The patient, identified as Resident #1 in inspection records, arrived at Glenburnie Rehab & Nursing Center with hospital discharge papers clearly stating he needed "CPAP at night" for his sleep apnea and congestive heart failure. Federal inspectors found no evidence the facility ever provided the device during his stay.
His hospital discharge summary documented acute respiratory failure secondary to congestive heart failure and obstructive sleep apnea, with specific instructions for nighttime CPAP use. The breathing device uses mild air pressure to keep airways open during sleep, preventing the repeated airway blockages that characterize sleep apnea.
On October 14, facility staff documented awareness of the problem. A progress note stated: "Writer spoke with NP (nurse practitioner) in regards to Bipap placement d/t (due to) rsd (resident) was on Cpap during stay in the hospital. NP stated she will place and order for Bipap. Writer notified respiratory therapist. he stated he will come to the facility and set up the machine."
The respiratory therapist never came. No machine was ever set up.
Inspectors reviewed the resident's complete clinical record and found no evidence a CPAP device was initiated at any point during his facility stay. The October 14 note remained the only documentation of efforts to provide the prescribed respiratory care.
LPN #1, a unit manager interviewed during the inspection, explained the facility's typical process for CPAP patients. "If a resident needs a CPAP on admission, this information is usually in the hospital discharge summary," she said. "The admitting nurse should verify the order with the physician and the physician should be informed that the facility does not have CPAP machines in stock."
She described what should happen next: the physician might place alternative orders until the central supply clerk could obtain a CPAP device for the resident. Most residents who need CPAP machines bring their own devices from home, she explained.
But even when residents have their own equipment, she acknowledged the facility bears responsibility. "Even if the resident has a CPAP at home, it is still the facility's responsibility to provide one at the facility if the resident is unable to bring the device from their home."
The breakdown occurred somewhere between recognition and action. Staff identified the need on October 14. The nurse practitioner promised to place an order for a BiPAP device, a more advanced version of CPAP that provides varying air pressures. The respiratory therapist said he would come set up equipment.
None of it happened.
Obstructive sleep apnea causes the upper airway to become blocked repeatedly during sleep, reducing or completely stopping airflow. For patients with congestive heart failure, untreated sleep apnea compounds respiratory distress and can worsen heart function.
The resident's case illustrates a gap between policy and practice at the facility. Staff understood the admission process for CPAP patients and knew alternative arrangements were needed when devices weren't immediately available. They documented conversations with medical providers about obtaining equipment.
But the clinical record shows no follow-up after October 14. No orders were actually placed. No respiratory therapist arrived. No alternative treatments were implemented while waiting for equipment.
When inspectors interviewed the administrator and director of nursing on October 29, they requested the facility's CPAP policy. None was provided before the inspection concluded.
The violation affected respiratory care for a vulnerable patient whose hospital stay had already been complicated by acute respiratory failure. His discharge plan specifically included nighttime CPAP therapy as part of his ongoing treatment for both sleep apnea and heart failure.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. But for Resident #1, the failure meant weeks without the prescribed breathing support that his doctors determined necessary for safe recovery.
The facility's own staff had identified exactly what needed to happen. The nurse practitioner knew an order was required. The respiratory therapist was contacted and ready to help. The unit manager understood the process and the facility's responsibilities.
What they couldn't accomplish was turning those conversations into actual care for a patient who needed to breathe safely through the night.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glenburnie Rehab & Nursing Center from 2025-10-29 including all violations, facility responses, and corrective action plans.
Additional Resources
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