Federal inspectors found that LPN #1 was told at 7:45 AM that Resident #2 could not breathe and was having problems with their oxygen concentrator. The nurse did not assess the resident, take vital signs, or check oxygen saturation levels during her entire shift.
By 10:40 AM, when a registered nurse and nurse practitioner finally reached Resident #2, they found the person sitting in a wheelchair, attached to the oxygen concentrator with a nasal cannula, gasping and using accessory muscles to breathe. Portable oxygen tanks were being used because of problems with the concentrator.
RN #1 told inspectors that LPN #1 never notified her that Resident #2 was having shortness of breath or that there were issues with the resident's oxygen equipment. The registered nurse said LPN #1 reported she had not conducted any respiratory assessment or taken vital signs or oxygen saturation levels that shift.
The delay proved critical. RN #1 told inspectors that if LPN #1 had notified her immediately at 7:45 AM about Resident #2's change in condition, she would have assessed the resident, contacted the provider, and transferred them to the Emergency Department. Resident #2 had a documented history of respiratory exacerbations.
The administrator confirmed during an interview at 11:17 AM that LPN #1 should have attended to Resident #2 immediately after staff notified her the resident could not breathe. The licensed nurse should have then notified the nursing supervisor and provider immediately.
Advanced Center's own change of condition policy, reviewed by inspectors, required staff to identify residents with potential changes in condition in a timely manner. Any alteration in a resident's baseline indicates a potential change of condition, and any resident with a change of condition must receive timely and appropriate intervention.
The policy specifically directed that all staff are responsible to report any concerns about a resident to the charge nurse. Licensed practical nurses are required to collect data and administer provider-ordered treatments or medications as indicated. The RN supervisor must be notified accordingly to assess and determine if a change of condition has occurred.
When a change of condition is identified, the policy mandated that the registered nurse make the nurse practitioner or medical doctor aware of the resident's current condition through in-person notification or telephone call using the Situation-Background-Assessment-Recommendation format.
The policy also required documentation in the resident's medical record and on the 24-hour report to ensure shift-to-shift communication and continuity of care.
None of these required steps were followed during the nearly three-hour window when Resident #2 struggled to breathe while connected to malfunctioning oxygen equipment.
Federal inspectors classified the violation as having caused minimal harm or potential for actual harm, affecting few residents. The incident occurred during a complaint investigation at the 169 Davenport Avenue facility in October.
The inspection found that Advanced Center failed to ensure residents received proper treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The facility's own policies outlined the exact steps that should have prevented the dangerous delay in care that Resident #2 experienced.
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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