A resident with chronic respiratory failure and OSA had BiPAP orders requiring 3L O2 bleed-in, but CNAs and Med Techs were routinely applying the device without facility training or competency validation. Surveyors found staff using incorrect setup, including a nasal cannula under the mask instead of oxygen connected to the BiPAP, and the DON confirmed the facility had no CNA BiPAP competencies. The resident had episodes of respiratory decline, including being found unresponsive after a missed BiPAP session and later turning blue/gray with low O2 saturation when the BiPAP oxygen was not connected, leading to hospital transfers for acute respiratory failure and suspected aspiration.
Failure to Complete Required Pre- and Post-Nebulizer Assessments: An RN administered a nebulizer treatment to a resident with asthma and chronic respiratory failure but did not complete the required post-treatment respiratory assessment, and the surveyor did not observe the pre-treatment assessment being performed. The resident’s order required complete pre and post assessments, including lung sounds, RR, pulse, and O2 sat, and the DON stated RNs were expected to complete lung assessments within 15 minutes before and after nebulizer treatment.
Two residents receiving oxygen therapy with humidification had distilled water bottles that did not meet facility policy. One bottle was left uncovered and was dated beyond the 72-hour limit, while the other was open but not dated when opened. The residents had diagnoses including heart failure, pneumonia, and chronic pulmonary disease, and the DON verified the issues during observation.
Oxygen tubing/nasal cannula care was not ensured for one resident with acute and chronic respiratory failure, cor pulmonale, and COPD. Staff observed the resident using oxygen with no date label on the cannula/tubing, and RNs and the DON stated monthly changes are expected but could not verify when the tubing was last changed because it was unlabeled and not clearly documented.
A resident with COPD and other respiratory and cardiac diagnoses had an oxygen order for 1-2 L/min via NC, but surveyors repeatedly found the concentrator set at 3.5 L/min and left on when not in use. The resident’s care plan did not identify COPD, and staff interviews confirmed the flow rate should have matched the physician’s order and that COPD should have been reflected in the care plan.
A resident with cerebral palsy, quadriplegia, chronic respiratory failure, and severe cognitive impairment had a physician order for Cough Assist BID and PRN, but the order was not entered into the TAR and the treatment was not consistently provided in the facility. Staff interviews showed confusion about whether the order existed, and the DON could not find evidence it was provided. The resident was hospitalized multiple times for respiratory distress, aspiration, pneumonia, and sepsis, and hospital records noted use of Cough Assist during those stays.
Failure to Provide Ordered Respiratory Care: Two residents did not receive needed respiratory services. One resident on continuous O2 had tubing for the room concentrator that was not changed as ordered, while another resident with OSA wanted to use a CPAP machine but the machine was unplugged, parts were stored in a bag, and staff had not obtained an order or assisted with setup. The DON confirmed oxygen tubing should be changed weekly and that CPAP use should be ordered and care planned.
Oxygen care was not managed consistently for two residents. One resident with COPD, acute respiratory failure with hypoxia, and CHF had an O2 concentrator in the room without an oxygen-in-use sign on the door and tubing that was not dated, while another resident with cardiomyopathy, ESRD, and anemia also had undated O2 tubing. Staff stated tubing should be changed every 7 days and dated, but the required dating and signage were not in place when observed.
A resident with CHF, interstitial lung disease, and chronic respiratory failure was receiving O2 via nasal cannula with humidification at 3 LPM. Facility policy required routine changes of oxygen delivery devices, and the MD order specified weekly changes of oxygen tubing and related supplies with staff to initial and date them. During observation, the surveyor noted the tubing tag showed a change date several weeks earlier, and a CNA confirmed this date despite stating tubing is changed weekly. The DON later acknowledged that the tubing should be changed weekly and that the facility missed changing this resident’s oxygen tubing as ordered.
A resident with COPD and pulmonary hypertension was admitted with a hospital discharge order for 2 L/min oxygen at night, but the facility did not transcribe this order into the medical record. Admission documentation conflicted about whether the resident used supplemental O2, yet an oxygen care plan was initiated without specifying flow rate or frequency. Nursing notes later showed the resident receiving 2 L/min O2 via nasal cannula and then 3 L/min as documented by an NP, all without an active oxygen order. When an O2 order was finally entered, it only directed staff to titrate to keep SpO2 above 90% and did not specify flow rate or duration (continuous vs. nocturnal), and there was no documented ongoing monitoring to ensure the resident’s oxygen saturation remained above the ordered level.
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