Every finding on record at Crocker Pointe Health and Rehabilitation

Based on record review, observation, and interview, the facility failed to ensure that orders for oxygen administration were complete and accurate. This affected three out of three residents (#56, #63 and #64) of three residents reviewed for oxygen therapy. The facility identified 19 residents receiving oxygen therapy at the facility. The facility census was 86.Findings include:1. A review of the medical record for Resident #56 revealed a readmission date of 06/05/25 with diagnosis of hypoxia, dementia, and diabetes.A review of the physician's orders for Resident #56 revealed an order dated 09/26/25 for oxygen continuous per nasal cannula. The order specified to titrate the oxygen to keep the oxygen saturation level greater than or equal to 90%. No liter flow was specified in the order.An observation on 10/07/25 at 2:48 P.M. revealed Resident #56 was sitting in their room, in a wheelchair, connected to an oxygen tank with a flow rate set at 6 liters of oxygen per minute. Resident #56 was in no distress and able to converse with ease. Licensed Practical Nurse (LPN) #572 verified the liter flow at the time of observation. An interview on 10/09/25 at 11:32 A.M. with Registered Nurse (RN) #621 confirmed that the physician's order for oxygen was not complete due to not specifying a liter flow rate. RN #621 further confirmed that they did not know what Resident #56 oxygen was ordered to be set at and could not monitor it for accuracy. 2. A review of the medical record for Resident #63 revealed an admission date of 06/02/25 with diagnosis of chronic obstructive pulmonary disease unspecified, obstructive sleep apnea, and Barrett's esophagus.A review of the physician's orders for Resident #63 revealed an order dated 08/12/25 for oxygen via nasal. Titrate for oxygen saturation equal to or greater than 90%. No flow rate or duration of use was specified in the order.An observation on 10/07/25 at 2:54 P.M. revealed Resident #63 lying in bed with the head of the bed elevated. Resident #63 was wearing an oxygen nasal cannula connected to an oxygen concentrator set at four liters per minute. Resident was eating a sandwich and in no distress. LPN #572 verified the liter flow at the time of observation.An interview on 10/09/25 at 11:32 A.M. with RN #621 confirmed that the physician's order for oxygen was not complete due to not specifying a liter flow rate. Further confirmed that they did not know what Resident #63 oxygen was ordered to be set at and could not monitor it for accuracy.3. A record review for Resident #64 revealed and admission date of 03/01/25 with diagnosis of cognitive deficit after a cerebral infarct, chronic obstructive pulmonary disease, and hypothyroidism.A review of Resident #64 physician's orders revealed an order dated 09/02/25 for oxygen continuous per nasal cannula to maintain oxygen saturation equal to or greater than 88%.An observation on 10/07/25 at 2:32 P.M. revealed Resident #64 sitting in her room in a recliner. Resident was wearing an oxygen nasal cannula connected to an oxygen concentrator set at two liters per minute. LPN #572 verified the liter flow at the time of observation.An interview on 10/09/25 at 11:32 A.M. with RN #621 confirmed that the physician's order for oxygen was not complete due to not specifying a liter flow rate. Further confirmed that they did not know what Resident #64 oxygen was ordered to be set at and could not monitor it for accuracy.Review of facility policy titled Oxygen Administration last revision date 06/30/24 revealed oxygen is administered to residents who need it, consistent with professional standards of practice. The policy specified oxygen is administered under orders of a physician, except in the case of an emergency. Review of facility policy titled Oxygen Administration last revision date 06/30/24 revealed oxygen is administered to residents who need it, consistent with professional standards of practice. The policy specified oxygen is administered under orders of a physician, except in the case of an emergency. This deficiency represents non-compliance investigated under Complaint Number 2601947.