The 81-year-old man, identified as Resident #98, had two active physician orders requiring oxygen therapy. One order from December specified oxygen at 2 to 4 liters per minute if his blood oxygen dropped below 90 percent. A January order required 2 liters of oxygen via nasal cannula at bedtime.
When inspectors arrived at 8:49 AM on September 23, they found the resident sitting in his wheelchair while a nursing assistant helped him with daily care. His oxygen concentrator was running, but all the tubing was stuffed into a plastic bag hanging on the machine. The nasal cannula was not in his nose.
The resident appeared lethargic and failed to respond to most questions or prompts from the nursing assistant while off his oxygen.
CNA #2 told inspectors at 8:51 AM that she had just moved the resident into his wheelchair and would reapply his oxygen after finishing getting him ready for the day.
Nine minutes later, LPN #1 acknowledged the resident should have been on oxygen at 2 liters per minute. She said he had required daytime oxygen over the weekend due to shortness of breath and low blood oxygen levels.
The nurse admitted the resident had not complained of breathing difficulties but was acting confused and lethargic, which she recognized as signs of low blood oxygen.
When LPN #1 finally checked his oxygen levels at 9:04 AM, they had plummeted to 81 percent on room air. She immediately applied oxygen at 2 liters per minute but had to increase the flow to 4 liters to bring his blood oxygen above 90 percent.
Normal blood oxygen levels range from 95 to 100 percent. Levels below 90 percent are considered dangerously low and can cause organ damage.
The resident suffered from chronic obstructive pulmonary disease, a group of lung diseases that cause progressive airflow obstruction and breathing difficulties. He also had Parkinson's disease, a neurodegenerative disorder that affects movement and can complicate respiratory function.
LPN #1 instructed the nursing assistant to notify licensed nurses if residents appear lethargic, fail to respond to prompts, or seem short of breath so they can properly assess the situation.
Two days later, the Director of Nursing acknowledged that residents showing lethargy and poor responsiveness should be assessed by licensed nurses for low blood oxygen levels. She admitted this assessment had not occurred.
The violation created potential for residents to experience increased fatigue and dangerously low oxygen levels, according to the inspection report. Federal regulations require nursing homes to provide safe and appropriate respiratory care when needed.
The facility's failure represented a breakdown in basic respiratory monitoring for a vulnerable resident whose medical conditions made oxygen therapy essential for his safety and well-being.
The inspection was conducted in response to a complaint. Meadow View Nursing and Rehabilitation is located at 46 North Midland Boulevard in Nampa.
The resident's confusion and lethargy while off oxygen demonstrated the immediate health risks created when staff failed to follow physician orders for respiratory care. His blood oxygen recovery only after nurses increased the flow to maximum ordered levels showed how critical the therapy was for his condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadow View Nursing and Rehabilitation from 2025-11-19 including all violations, facility responses, and corrective action plans.
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