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F0695
D

Failure to Properly Store Nebulizer Masks for Residents Receiving Oxygen Therapy

The Villages, Florida Survey Completed on 07-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide respiratory care services consistent with professional standards of practice for two residents who were receiving oxygen therapy. For both residents, observations on multiple occasions revealed that their nebulizer masks were left on top of their bedside tables and were not stored in bags as required. Photographic evidence was obtained to document these findings. Both residents had active physician orders for Ipratropium-Albuterol nebulizer treatments to be administered multiple times daily for chronic respiratory conditions, including COPD and chronic respiratory failure. Interviews with facility leadership confirmed the improper storage of the nebulizer masks. The Director of Nursing acknowledged that the masks were not stored appropriately, and the Administrator stated that the facility did not have a policy regarding the storage of nebulizer or oxygen supplies. The lack of proper storage practices and absence of a relevant policy contributed to the deficiency in providing safe and appropriate respiratory care for the affected residents.

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