Federal inspectors found that ExcelCare at Newark failed to consult with a resident's physician when she developed respiratory distress in November, despite facility requirements to immediately notify doctors of significant changes in patient condition.
The resident, identified as R1 in inspection records, was recovering from a right femur fracture when the breathing problems began on November 23. During an occupational therapy session at 2:52 PM, a therapist documented that R1 "presents with labored breathing, oxygen saturation of 89%." The session was cut short because R1 "unable to participate."
Normal oxygen saturation levels range from 95% to 100%. Levels below 90% indicate significant breathing problems requiring immediate medical attention.
Despite documenting the respiratory distress and dangerously low oxygen levels, facility records show no evidence that medical staff contacted R1's physician.
The situation deteriorated over the next two days. At approximately 3:00 AM on November 25, R1's roommate pressed the call bell for help. "I answered the call bell," LPN E7 told inspectors during a December interview. "R1's roommate said that R1 can't breathe. I saw R1 and she didn't look well. R1 said she couldn't breathe. R1 was at 88%."
The nurse immediately started oxygen therapy. "I put her on O2 at 2 liters. It was between 3:00 and 4:00 AM. It was before my break," E7 said.
But the oxygen wasn't enough.
At 5:51 AM that same morning, nursing staff called 911 requesting emergency assistance. Paramedics arrived at 7:04 AM and found that facility staff had placed R1 "on 5 lpm of oxygen via NRB," according to the EMS report. The abbreviation refers to a non-rebreather mask, which delivers high concentrations of oxygen for patients in severe respiratory distress.
The EMS report documented that "nursing staff relayed at around 3am R1 began complaining of SOB," using medical shorthand for shortness of breath.
Even after initiating oxygen therapy and calling paramedics, inspection records show the facility still had not contacted R1's physician about her condition.
The occupational therapist who first documented R1's breathing problems told inspectors she immediately reported her concerns to nursing staff. "I remember R1 did not do therapy that day," E8 said during a December interview. "I asked why she couldn't do therapy. R1 told me she couldn't do therapy because of her breathing. I checked her vitals and put them in my note. I told the nurse whose cart was immediately outside of R1's room."
Despite this direct communication between therapy and nursing staff on November 23, no physician consultation occurred.
Federal regulations require nursing homes to immediately notify residents' doctors and family members of significant changes in condition, injuries, or situations that affect patient care. The requirement ensures physicians can adjust treatment plans and family members stay informed about their loved ones' health.
ExcelCare at Newark's failure to consult R1's physician meant the doctor remained unaware of the developing respiratory crisis for at least 48 hours, from the initial documentation of breathing problems on November 23 through the emergency response on November 25.
The inspection found the facility "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."
Inspectors confirmed their findings with multiple facility administrators during exit conferences on December 23. The violation affected one resident and was classified as causing minimal harm or potential for actual harm.
R1's roommate ultimately became the person who ensured she received help, pressing the call bell when R1 couldn't breathe in the early morning hours of November 25.
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.