**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, Medical Director interview and oxygen vendor interview the facility failed to administer oxygen (02) as ordered by the physician for 1 of 2 residents reviewed for oxygen (Resident #46). The findings included: Resident #46 was admitted to the facility on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, asthma, and dependence on supplemental 02, right hemiplegia and hemiparesis Most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had cognitive impairment, used supplemental 02 and had a one sided impairment on the upper and lower extremities. Physician orders for Resident #46 included: -Incruse Ellipta 62.5 micrograms/actuation powder for inhalation, 1 puff daily for wheezing and shortness of breath dated 7/18/22 -02 at 5 liters per minute (l/min) via nasal cannula continuously for dependence on supplemental 02 dated 8/10/22 Resident #46's Care plan updated on 8/9/22 revealed Resident #46 had impaired respiratory status and required supplemental 02. The goal was Resident #46 would be free of respiratory infection and would have adequate 02 exchange. The interventions included monitor 02 sat every shift, 02 at 5L/min continuously to maintain 02 sat (measurement of the level of oxygen in the blood) above 89%, administer medication (incruse ellipta) as ordered. An observation was made of Resident #46 on 8/30/22 at 8:28 AM, the resident was lying in his bed with his nasal cannula in place in his nares. The nasal cannula tubing was connected to the 02 concentrator and the 02 concentrator was set at 6L/min. The resident did not appear to be in any distress. On 8/30/22 at 3:42 PM Resident #46 was observed in the dining room near the window. His nasal cannula was in place in the resident's nares and connected to the portable 02 tank. The resident's portable 02 tank was set on 8L/min and the 02-gauge needle was in the red, which indicated it was empty. The resident was in no respiratory distress. During an interview with Nurse Aide (NA) #3 on 8/30/22 at 4:07 PM revealed nurses were responsible for adjusting the residents 02 to the correct rate. NA's could apply the resident's nasal cannula and turn on the 02 concentrator or apply nasal cannula from the portable 02 tank to the resident, but the nurse was responsible for turning on the 02 tank. NA #3 demonstrated how she turned on the 02 concentrator. When turned on it was at 6L/min. She stated she did not think it was right and would notify the nurse. An interview was conducted on 8/30/22 at 4:20 PM with the Director of Nursing (DON). She stated Resident #46's 02 order in the electronic medical record (EMR) was 5L/min continuously. On 8/30/22 at 4:25 PM until 4:34 PM a continuous observation was conducted by this surveyor and the DON of Resident #46. During the observation an interview was conducted with the DON. Resident #46 was observed self-propelling in his wheelchair (WC) exiting from the activity room. The resident's 02 tank was held in a fabric sleeve attached to the back of his WC. The DON observed and indicated the dial on the 02 tank was set at 8L/min and adjusted the 02. When she was done, this surveyor asked that she view the 02 gauge. The 02 gauge was observed in the red, which indicated the tank was empty. The DON removed the nasal cannula tubing from the 02 tank, there was no sound of air escaping the 02 tank observed when the tubing was removed. The DON removed the 02 tank from the sleeve and stated she would get another 02 tank. Resident #46 was in no distress and continued to propel himself across the hall to the dining room. At 4:28 PM the DON returned with an 02 tank and placed it in the sleeve on the back of the resident's WC. This surveyor asked the DON if she had a pulse oximeter to check the resident's 02 sat. It took the DON approximately one minute to retrieve the pulse oximeter and at 4:29 PM the pulse oximeter was applied and the residents 02 sat was 74%. Resident #46 was in no respiratory distress; his breathing was normal, and his color was good. When asked if he felt ok, he nodded yes. At 4:30 PM the nasal cannula tubing was attached to the 02 tank by the DON. At 4:33 PM the Resident #46's 02 sat was 86% and at 4:34 PM the 02 sat was 92%. Resident #46 did not show any signs of distress at any time during the observation. During an interview and observation on 8/30/22 at 4:46 PM Nurse #2 explained, resident's that used 02 had their 02 sats measured every shift by either the nurse aide or nurse. If the 02 sat was below 90% it should be reported to the nurse. She further explained Resident #46 used 02 at 5L/min and she had not checked Resident #46's 02sat or tank yet because he was not in his room. She stated the resident was mobile in his WC and she would have to find him to check his 02 sat. Nurse #2 revealed she received report from Nurse #1 and Nurse #1 had changed resident #46's 02 tank and checked his 02 sat sometime before her shift ended. Nurse #2 stated she was not aware that the resident's 02 tank was set on 8L/min or that the in room concentrator was set on 6L/min. An observation was made with Nurse #2 of the 02 concentrator. Nurse #2 indicated the concentrator was set too high and she had adjusted it back to 5L/per min. She stated she did not know how that happened. An interview was conducted on 8/30/22 at 5:05 PM with the DON, who indicated she was not aware that Resident #46's 02 concentrator was set at 6L/min. She indicated nurses were responsible for ensuring their residents were receiving 02 at the ordered rate. During an interview on 8/31/22 at 11:00 AM Nurse #1 revealed she cared for Resident #46 during dayshift on 8/30/22. She further revealed the resident wore 5L/min and that she changed his 02 tank and turned the tank on 5L/min around 12:30 PM on 8/30/22. On 8/31/22 at 1:43 PM an interview was conducted with the oxygen vendor that supplies 02 tanks for the facility. The vendor revealed the facility used E sized tanks. An E sized tank that was completely full and had 02 running at 5L/min would be empty in 2 hours (hr) and 16 minutes (min). He further revealed if the E sized tank was completely full and had 02 running at 8L/min the tank would be empty in 1hr 25min. During an interview on 8/31/22 at 1:14 PM The Medical Director revealed he was familiar with Resident #46 and his need for 02 use. He indicated if the resident's 02 sats were lower than 88% he expected the staff to ensure the resident was wearing the 02 or encourage the resident to wear the 02 then recheck the 02 sat. If the 02 sat remained low, he expected to be notified. He further indicated he expected the nursing staff to use the ordered dose of 02. If there was a concern that the resident needed a change in the 02 dose, staff should call for a new order. The Medical Director stated he was aware of the events that took place with Resident #46 on 8/30/22 and did not believe the that it had any significant adverse effects on the resident.