The resident, identified as R3 in the September inspection report, arrived at the facility on September 15 with a cascade of serious conditions: acute respiratory failure with low oxygen levels, pneumonia, chronic obstructive pulmonary disease in acute crisis, chronic heart failure, irregular heartbeat, and high blood pressure.
His hospital discharge papers were explicit. Albuterol nebulizer treatments, 2.5 milligrams every six hours. The medication helps open airways for patients struggling to breathe.
R3 told inspectors he never received a single treatment during his stay. He had been on continuous oxygen therapy and nebulizer treatments for years, he said. By September 16, he demanded to be discharged because "he was not getting the medication he needed."
The facility's own medication records confirmed his account. Despite clear orders for treatments every six hours, staff documented no administration of the prescribed albuterol solution.
V15, the facility's nurse practitioner, verified to inspectors that R3's nebulizer treatment orders were never transcribed into the facility's system. They were never administered.
The failure violated the facility's own medication policy, dated October 14, 2024, which promises "accurate acquiring, receiving, dispensing, and administering of all medications" to meet each resident's needs.
For a patient with acute respiratory failure, the oversight wasn't academic. R3 had arrived from the hospital with lungs already compromised by pneumonia and COPD exacerbation. His oxygen levels were dangerously low. The nebulizer treatments were designed to help him breathe.
Instead, he spent 24 hours without the respiratory support his physician had deemed necessary for his condition.
Federal inspectors found the medication error during a complaint investigation at the Rock Island facility. They reviewed three residents' respiratory treatments and found St Anthony's had failed one of them completely.
The inspection report doesn't detail what prompted R3's original hospitalization or how his respiratory crisis developed. But his discharge diagnosis painted a picture of a patient whose lungs and heart were under severe stress.
Acute respiratory failure means the lungs can't provide enough oxygen to the blood or remove enough carbon dioxide. Combined with pneumonia and a COPD flare-up, R3's breathing was compromised on multiple levels.
Chronic systolic heart failure added another layer of complexity. His heart couldn't pump blood effectively, potentially causing fluid to back up into his lungs and making breathing even harder.
The albuterol treatments he never received work by relaxing muscles around the airways, allowing them to open wider. For patients with COPD and acute breathing problems, these treatments can mean the difference between stable breathing and respiratory distress.
R3's decision to leave after one day speaks to his desperation. Patients don't typically discharge themselves from nursing facilities without serious concerns about their care.
He had lived with his breathing problems for years, he told inspectors. He knew what treatments he needed and when he wasn't getting them.
The facility's medication administration records showed a system breakdown at multiple levels. The hospital's clear orders never made it into St Anthony's treatment protocols. No staff member caught the omission. No supervisor noticed the gap.
R3 spent his single day at the facility asking for treatments that never came.
By the time inspectors arrived, R3 was long gone. But his experience illustrated what federal regulators call a significant medication error - the kind that can cause actual harm to residents who depend on nursing homes for life-sustaining care.
The inspection classified the violation as causing "minimal harm or potential for actual harm." But for R3, struggling to breathe without his prescribed treatments, the distinction likely felt academic.
He voted with his feet, leaving St Anthony's after 24 hours to find the respiratory care his doctor had ordered and his lungs required.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Anthony's Nsg & Rehab Ctr from 2025-09-24 including all violations, facility responses, and corrective action plans.