The incident began November 23rd when the resident, identified in records as R1, was receiving occupational therapy. The therapist documented that R1 "presents with labored breathing, oxygen saturation of 89%" and had to shorten the therapy session because R1 was "unable to participate."
R1 had been admitted to the facility with a right femur fracture. Normal oxygen saturation levels range from 95% to 100%.
The therapist told R1 she couldn't do therapy "because of her breathing" and checked her vital signs, documenting them in notes. The therapist said she "told the nurse whose cart was immediately outside of R1's room."
But facility records show no evidence that anyone consulted R1's physician about the new breathing problems or low oxygen levels.
Two days later, at 3:00 AM on November 25th, R1's roommate rang the call bell. "I answered the call bell," said the licensed practical nurse who responded. "R1's roommate said that R1 can't breathbreath. I saw R1 and she didn't look well. R1 said she couldn't breathe."
The nurse checked R1's oxygen saturation. It had dropped to 88%.
"I put her on O2 at 2 liters," the nurse said. "It was between 3:00 and 4:00 AM. It was before my break."
Less than three hours later, at 5:51 AM, someone at the facility called 911 requesting emergency assistance for R1.
The EMS report documented what paramedics found when they arrived at 7:04 AM: "Nursing staff relayed at around 3am R1 began complaining of SOB [shortness of breath]. They [nursing staff] placed R1 on 5 lpm [liters per minute] of oxygen via NRB [non-rebreather mask]."
The nursing staff had increased R1's oxygen from 2 liters per minute to 5 liters per minute and switched her to a non-rebreather mask, which delivers higher concentrations of oxygen than standard nasal cannulas.
Still, no one had called R1's doctor.
Federal regulations require nursing homes to immediately notify residents' physicians of significant changes in condition. Starting a resident on oxygen therapy for breathing distress and low oxygen saturation typically constitutes such a change.
The facility's failure spanned multiple shifts and involved several staff members who witnessed or were told about R1's breathing problems.
On November 23rd, the occupational therapist observed R1's labored breathing and 89% oxygen saturation during therapy, then reported the problems to nursing staff. No physician consultation occurred.
Two days later, when R1's breathing worsened in the early morning hours and her oxygen saturation dropped to 88%, the night nurse started oxygen therapy but again failed to contact R1's doctor.
Even when staff increased R1's oxygen and switched to a non-rebreather mask before calling paramedics, they still hadn't consulted with her physician about the respiratory crisis that had been developing for days.
The inspection found that facility records "lacked evidence of documentation of consultation with R1's medical provider when she complained of shortness of breath, had a low oxygenation saturation level and was started on oxygen therapy."
R1's breathing problems were severe enough to prevent her from participating in physical therapy, require supplemental oxygen, and ultimately necessitate emergency medical services. Yet her physician remained unaware of the developing respiratory crisis until paramedics arrived to transport her from the facility.
The violation affects how quickly residents receive appropriate medical intervention when their conditions change. Physicians cannot adjust treatment plans, order additional tests, or prescribe medications for problems they don't know exist.
Federal inspectors confirmed their findings with facility administrators during an exit conference on December 23rd. The inspection report classified the violation as causing "minimal harm or potential for actual harm" to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Excelcare At Newark LLC from 2025-12-23 including all violations, facility responses, and corrective action plans.