Advanced Center for Nursing & Rehabilitation: Oxygen Failures - CT
Immediate jeopardy means inspectors concluded the failure had placed residents in a situation where serious injury, harm, or death was possible or had already occurred. The facility serves a limited number of residents affected, according to the citation, but for those residents, oxygen is not optional.
The facility's own written policy spelled out exactly what was supposed to happen when oxygen equipment failed. Staff were to immediately move the resident to a portable tank. The supervisor and the treating provider were to be notified without delay. The malfunctioning concentrator was to be pulled from service. Any report of shortness of breath was supposed to trigger an immediate nursing assessment, with vital signs, oxygen saturation levels, and a full respiratory examination, followed by documentation and a call to the provider and supervisor.
None of that happened the way it was written.
The gap between the policy on paper and what actually reached residents is what brought inspectors to Davenport Avenue. The facility's own documentation acknowledged that changes in respiratory status were to be assessed, documented, and reported without delay. The inspection record does not suggest that standard was met.
Oxygen concentrators are the machines most nursing home residents use as their primary source of supplemental oxygen. They pull air from the room, filter out nitrogen, and deliver concentrated oxygen through a tube. When they malfunction, a resident who cannot breathe adequately on room air has seconds to minutes before the situation becomes a medical emergency. The portable tank is the backup. It exists precisely because concentrators can fail.
The facility's policy understood this. It named the portable tank as the immediate response. It named the supervisor. It named the provider. It laid out a chain of notification designed so that no one who needed to know would be left uninformed while a resident struggled to breathe.
That chain did not hold.
The inspection was prompted by a complaint, meaning someone, a resident, a family member, a staff member, contacted regulators before inspectors arrived. The complaint process exists because problems inside nursing homes are not always visible from the outside, and the people most affected are often the least able to advocate for themselves. Oxygen-dependent residents are, by definition, medically fragile. Shortness of breath in an elderly person with compromised respiratory function can escalate quickly.
Advanced Center for Nursing & Rehabilitation sits at 169 Davenport Avenue in New Haven, a city with one of the highest poverty rates in Connecticut. The facility holds a Medicare and Medicaid provider number, meaning it receives federal funding and is subject to federal oversight. The October 2 inspection was a complaint survey, not a routine annual visit.
The immediate jeopardy tag, designated F0695 under the federal deficiency coding system, covers respiratory care. It is not a paperwork violation. It is not a documentation gap. It is a finding that residents who needed functioning oxygen equipment did not have it when they needed it, and that the facility's own systems, the shift-to-shift communication, the 24-hour report, the supervisor notification chain, did not catch the failure in time to prevent the harm inspectors concluded was possible.
The plan of correction, if one was submitted, is available through the facility or the Connecticut state survey agency. What the inspection record contains is the finding itself: a nursing home with a written policy for exactly this kind of emergency, and residents for whom that policy did not work.
For someone who cannot breathe without a machine, the difference between a policy that functions and one that does not is not administrative. It is the difference between getting air and not getting it.
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.
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
ADVANCED CENTER FOR NURSING & REHABILITATION in NEW HAVEN, CT was cited for violations during a health inspection on October 2, 2025.
The facility serves a limited number of residents affected, according to the citation, but for those residents, oxygen is not optional.
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.