Staff at Agility Health and Rehabilitation were giving Resident 9 oxygen at 4.5 liters per minute when the doctor had ordered 2 liters per minute. Licensed Practical Nurse Staff G spotted the error during a September 24 interview with inspectors, stating the oxygen "was supposed to be at 2 lpm."
The violations extended beyond incorrect dosing. Inspectors found both residents using oxygen concentrators without humidifier bottles, equipment designed to prevent the dry oxygen from irritating nasal passages and airways.
When inspectors observed Resident 8 on September 19, the patient's humidifier bottle was completely empty despite being dated September 8 — eleven days earlier. The resident told inspectors that COPD was a new diagnosis and they were "having trouble keeping the CPAP on at night, but when it was able to stay on, they woke up feeling great."
Resident 9's concentrator ran without any humidifier bottle at all during multiple inspection visits. On September 19, inspectors found the patient seated by a window, not wearing oxygen despite having a small tank with tubing attached to their wheelchair.
The facility's own policies called for weekly changes of oxygen tubing and humidifier bottles. Treatment Administration Records showed orders from February requiring staff to change humidifier bottles every 28 days and oxygen tubing weekly every Sunday night shift.
Staff documented completing some tasks but missed others entirely. For Resident 9, records showed the humidifier bottle was changed August 26 but inspectors found no bottle in use during September visits. Oxygen tubing changes were documented September 7, 14 and 21, but the concentrator ran at the wrong flow rate.
The oxygen monitoring created additional problems. A February physician's order directed staff to check Resident 8's oxygen saturation every shift, maintaining levels between 90-98 percent. Staff recorded the measurements but failed to document whether readings were taken with or without supplemental oxygen — a critical distinction for patients with COPD.
During interviews, facility leadership acknowledged the systemic problems. Director of Nursing Staff B stated "they needed to change how the orders were written." Resident Care Manager Staff F confirmed that "oxygen tubing and humidifiers should be changed weekly, and residents should receive oxygen at a rate ordered by the provider."
Staff E, when questioned about documentation gaps, said they were "sure the nurses changed the tubing, and not the bottle." Staff F acknowledged "the tasks needed to be separated into different orders."
Both residents carried diagnoses requiring careful oxygen management. Resident 8 experienced shortness of breath with exertion and when lying flat, used a CPAP machine at night, and required nasal saline gel for dryness related to oxygen therapy. Resident 9 also had COPD with shortness of breath when lying flat.
The inspection revealed a facility struggling with basic oxygen safety protocols despite having written policies in place. Equipment sat empty for days, flow rates exceeded prescribed levels by more than double, and staff documentation failed to capture essential monitoring information.
Federal regulations require nursing homes to ensure residents receive treatments and medications as prescribed by physicians. The oxygen therapy violations affected multiple residents and involved both dosing errors and equipment maintenance failures that could compromise respiratory care for vulnerable patients with chronic lung disease.
The deficiencies occurred despite the facility having detailed treatment orders dating back to February 2025, suggesting the problems persisted for months before federal inspectors identified them during their November complaint investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Agility Health and Rehabilitation from 2025-11-25 including all violations, facility responses, and corrective action plans.