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F0656
D

Failure to Include Oxygen Therapy in Resident Care Plan

Billings, Montana 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 develop and implement a comprehensive, person-centered care plan for a resident who required oxygen therapy. Observation revealed the resident was using a nasal cannula with an oxygen concentrator set at 2 liters per minute, as ordered by the medical provider. However, review of the resident's current care plan showed no focus, goal, or interventions related to oxygen therapy. During an interview, a staff member confirmed that the care plan had not been updated to include the resident's oxygen therapy, and was unsure why this omission occurred. The deficiency was identified through observation, interview, and record review, which confirmed that the resident's care plan did not address the ordered oxygen therapy, despite the resident actively receiving this treatment.

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