F0695

D

Failure to Maintain Clean Oxygen Concentrator Filter for Resident on Oxygen Therapy

Marietta, Georgia Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a clean oxygen concentrator filter for a resident receiving oxygen therapy. The resident had diagnoses including COPD, chronic respiratory failure with hypoxia, interstitial pulmonary disease, and paroxysmal atrial fibrillation, and the MDS documented ongoing oxygen therapy. Physician orders directed that the oxygen concentrator filter be cleaned once weekly and as needed, and the resident’s care plan included oxygen therapy with monitoring for signs and symptoms of acute respiratory insufficiency. Multiple observations over several days showed the oxygen concentrator filter contained gray, fuzzy debris.

Staff interviews revealed that responsibility for concentrator maintenance had recently shifted from a respiratory therapist, who previously checked concentrators twice weekly, to nursing staff, who were expected to clean filters weekly. A CNA stated that another nurse specialized in oxygen concentrators and changed them but was unsure of the schedule, and confirmed the presence of gray, fuzzy debris on the filter. An LPN-Unit Manager reported checking concentrators on a prior date but acknowledged not turning the concentrator around to inspect the filter and stated it had likely been over two weeks since the filter had been checked. The DON confirmed there was no respiratory therapist currently and that external filters were expected to be cleaned weekly, and the Administrator stated that concentrators were expected to be cleaned weekly, monitored, and audited. The facility’s Oxygen Administration policy required following manufacturer recommendations for cleaning equipment filters and providing care of equipment in accordance with facility policies, which was not followed in this instance.