New Lebanon Rehab: Oxygen Mask Used at Wrong Flow Rate - OH
NEW LEBANON, OH. When a nursing assistant noticed Resident #108 looked unwell during lunch rounds on February 27, 2025, the licensed practical nurse who responded found oxygen saturation levels in the 60 percent range — a medical emergency. What followed was a cascade of decisions made by people who, by their own later admission, did not know how the equipment they were using was supposed to work.
The resident, who had type II diabetes, stage III kidney disease, and dementia, was on 2 liters of oxygen per minute through a nasal cannula when the aide flagged LPN #173 around midday. LPN #173 assessed vital signs, called for backup, and reached Nurse Practitioner #83, who ordered oxygen at 5 liters per minute via non-rebreather mask. The order was placed. The mask was applied. Saturation climbed to 85 percent. The resident was sent to the hospital by emergency services.
The problem: a non-rebreather mask is designed to be used at 10 to 15 liters of oxygen per minute. At 5 liters, the mask's reservoir bag, which is supposed to stay inflated so the resident inhales concentrated oxygen rather than room air, does not function as intended. The device was applied correctly in the sense that it was placed on the resident's face. It was applied incorrectly in every clinical sense that mattered.
LPN #173 told inspectors she was unaware what oxygen flow rates were standard of care for a non-rebreather mask. She followed the provider's order. LPN #210, who was called into the room to assist, knew more: she told inspectors she was aware the mask required high-flow oxygen of at least 10 to 12 liters per minute. She also knew the facility's concentrators could go up to 10 liters. She verified the order had been written for 5 liters. She confirmed the mask had been placed on the resident as ordered.
NP #83, when interviewed, said he had intended to order the mask at the maximum flow rate the resident's concentrator would allow. He believed that maximum was 6 liters per minute. He had asked staff how high the concentrator went before writing the order. He was not aware the facility had concentrators that supported 10 liters. Had he known, he said, he would have ordered 10.
The facility's concentrators could support 10 liters. Nobody told him that. The nurse who knew it did not intervene. The nurse who placed the mask did not know enough to question the order. The order was written, the mask went on, and the resident's saturation rose only to 85 percent before emergency services were called.
There was a second problem the mask itself. LPN #173 documented that the non-rebreather mask did not fit Resident #108 properly around the chin, because of multiple skin folds in the neck. Staff had to hold the mask in place. A mask held against a face by hand, at half the minimum required flow rate, on a resident whose saturation had dropped into the 60s, was the intervention deployed while the facility waited for the ambulance.
Resident #108 returned to the facility that same evening. Admitting orders from the hospital included oxygen at 5 liters per minute via non-rebreather mask, the same order that had been in place before transport. The inspection report does not describe what happened after that. The resident died on February 27, 2025. The report does not specify whether the death occurred before or after the hospital visit, or what the cause of death was determined to be.
The facility had no policy specific to non-rebreather masks. Inspectors cited guidelines from the National Institutes of Health establishing that the standard flow rate for the device is 10 to 15 liters per minute. The gap between what those guidelines say and what happened in that room on February 27 was not a matter of a split-second decision under pressure. NP #83 asked staff a question before writing the order. The staff member who could have answered it correctly was in the room. The answer that came back was wrong, or did not come back at all, and nobody caught it before the mask went on.
The complaint investigation was completed September 30, 2025. The deficiency was cited at a level of minimal harm or potential for actual harm. The inspection report does not say what became of the resident in the hours after returning from the hospital, only that by the end of February 27, Resident #108 was gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Lebanon Rehabilitation and Healthcare Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 11, 2026 · Our methodology
NEW LEBANON REHABILITATION AND HEALTHCARE CENTER in NEW LEBANON, OH was cited for violations during a health inspection on September 30, 2025.
What followed was a cascade of decisions made by people who, by their own later admission, did not know how the equipment they were using was supposed to work.
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.