Inspectors found Resident #6 at Avir at Schertz on September 10th with the two-pronged device properly positioned in his nose but the other end of the tubing dangling free from the oxygen machine. The machine was on, running, and set to deliver two liters per minute of oxygen through tubing that led nowhere.
The resident told inspectors he wore oxygen "all the time because if he did not, he could get short of breath." When asked if his oxygen was on and running, he said yes, the oxygen was running through the tubing and prongs in his nose. He didn't feel short of breath at that moment.
He was wrong about the oxygen running. The charge nurse confirmed what inspectors observed.
"The resident's O2 tubing was in his nose but not connected to the oxygen machine," RN A told inspectors during an interview ten minutes later.
The 78-year-old resident had been admitted to the facility in April with chronic obstructive pulmonary disease and coronary artery disease. His cognitive assessment showed moderate impairment, suggesting some difficulty making decisions about care and daily activities. His care plan specified oxygen delivery via nasal prongs at 2-4 liters every shift.
But the facility had no documented care plan focus area for his chronic obstructive pulmonary disease, the primary condition requiring oxygen therapy.
RN A explained the risks when inspectors asked what could happen to a resident not properly connected to oxygen. The patient "could cause shortness of breath," she said. "Woozy, dizzy. Doesn't get enough air to the brain, he can get weird."
The charge nurse on duty was responsible for ensuring oxygen tubing was set up properly and connected to the machine, RN A confirmed.
Chronic obstructive pulmonary disease causes ongoing damage to airways and air sacs in the lungs, making breathing difficult. For residents like #6 who require continuous oxygen therapy, proper connection to delivery systems prevents respiratory distress, falls from dizziness, decreased ability to perform daily tasks, and potential hospitalization.
The inspection occurred after a complaint was filed against the facility. Inspectors requested the facility's respiratory care policy from the administrator on September 10th at 4:12 p.m.
The policy was never provided before the survey concluded on September 17th.
The facility's failure placed residents at risk of decreased oxygen levels, respiratory distress, falls, decreased ability to perform daily tasks, and hospitalization, according to the inspection report. Federal inspectors classified the violation as causing minimal harm or potential for actual harm.
Resident #6 had originally been admitted to Avir at Schertz on an earlier date before his current admission in April. The inspection found that few residents were affected by respiratory care deficiencies, but the case illustrated systemic problems with oxygen delivery oversight.
The resident's moderate cognitive impairment may have prevented him from recognizing that no oxygen was flowing through his nasal cannula. His belief that the system was working properly while sitting disconnected from his life-sustaining therapy highlighted the vulnerability of cognitively impaired residents who depend entirely on staff for proper medical equipment management.
The charge nurse's acknowledgment that disconnected oxygen could make residents "weird" from insufficient brain oxygen underscored the serious neurological risks beyond respiratory symptoms. Yet the basic safety check of ensuring tubing connection had failed.
Avir at Schertz operates at 3301 FM 3009 in Schertz, Texas. The facility has not provided its respiratory care policy to federal inspectors despite multiple days to produce the documentation following the September 10th request.
The inspection narrative noted that Resident #6 wore his nasal cannula consistently because he understood his need for supplemental oxygen. His compliance with wearing the device made the staff's failure to ensure proper connection more striking. He was doing his part while the facility failed to do theirs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Schertz from 2025-09-17 including all violations, facility responses, and corrective action plans.