The Pavilion At Sunny Hills

Review of Resident 2's care plan for asthma dated 1/20/26, showed give oxygen therapy as ordered by the physician.

Review of Resident 3's MDS assessment dated [DATE], showed a BIMS score of 12 (moderately impaired cognition).

Review of Resident 3's Order Summary Report dated 1/30/26, showed may use oxygen via nasal cannula at one to five LPM as needed to maintain oxygen of more than 92%. On 1/30/26 at 0945 hours, an observation was conducted in Resident 3's room.

The oxygen tubing curled around the portable oxygen tank was not bagged and labeled.

The portable oxygen tank was inside an oxygen holder at the back of Resident 3's wheelchair. In addition, Resident 3 was on oxygen therapy using an oxygen concentrator via nasal canula.

However, there was no oxygen in use signage outside of Resident 3's room. On 1/30/26 at 0949 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 verified Resident 3's oxygen tubing curled around the oxygen tank at the back of Resident 3's wheelchair was not bagged and labeled.

CNA 3 also verified Resident 3's entrance door did not have an oxygen in use sign. On 1/30/26 at 0952 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 verified Resident 3's oxygen tubing curled around the oxygen tank at the back of Resident 3's wheelchair was not bagged and labeled. LVN 5 stated it should have been bagged and labeled. LVN 5 also verified there was no oxygen in use signage in Resident 3's room entrance door. On 1/30/26 at 1100 hours, an interview was conducted with the IP.

The IP was informed and acknowledged the above findings.

The IP stated the oxygen and nebulizer tubing should be changed, bagged and dated by the night shift once a week and as needed.

The IP stated there should be an oxygen in use signage for all rooms with residents using oxygen.

The IP further stated the oxygen and nebulizer tubing should have been bagged and dated when not in use.

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