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F0695
D

Failure to Follow Oxygen Therapy Orders for Two Residents

Rexburg, Idaho Survey Completed on 01-09-2026

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 oxygen therapy as ordered for two residents. One resident with COPD and depression had a physician order for continuous oxygen at 1.5 L/min via nasal cannula starting 11/6/25, but was observed on multiple occasions receiving oxygen at 2 L/min via nasal cannula in both the dining room and her room. Both the bedside oxygen concentrator and the portable concentrator on her walker were labeled and set to deliver 2 L/min, and an RN confirmed that the oxygen rate should have been 1.5 L/min as ordered and had not been. Another resident with diagnoses including orthopedic aftercare, Sjogren's disease, and diabetes had a physician order for weekly oxygen tubing changes and humidifier bottle changes every Sunday on the night shift, starting 12/21/25. Surveyors observed on three separate days that this resident’s oxygen humidifier bottle was still dated 12/28/25, indicating it had not been changed according to the order. The DON stated that the humidifier should have been changed on the most recent Sunday and had not been.

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