A resident with COPD history, CHF, asthma, and cognitive impairment had oxygen tubing that was not changed as ordered and nebulizer tubing that was undated, with the nebulizer mouthpiece left unbagged on the nightstand. The ADON observed the respiratory equipment and stated the tubing should have been changed weekly and the mouthpiece bagged when not in use, but it was not.
Failure to Post Oxygen-In-Use Signage: The facility failed to post oxygen warning signage outside the rooms of two residents receiving O2. One resident had an order for continuous O2 at 1 L via NC and diagnoses including vascular dementia and heart disease; the other had an order for O2 at 2 L via NC PRN for SOB and diagnoses including HF, hypotension, AFib, PE, and SOB. Observations showed both residents receiving O2 without the required signage outside their room doors, and the DON confirmed the missing signs.
Respiratory care was not provided as ordered for two residents. One resident's suction equipment was observed unbagged at the bedside, and an LPN confirmed it should have been bagged. Another resident's BIPAP mask was left unbagged, the nasal cannula and humidifier were overdue for weekly changes, and the oxygen concentrator filter had a white powdery substance; the WCN and ADON acknowledged the equipment had not been cleaned or documented as ordered.
Respiratory care was not provided consistently for three residents with oxygen and other respiratory therapy needs. Staff failed to date oxygen tubing and a humidification bottle, failed to bag oxygen, nebulizer, CPAP, and BiPAP equipment when not in use, and failed to document lung sound checks after nebulizer treatments for one resident. Observations and interviews confirmed undated tubing, un-bagged masks and hoses, and missing post-treatment lung sound monitoring.
Respiratory equipment was not properly changed, labeled, or stored for a resident receiving nebulizer treatment. An undated aerosol mask attached to a nebulizer was observed on the resident’s nightstand, open to air, and remained there on a later observation. An LPN confirmed the mask was open to air and not stored properly, and the DON confirmed the mask and tubing had not been dated or stored properly.
Improperly Labeled Oxygen Tubing: A resident with COPD and an order for oxygen therapy was observed with portable oxygen tubing that was not labeled with the change date. An LPN confirmed the tubing should have been labeled, and the DON stated oxygen tubing should be changed weekly and labeled with the change date.
Oxygen Flow Rate Not Set as Ordered: A resident with CHF had a physician order for continuous O2 at 1 L via NC, but was observed in the therapy room receiving O2 from a portable tank set at 2 L instead. An LPN checked the tank and confirmed the resident was receiving 2 L rather than the ordered 1 L, and the chart showed no change to the order.
Improper Storage of CPAP Face Mask: A resident with OSA, dementia, asthma, and depression had a CPAP order for bedtime use, but the CPAP face mask was repeatedly observed sitting on the bedside table or on top of the CPAP machine and not stored in a container or bag. An LPN acknowledged the mask should have been stored properly, and the DON confirmed that when not in use, the CPAP mask should be kept in a container or bag.
Failure to follow the oxygen administration policy occurred when a resident's nasal cannula tubing remained dated beyond the weekly change interval. The resident had an order for O2 at 2 L/min via NC, and an LPN confirmed the tubing should have been changed weekly.
Respiratory care was not provided in accordance with policy for three residents. Two residents ordered continuous O2 had tubing and humidifier issues, including an empty or undated humidifier bottle and tubing not changed on schedule, while another resident’s BiPAP nasal prongs were left out of a bag when not in use. The DON confirmed the equipment concerns.
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