Northridge Health Center: Oxygen Left on Floor - OH
Resident #72 required continuous oxygen due to anoxic brain damage, pneumonia caused by antibiotic-resistant staph infection, chronic obstructive pulmonary disease, asthma, emphysema, and acute respiratory failure. The resident's cognitive skills were severely impaired and they were completely dependent for eating, toileting, and moving in bed.
When inspectors observed the resident at 9:56 a.m. on September 3, the oxygen concentrator was running but delivering nothing. The nasal cannula had fallen to the floor under medical equipment.
One minute later, Licensed Practical Nurse #202 entered the room as the surveyor was leaving. She identified herself as the resident's primary care nurse that day. LPN #202 walked directly to the bed, turned off the tube feeding, and left the room without addressing the oxygen equipment on the floor.
The nurse returned to her medication cart and began walking away down the hallway.
When the inspector immediately approached LPN #202 about the resident's oxygen therapy, she said she wasn't sure if the resident was supposed to receive oxygen. She opened the physician orders on her computer and discovered the resident had an order for continuous oxygen.
After the inspector requested she assess the resident's oxygen status, LPN #202 returned to the room and confirmed the tubing was on the floor. She used a pulse oximeter to check the resident's blood oxygen levels.
The readings showed between 86 and 88 percent oxygen saturation. Normal levels range from 95 to 100 percent.
LPN #202 told the inspector the resident's oxygen saturation had been 95 percent that morning when she assessed it, indicating the levels had dropped significantly while the resident went without supplemental oxygen.
The nurse obtained new tubing, connected it to the concentrator, and placed the nasal cannula in the resident's nostrils. She then left the room again.
But the problems weren't over.
The inspector noticed the oxygen concentrator was set to deliver 1.5 liters per minute. When asked how much oxygen the resident should receive, LPN #202 again said she wasn't sure and had to check the computer orders a second time.
The physician had ordered two liters of oxygen per minute, delivered continuously through a nasal cannula. LPN #202 returned to adjust the flow rate to the correct setting.
The resident had been admitted to Northridge Health Center on August 30, just four days before the inspection. The care plan dated September 1 specifically noted the potential for complications related to the resident's lung diseases and included interventions to "give oxygen as ordered."
Facility policy on oxygen administration, revised in October 2022, required staff to verify physician orders and turn oxygen on as directed by the medical practitioner. The policy's stated purpose was "to provide guidelines for safe oxygen administration."
The deficiency affected one of three residents reviewed for oxygen therapy at the 69-bed facility.
For someone with the resident's combination of severe respiratory conditions, interrupted oxygen delivery can worsen already compromised breathing and potentially lead to dangerous drops in blood oxygen levels. The resident's multiple lung diseases - including COPD, asthma, and emphysema - made continuous oxygen therapy medically necessary.
The inspection was conducted as part of a complaint investigation. The oxygen violation was discovered incidentally during the review of other issues at the facility.
LPN #202's uncertainty about basic oxygen orders for a resident under her direct care that day highlighted gaps in either training or communication about critical medical needs. The resident's severe cognitive impairment meant they couldn't advocate for themselves or alert staff to breathing difficulties.
The incident occurred during the day shift when staffing levels are typically highest and oversight should be most robust. Yet the primary nurse assigned to care for this medically complex resident was unaware of fundamental treatment requirements.
The resident's oxygen saturation drop from 95 percent to the mid-80s during the period without supplemental oxygen demonstrated the immediate physiological impact of the care failure. For someone already struggling with multiple respiratory conditions and brain damage from oxygen deprivation, any interruption in prescribed oxygen therapy poses serious risks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northridge Health Center, The from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
NORTHRIDGE HEALTH CENTER, THE in NORTH RIDGEVILLE, OH was cited for violations during a health inspection on September 11, 2025.
The resident's cognitive skills were severely impaired and they were completely dependent for eating, toileting, and moving in bed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.