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:
Two residents receiving O2 had flow rates set above their physician orders, and one resident’s tubing remained dated beyond the weekly change interval. Staff, including an RN and the DON, confirmed the mismatched flow rates and noted that tubing should be changed weekly by the RT. The facility policy required O2 to be administered per physician order and tubing/cannula to be changed weekly.
Oxygen Concentrator Left in Room After Order Discontinued: A resident with morbid obesity with alveolar hypoventilation and diabetes was observed with an oxygen concentrator at bedside even though there was no current oxygen order. The resident stated he used oxygen only when needed, and the CNO confirmed the oxygen had been discontinued earlier and the concentrator should not have remained in the room.
Missing Order for CPAP Use and Maintenance: A resident with sleep apnea and stroke had a CPAP in the room, but there was no physician order or care plan documentation for its use or maintenance. Staff knew the resident had the CPAP, yet CNAs and an RN reported they did not routinely clean the mask or tubing, and the LPN Resident Care Manager confirmed no order existed for the CPAP or its care.
A resident with a continuous O2 order was found without oxygen in place, and an LPN later said the order had been misread. Two other residents with COPD had respiratory equipment that was dirty or outdated, including a gray concentrator filter, tubing and water bottles dated weeks earlier, and tubing lying on the floor with visible dust. Staff gave inconsistent accounts of who was responsible for changing or cleaning the equipment, and the DON acknowledged the dirty equipment and old mask placed residents at risk for respiratory infection or pneumonia.
A resident with acute respiratory failure with hypoxia and severe cognitive impairment was ordered oxygen via NC at 2 to 5 LPM to keep O2 saturation at or above 95%. During observation, the resident was lying in bed with the NC on the side of the face instead of in the nose while the concentrator was set at 2.5 LPM. RN and DON stated the NC should be in the nose to deliver oxygen as ordered.
A resident with COPD and chronic respiratory failure did not receive oxygen at the ordered flow rate. Staff found the oxygen concentrator set below the ordered amount on multiple observations, and the resident stated the oxygen was supposed to be set higher. The DON, LVNs, and ADON acknowledged the setting was incorrect and that the ordered flow should have been followed.
Incorrect Oxygen Flow Rates and Delayed Tubing Changes
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for two residents receiving oxygen therapy. Resident #5 had an order dated 1/7/2025 for oxygen at 2 liters via nasal cannula continuously for infiltrate of the left lung, but during observations on 7/7/2026, 7/8/2026, and 7/9/2026 the resident’s oxygen was running at 3 liters per minute. On 7/7/2026 and 7/8/2026, the oxygen tubing in Resident #5’s room was dated 6/26, and on 7/9/2026 Staff F, RN confirmed the tubing date and the 3-liter flow rate. Staff F stated the tubing should have been changed the prior week and that the resident was running at 3 liters despite an order for 2 liters. Resident #6 had a physician order dated 3/18/2026 for oxygen at 3 liters via nasal cannula continuously for chronic respiratory failure with hypoxia, but during observations on 7/7/2026 at 10:10 AM and 12:12 PM, and again on 7/8/2026 at 8:02 AM, the resident’s oxygen was being administered at 4 liters per minute. On 7/9/2026 Staff F, RN entered the room and confirmed the oxygen was at 4 liters, stating it should not be at that rate because the order was for 3 liters. The DON stated nursing staff should check oxygen flow rate every shift and as needed, and that tubing should be changed weekly by the respiratory therapist. The facility policy also stated oxygen tubing and mask/cannula are to be changed weekly and as needed if soiled or contaminated.
Oxygen Concentrator Left in Room After Order Discontinued
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when the facility failed to remove an oxygen concentrator from Resident #12's room after the physician discontinued the oxygen order. Resident #12 was admitted and later readmitted to the facility with diagnoses including morbid obesity with alveolar hypoventilation and diabetes. On 7/7/26, the resident was observed sitting in his power chair with an oxygen concentrator at his bedside. When asked about oxygen use, the resident stated he only used oxygen when he needed it. Review of the resident's physician orders showed no current oxygen order, and the CNO stated on 7/8/26 that the oxygen concentrator should not have been in the room because oxygen had been discontinued on 6/17/26.
Missing Order for CPAP Use and Maintenance
Penalty
Summary
The facility failed to obtain physician orders for the use and maintenance of a CPAP for Resident 76, who was admitted in 6/2026 with diagnoses including sleep apnea and stroke. There was no documentation in the admission MDS or care plan showing that the resident used a CPAP. Observations from 7/6/26 through 7/10/26 showed the CPAP in the resident’s room on the nightstand. The resident stated that a friend brought the CPAP to the facility a day after admission, but staff did not clean the mask or tubing daily and the mask did not fit well. Staff interviews showed the CNA staff were aware of the CPAP but did not clean the mask or hose, one CNA reported washing the mask one time, and an RN stated she filled the chamber with water a few times but did not clean the mask or tubing. The LPN Resident Care Manager confirmed the resident did not have an order for the CPAP or for cleaning and caring for the equipment.
Respiratory Equipment Not Maintained or Applied as Ordered
Penalty
Summary
Resident #12 had an order for oxygen at 2 liters per minute via nasal cannula continuously, with titration up to 4 liters to keep oxygen saturations above 90% every shift. The resident’s care plan also directed staff to apply oxygen at 2 liters via nasal cannula. During an observation, the resident was up in a chair with no oxygen in place. The resident stated she had been wearing oxygen but was not sure when or why staff stopped applying it. The nurse later stated she had misread the order as oxygen could be applied only if saturations fell below 90%, and she acknowledged the resident did not wear oxygen despite the active continuous order. Resident #27 had diagnoses including dementia, COPD, anxiety, and shortness of breath, and her MDS indicated she required oxygen therapy. Her care plan directed staff to change oxygen tubing as needed and nebulizer tubing every week. During multiple observations, the resident’s oxygen concentrator filter was gray and dirty, and the tubing and empty water bottle were dated 5/24/26. The resident stated staff usually changed the equipment, but it had not been changed that she could recall. Later, the tubing and water bottle remained dated 5/24/26, and the concentrator filter was still dirty. Staff interviews reflected uncertainty about who was responsible for changing the equipment, and the ADON stated the tubing and water bottle should have been changed by 07/02/26, while the DON stated the dirty filter and old nebulizer mask placed the resident at risk for respiratory infection or pneumonia. Resident #9 had COPD and an order for oxygen at 2 to 4 liters per nasal cannula to maintain PO2 greater than 90%. The resident’s oxygen tubing was observed lying on the floor and had a piece of tape dated 06/22/26, with brown dust visible in the wheel-mark pattern on the tubing. The resident was unable to state when the tubing was last changed or how often it was changed. Staff interviews showed differing practices about changing oxygen tubing, with some stating it should be changed weekly or when dirty, while the DON stated she had been advised not to date the tubing and to change it when visibly soiled. The facility policy stated cannula or mask needed to be changed if it malfunctions or becomes visibly contaminated.
Oxygen Not Properly Delivered via Nasal Cannula
Penalty
Summary
The facility failed to ensure oxygen was administered in accordance with the physician’s order and facility policy for one sampled resident. Resident 44 was admitted with diagnoses including acute respiratory failure with hypoxia and encephalopathy. The MDS dated 5/28/2026 indicated the resident had severe cognitive impairment, was on oxygen therapy, and was dependent for eating, oral care, toileting, personal hygiene, showering, dressing, and footwear. A physician’s order dated 6/4/2026 directed oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift, and the care plan was revised to reflect humidified oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift. During a concurrent observation on 6/29/2026 at 10:33 AM, Resident 44 was observed lying in bed with the nasal cannula on the left side of the face while the oxygen concentrator was set at 2.5 LPM. During interviews, RN 3 stated the nasal cannula should be placed correctly in the resident’s nose for the resident to receive oxygen, and the DON stated the nasal cannula should always be in the resident’s nose to help maintain oxygen saturation at 95% and above. The facility policy titled Oxygen Administration stated oxygen is administered to residents who need it, consistent with professional standards of practice and comprehensive person-centered care plans, and under physician orders.
Incorrect Oxygen Flow Settings
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident with COPD, chronic respiratory failure, and functional quadriplegia. The resident’s care plan directed that oxygen be administered at 2 L/min via nasal cannula continuously to maintain SPO2 above 90%, and the physician order summary reflected oxygen at 2 L/min via nasal cannula continuously. However, during observation and interview on 06/30/2026, the resident’s oxygen concentration machine was set at 3 L/min, and the resident stated her oxygen was supposed to be set at 4 L/min. The LVN stated the resident was supposed to be on 4 L/min and adjusted the oxygen to 3.5 L/min, and the DON later stated the resident was to be getting 4 L/min and adjusted the setting to 4 L/min. A subsequent physician order dated 07/01/2026 directed oxygen at 4 L/min via nasal cannula to maintain SPO2 above 90%. During observation on 07/02/2026, the resident’s oxygen was again found set at 3.5 L/min. An LVN checking the setting stated it was at 3.5 L/min and that if physician orders were not followed, the resident could become short of breath and the orders would not be followed. The ADON stated the oxygen machine should be set with the ball meter at eye level, that if the order said 4 L/min it should be set on 4 L/min, and that 3.5 L/min was not good enough. The facility’s oxygen administration policy required verifying a physician order and adjusting the oxygen delivery device so the proper flow of oxygen was being administered.
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