The resident, identified only as Resident #3, had acute respiratory failure with low oxygen levels in body tissues, Chronic Obstructive Pulmonary Disease, and anxiety disorder. A physician ordered oxygen administration via nasal cannula at two to three liters per minute as needed for shortness of breath to maintain oxygen saturation above 92 percent on September 19, 2022.
When inspectors observed the resident on September 24, 2025, an oxygen concentrator was running and set at three liters via nasal cannula. The resident scored fifteen out of fifteen on a mental status assessment, indicating they were alert and oriented to person, place, and time. They were independent with activities of daily living and utilized oxygen therapy.
But no care plan existed.
Inspectors reviewed clinical records on September 25 and September 26 and failed to identify any resident care plan addressing the respiratory diagnoses or oxygen utilization. The facility scrambled to develop a care plan on September 29 — only after inspectors began their review.
Regional Nurse Licensed Practical Nurse #5 acknowledged during a September 30 interview that a care plan should have been in place identifying the resident's respiratory diagnoses and oxygen utilization. The nurse explained the Interdisciplinary Team was responsible for reviewing and revising care plans but was "unsure why a care plan was not in place."
Federal regulations require nursing homes to develop complete care plans within seven days of comprehensive assessments. The facility's own policy, dated January 30, 2025, mandates that the Interdisciplinary Team develop comprehensive, person-centered care plans for each resident.
The policy specifies that care plans must include measurable objectives and timeframes, describe services to maintain residents' highest practicable physical, mental and psychosocial well-being, and incorporate identified problem areas and risk factors. Care plans should reflect treatment goals, identify responsible professional services, and reflect recognized standards of practice.
The resident's quarterly assessment had identified their oxygen therapy use. The facility policy requires the team to review and update care plans when there's been a significant change in the resident's condition, when residents are readmitted from hospital stays, and at least quarterly alongside required assessments.
For Resident #3, none of this happened.
The resident continued receiving oxygen therapy while facility staff failed to create formal interventions addressing their respiratory condition. The physician's order from September 2022 remained in effect, directing oxygen administration to prevent dangerous drops in blood oxygen levels — a critical safety measure for someone with COPD and acute respiratory failure.
Chronic Obstructive Pulmonary Disease restricts airflow and makes breathing difficult. Acute respiratory failure with hypoxia means the lungs cannot provide adequate oxygen to body tissues, a potentially life-threatening condition requiring careful monitoring and intervention.
The facility's comprehensive care planning policy emphasizes that identifying problem areas and developing targeted interventions represents "the endpoint of an interdisciplinary process." Assessments should be ongoing, with care plans revised as residents' conditions change.
But for more than two years, Resident #3's oxygen-dependent respiratory conditions went without formal care planning. The resident received oxygen therapy based solely on the 2022 physician's order, without the comprehensive interventions and monitoring protocols that care plans provide.
The interdisciplinary team that LPN #5 said was responsible for care plan development includes multiple healthcare professionals who should collaborate on resident care. Their failure to address Resident #3's respiratory needs violated both federal regulations and the facility's own policies.
Only when federal inspectors arrived and began reviewing records did the facility recognize the gap. The September 29 care plan development came three years after the initial physician's order and only under regulatory scrutiny.
The inspection classified this as minimal harm or potential for actual harm affecting few residents. But for Resident #3, the absence of formal care planning meant their complex respiratory condition lacked the structured interventions and monitoring that comprehensive care plans provide.
Advanced Center for Nursing & Rehabilitation operates at 169 Davenport Avenue in New Haven. The facility must now explain to federal regulators how a resident with life-threatening respiratory conditions received oxygen therapy for over two years without the basic care planning that regulations require.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Advanced Center For Nursing & Rehabilitation from 2025-10-02 including all violations, facility responses, and corrective action plans.
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