State inspectors found Resident 9 breathing oxygen at 4.5 liters per minute on September 24, when their physician had ordered 2 liters per minute. The licensed practical nurse observing the patient acknowledged the error during the inspection, stating the oxygen "was supposed to be at 2 lpm."
The violations extended beyond incorrect dosing. Resident 8, another COPD patient, was found with an empty humidifier bottle that hadn't been refilled since September 8. The resident required 2.5 liters of oxygen per minute through nasal tubing and used a CPAP machine at night for their newly diagnosed chronic obstructive pulmonary disease.
During the inspection, Resident 8 told investigators COPD was "a new diagnosis for them" and they were "having trouble keeping the CPAP on at night, but when it was able to stay on, they woke up feeling great."
Both residents' oxygen concentrators lacked proper humidification. Resident 9's machine ran without any humidifier bottle attached, despite facility orders requiring bottle changes every 28 days. The resident's physician had prescribed oxygen to keep blood oxygen saturation levels above 90 percent.
Equipment maintenance failures compounded the oxygen delivery problems. Staff documented following weekly tubing and filter cleaning orders, but the actual care didn't match the paperwork. Resident 8's humidifier sat empty for over two weeks while staff recorded completing maintenance tasks.
The facility's Director of Nursing acknowledged the systemic problems during interviews. Staff B stated "they needed to change how the orders were written." The Resident Care Manager, Staff F, confirmed basic safety protocols: "oxygen tubing and humidifiers should be changed weekly, and residents should receive oxygen at a rate ordered by the provider."
Inspectors discovered confusion among nursing staff about their responsibilities. Staff E reviewed documentation and stated they were "sure the nurses changed the tubing, and not the bottle." Staff F said "the tasks needed to be separated into different orders."
The oxygen monitoring failures created additional safety risks. A February physician's order directed staff to check blood oxygen saturation levels every shift, maintaining readings between 90-98 percent. While staff documented taking measurements, they failed to indicate whether readings were taken with or without supplemental oxygen, making the data medically meaningless.
Resident 9's case illustrated the scope of the violations. On September 19, inspectors observed the resident seated by a window without wearing oxygen, despite needing continuous therapy. A small oxygen tank with nasal tubing sat unused on their wheelchair while their bedside concentrator ran at 4 liters per minute without humidification.
Five days later, the same resident was found receiving 4.5 liters per minute instead of the prescribed 2 liters, with tubing that had been changed three days earlier but still no humidifier bottle.
The facility's Treatment Administration Records showed a pattern of documented compliance that didn't match actual care. Orders for weekly equipment changes appeared completed on paper, but residents continued using empty humidifiers and receiving incorrect oxygen flow rates.
Both residents had been diagnosed with COPD and experienced shortness of breath when lying flat, making proper oxygen therapy critical for their breathing and sleep quality. Resident 8's care plan specifically noted increased nasal saline gel was needed for dry nasal passages related to oxygen use with humidification.
The violations affected multiple aspects of respiratory care, from basic equipment maintenance to precise medication dosing. Staff acknowledged the problems during the inspection but had not corrected them despite documented physician orders dating back months.
State inspectors cited the facility for failing to ensure residents received treatment and care in accordance with professional standards of practice, noting the violations posed minimal harm or potential for actual harm to some residents.
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.