WASHINGTON, IN - A complaint investigation at Villages At Oak Ridge, The concluded on April 2, 2025, revealed staffing deficiencies that led to failures in implementing and following oxygen therapy orders for residents.
Staffing Shortages Linked to Oxygen Order Failures
Federal investigators documented that insufficient nursing staff at the Washington, Indiana facility resulted in oxygen orders not being properly entered into resident care systems and, subsequently, not being followed as prescribed.
The citation, issued under F690 (which addresses bowel and bladder incontinence care) with a cross-reference to F725 (sufficient nursing staff), indicates the violations were interconnected - inadequate staffing levels directly contributed to lapses in respiratory care protocols.
The deficiency was classified at a "minimal harm" level, meaning while the violation occurred, investigators determined it did not result in actual harm to residents but had the potential to cause more than minimal harm if left uncorrected.
Understanding the Medical Significance
Oxygen therapy is a critical intervention for residents with respiratory conditions including chronic obstructive pulmonary disease (COPD), pneumonia, heart failure, and other cardiopulmonary disorders. When oxygen orders are not properly documented in a facility's care system, nursing staff may be unaware of a resident's prescribed oxygen flow rate, duration of use, or specific circumstances requiring supplemental oxygen.
Proper oxygen administration requires precise documentation including the prescribed liter flow rate, delivery method (nasal cannula, face mask, or other devices), continuous versus intermittent use schedules, and target oxygen saturation levels. Without this information accessible to all caregiving staff, residents may receive incorrect oxygen levels or miss treatments entirely.
Insufficient oxygen delivery can lead to hypoxemia - dangerously low blood oxygen levels - which may cause confusion, shortness of breath, elevated heart rate, and in severe cases, organ damage. Conversely, excessive oxygen in certain populations, particularly those with COPD, can suppress respiratory drive and lead to carbon dioxide retention.
Industry Standards for Oxygen Management
According to established nursing home care protocols, oxygen orders should be entered into resident care systems immediately upon physician prescription. The order should then be verified by a licensed nurse, and all direct care staff should be informed of the resident's oxygen requirements during shift handoffs and through accessible care documentation.
Standard practice requires nursing facilities to maintain sufficient staff to ensure timely processing of physician orders, particularly for life-sustaining treatments such as oxygen therapy. The federal requirement under F725 mandates that facilities have "sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety."
When staffing levels fall below what is necessary to manage these fundamental care processes, critical orders may remain unprocessed in queue systems, fax machines, or electronic inboxes - creating gaps in care that can affect resident health outcomes.
The Connection Between Staffing and Care Quality
The documented violation illustrates a pattern frequently observed in nursing home oversight: inadequate staffing does not typically result in a single isolated failure but rather creates systemic vulnerabilities across multiple care domains. When nurses are stretched thin managing immediate resident needs, administrative tasks including order entry and care plan updates may be delayed or overlooked.
Nursing homes are required to assess their staffing needs based on resident acuity levels, the complexity of care required, and the specific services offered. Facilities providing respiratory therapy services must account for the additional time required to manage oxygen equipment, monitor resident responses, and document oxygen saturation readings.
The Centers for Medicare and Medicaid Services (CMS) has emphasized that staffing sufficiency is not merely about meeting minimum numerical requirements but about ensuring enough qualified personnel are present to meet all resident care needs safely and effectively.
Additional Issues Identified
The inspection documentation indicates this citation was part of a broader survey that identified deficiencies requiring corrective action. The facility is required to submit a plan of correction to the state survey agency detailing how it will address the staffing and oxygen order management failures and prevent similar occurrences.
Facilities found deficient must implement systemic changes, which may include revising staffing schedules, implementing additional checks for order processing, enhancing communication protocols between shifts, and providing additional staff training on order management procedures.
What Should Have Occurred
According to standard care protocols, when a physician prescribes oxygen therapy for a nursing home resident, the following sequence should occur: the order is received and logged immediately, a licensed nurse reviews and verifies the order, the order is entered into the electronic or paper-based care system, direct care staff are notified of the new order, the oxygen equipment is set up at the prescribed rate, and the resident's response to therapy is monitored and documented.
Each step in this process requires adequate staffing to be completed in a timely manner. When any link in this chain fails due to insufficient personnel, residents may not receive prescribed treatments as intended by their physicians.
The Villages At Oak Ridge is located at 1694 Troy Road in Washington, Indiana. The facility's plan to correct the identified deficiencies can be obtained by contacting the nursing home directly or through the state survey agency.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villages At Oak Ridge, The from 2025-04-02 including all violations, facility responses, and corrective action plans.
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