The facility failed to administer oxygen as ordered for three residents who experienced low O2 saturations. One resident had an O2 saturation of 89% on RA with an order to apply O2 to keep saturations above 90%; staff notified an RN, who assessed the resident, called 911, and prepared transfer paperwork but did not apply O2 or recheck the saturation before transfer. A second resident, care planned as at risk for respiratory distress with orders to maintain O2 saturations above 90%, became lethargic with an O2 saturation in the low 80s on RA; the RN called the POA and 911 and left the room for paperwork, and later could not recall if O2 was applied, with no documentation that it was. A third resident had documented O2 saturations in the high 80s on RA; the RN contacted the provider and believed they may have applied O2 but had no documentation of doing so before ambulance transfer. The DON confirmed that O2 was readily available, that orders required O2 when saturations remained below 90%, and that these residents had documented low O2 saturations without documented O2 administration, and that one resident’s care plan goal for O2 saturation was not met.
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
Respiratory care was not provided as ordered for several residents. A cognitively intact resident using a Trilogy NIV had no documented device settings or record of when the mask and tubing were last changed, another resident ordered for continuous oxygen titration had only daily SpO2 checks instead of more frequent monitoring, and two residents had oxygen tubing that was not dated. The DON confirmed the missing settings, limited SpO2 monitoring, and lack of tubing dating.
A resident with obstructive sleep apnea had a provider order for nightly BiPAP use and relied on staff for equipment care, but the facility failed to replace the BiPAP mask and tubing according to its own policy and provider recommendations. Over several observations, the mask and tubing were seen lying on the bed, sometimes lodged between the mattress and side rail, and the mask appeared cloudy with dried white spots. An LPN reported that central supply was responsible for respiratory equipment changes, while central supply staff stated they were unaware the resident used a BiPAP and had not ordered or changed any supplies. The DON confirmed the resident’s respiratory equipment had not been replaced as required.
The facility failed to maintain complete respiratory orders for two residents on oxygen and one resident using a PAP device. One resident’s oxygen order lacked a dose and route, another resident’s oxygen order lacked a dose, and a third resident had documented PAP use in progress notes and at bedside but no physician order. Staff and the ADON confirmed the missing order details, while observations showed the residents using oxygen at 2 L/min and the PAP machine in the room.
The facility failed to obtain valid orders for PAP device modes and settings for three residents receiving CPAP/BiPAP therapy. One resident had OSA and daytime O2, another had OSA with nightly BiPAP and O2, and a third had respiratory failure with hypoxia, OSA, and pulmonary hypertension; in each case, the chart lacked the specific PAP settings, and staff confirmed the orders were incomplete. Observations also showed one resident without the ordered oxygen in place while the concentrator was running.
A resident with obstructive sleep apnea had a CPAP machine in the room, and the MDS and care plan documented CPAP use and risk for altered respiratory status. However, the order summary contained no physician order for CPAP pressure settings, and the DON and an LPN confirmed the EMR lacked an order; the CCL stated the facility did not have a system to ensure residents admitted with a personal CPAP had an order.
Oxygen tubing was not connected from the concentrator to the humidification bottle for a resident receiving continuous O2 at 3 L/min via nasal cannula for COPD. The resident had intact cognition and reported not feeling any oxygen flow, while repeated observations showed the humidification chamber did not bubble. An LPN confirmed the resident was not receiving O2 because the connecting tube was not attached.
Oxygen Flowrate Not Set to Ordered Level: A resident with COPD, chronic respiratory failure, CHF, and dependence on supplemental O2 was observed with the O2 concentrator set above the ordered daytime rate on multiple occasions. The resident’s order required 2 L/min during the day and 4 L/min at rest and while sleeping with AVAPS, but staff found the concentrator at 3.5 L/min and later at 4 L/min when it should have been 2 L/min; an LPN confirmed the incorrect setting.
Failure to verify BiPAP settings and oxygen orders for a resident with morbid obesity and alveolar hypoventilation. The resident had an order for nightly BiPAP AUTO with specific settings, and the care plan directed staff to ensure the settings and supplemental O2 were correct each time the device was applied. An RN said the BiPAP came from home and staff did not program or adjust it, and the RNC confirmed the settings had not been verified and no O2 order had been obtained for use with the BiPAP.
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