserviced prior to the start of their shift. Any nurse that is on leave or vacation will receive this education and competency on their first shift upon return. This education and competency will be incorporated in the orientation process for all new hires starting on 12/4/24. The [R] for residents #33, #44, and #60 were cleaned by the Director of Maintenance and replaced back on the [R]. All residents with tracheostomies and all residents that use oxygen supplementation via oxygen concentrators are potentially affected. Nursing Supervisor will check the supplies in Resident #86 room and any residents with tracheostomy q shift for the next 3 months to assure that all required supplies are present in the room. For Resident #86 these supplies include Tracheostomy Care Kit, Ambubag, Suction Machine, Suction Kit, Normal Saline Bottles, Sterile Water Bottles, Drain Gauze, Sterile Gauze, Inner Cannulas (#6), Tracheostomy Set for Emergency Use (includes outer cannula, inner cannula, obturator, trachea ties, size #5), Corrugated Tubing, Yankeauer Suction Catheter, Velcro Trach Ties, Suction Connecting Tubes, Aerosol Drainage Bag w/ Y-Adaptor and Straight Adaptor. Central Supply Coordinator will maintain a weekly inventory of trach supplies. Inventory will be submitted to the Director of Nursing on a weekly basis for review. Director of Nursing will instruct Central Supply Coordinator on a weekly basis of any supplies that need to be ordered. If a potential admission is identified requiring trach supplies, the Director of Nursing will identify supplies needed and assure supplies are available in building prior to admission. Director of nursing or designee will inservice nurses upon hire and annually on tracheostomy care and care of the tracheostomy in an emergency. Director of nursing or designee inserviced the maintenance department on properly cleaning oxygen concentrators filters. Policy of care of the oxygen concentrator was revised to clean filters weekly by the maintenance department. QAPI was implemented to not only address immediate rectification, but also to maintain an ongoing system to ensure proper trach care and supplies present for residents who need. Within this QAPI there will be continued education with all nurses on Trach Care, Emergency Trach Care and supplies needed. The Director of Nursing, Infection Preventionist and/or designee will conduct 5 observations per week of nurses performing trach care and reviewing emergency trach care and supplies starting 12/9/24. Any nurses noted with deviation from standard of practice will be immediately reinserviced and have a successful competency completed prior to being able to care for a resident with a trach. Maintenance director or designee will audit 5 oxygen concentrators weekly to assure they are properly cleaned. Results of these audits will be reported to the Administrator on a weekly basis for review for the next 3 months. QAPI meeting will be held on a monthly basis to ensure proper procedures regarding cleaning of the concentrator filters, trach care, emergency trach care and availability of proper supplies are in place and followed for the next 2 months and quarterly thereafter for the next year.
Removal Plan
- All nurses, including new hires, will be educated on tracheostomy care, emergency tracheostomy care, and identifying supplies needed with competency and return demonstration.
- A nursing supervisor will check the supplies in Resident #86's room to assure all required supplies are present in the room.
- Central supply will maintain inventory of tracheostomy supplies.
- The DON will assure tracheostomy supplies are available prior to admission.
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.
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