§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
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Observations:
Based on facility policy review, review of manufacturer's instructions, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide adequate treatment and services for respiratory therapy for one of two sampled residents who utilized respiratory equipment. (Resident 47)
Findings include:
Review of the facility policy entitled, "Nebulizer Administration Policy," last reviewed February 6, 2026, revealed that when administering aerosolized medication via the tracheobronchial tree (a branching network of airways in the respiratory system that carries air from the environment to the lungs for gas exchange) using a nebulizer (a medical device that converts liquid medication into a fine mist for inhalation), prescribed medications were to be placed in the nebulizer cup for delivery of medication and only sterile solutions would be used.
A review of "Drive Power Neb Ultra Compressor Nebulizer" manufacturer's instructions for model number 18080 revealed that the machine was supposed to be used for the administration of prescribed medications.
Clinical record review revealed that Resident 47 had diagnoses that included chronic obstructive pulmonary disease (COPD) and a history of a coronavirus disease 2019, and was a daily cigarette smoker. Review of the Minimum Data Set assessment dated December 15, 2025, revealed that the resident was alert and oriented and that she utilized oxygen therapy. A physician's order dated March 3, 2024, directed staff to administer a medication that relaxes muscles in the airway to increase airflow to the lungs (ipratropium-albuterol solution) four times a day, as needed, for shortness of breath or wheezing via a nebulizer. A physician's order dated November 25, 2025, directed staff to assess Resident 47 for shortness of breath when lying flat on every shift. A review of the care plan identified that Resident 47 was at risk for respiratory complications due to altered pulmonary status and COPD and included administration of respiratory treatments as ordered. Staff were to assess the resident before and after each treatment. A review of Resident 47's Medication Administration Records from February 9, 2026, through March 9, 2026, revealed that staff documented the resident was short of breath while lying flat on day shift (7:00 a.m. to 7:00 p.m.) and night shift (7:00 p.m. to 7:00 a.m.) on March 7, 2026, and on day shift on March 8, 2026. There was no evidence that staff administered the as needed nebulizer medication for the shortness of breath at those times.
Observation on March 8, 2026, at 2:45 p.m., revealed that the resident was lying in bed with a nebulizer mask on her face. An aerosolized mist was observed coming from the mask, and the sound of the compressor nebulizer running was heard.
In an interview on March 10, 2025, at 2:30 p.m., Resident 47 stated that she felt short of breath after her cigarette breaks, used water from her drinking cup in the nebulizer, and was not aware of the health risks of using water in her nebulizer. She was not aware that nebulizer medication was available to her and she would have preferred to have the medication.
In an interview on March 10, 2025, at 2:20 p.m., the Administrator confirmed that staff did not administer a nebulizer medication to the resident, and that Resident 47 poured her drinking water into her nebulizer cup and administered it to herself.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 04/03/2026
On 3/12/26 Optum CRNP spoke with R47, non-compliance noted as the root cause of the deficient practice; risk of non-compliance discussed w R47 and she expressed understanding. On 3/18/26 noncompliance continued. Nursing assessment completed, no negative findings. Optum practitioner at that time discontinued the nebulized order.
All residents with medications administered via nebulization have the potential to be affected. On 3/13/2026 DON/ designee evaluated the residents' receiving medications via nebulization to ensure residents were receiving adequate treatment and services for respiratory therapy, no negative outcomes identified. Proactive education was completed, where able, to remind residents that only approved medication should be applied to the nebulizer machines.
To reduce the potential for recurrence, on DON/ designee reeducated the licensed nursing staff on the Nebulization Administration Policy.
To monitor and maintain ongoing compliance DON/ designee will audit weekly x 4 and monthly x 2 residents receiving medication via nebulization to ensure receiving adequate treatment and services for respiratory therapy. Results will be reviewed monthly during the facility quality assurance performance program.
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