The resident died at 10:40 AM on the inspection date. The nurse had been told at 7:45 AM that the patient couldn't breathe.
LPN #1 told federal inspectors at Advanced Center for Nursing & Rehabilitation that nursing assistants notified her "shortly after the start of the shift" that Resident #2 was experiencing shortness of breath. She directed them to bring two portable oxygen tanks into the room.
Then she did nothing else.
"She should have taken Resident #2's vital signs, assessed Resident #2 and then notified the provider and the nursing supervisor but she did not," the inspection report states.
The nursing supervisor, RN #1, was making rounds on Resident #2's unit at 9:20 AM — nearly two hours after the breathing crisis began. She asked LPN #1 if she needed anything.
LPN #1 said no.
At 10:40 AM, nursing assistant #1 yelled across the facility that Resident #2 couldn't breathe and needed help. RN #1 ran to the room, followed by the nurse practitioner.
They found Resident #2 sitting in a wheelchair, attached to an oxygen concentrator with a nasal cannula, gasping and using accessory muscles to breathe.
The resident died moments later.
RN #1 told inspectors that before 10:40 AM, LPN #1 had never mentioned that Resident #2 was having breathing problems, that there were issues with the patient's oxygen concentrator, or that portable tanks were being used instead.
LPN #1 admitted to the nursing supervisor that she had not conducted a respiratory assessment, taken vital signs, or measured oxygen saturation levels during her entire shift.
The nurse practitioner told inspectors he was unaware that Resident #2 had been reporting shortness of breath since 7:45 AM. Had he been notified immediately, he said, he would have transferred the resident to the emergency department.
"This could have prevented Resident #2's death," the inspection report quotes him saying.
Resident #2 had a documented history of respiratory exacerbations, making the delay even more dangerous. RN #1 told inspectors that if LPN #1 had notified her immediately of the breathing problems at 7:45 AM, she would have assessed the resident, called the provider, and arranged emergency department transport.
The administrator learned about the three-hour delay only after the resident had died.
"The Administrator explained LPN #1 should have attended to Resident #2 immediately after staff notified her around 7:45 AM Resident #2 could not breathe and then notify the nursing supervisor and provider," the inspection report states.
The facility's own change of condition policy, dated earlier this year, explicitly requires staff to identify residents with potential changes of condition "in a timely manner." Any alteration from a resident's baseline indicates a potential change of condition requiring "timely and appropriate intervention."
The policy assigns specific responsibilities to each staff level. All staff must report concerns about residents to the charge nurse. Licensed practical nurses must collect data and administer treatments or medications as ordered by providers.
The registered nurse or supervisor must then assess whether a change of condition has occurred and notify the nurse practitioner or medical doctor using a standardized communication format.
None of this happened.
Instead, nursing assistants — the lowest-paid and least-trained staff in the facility — were left to manage a dying resident's oxygen crisis while the licensed nurse responsible for clinical assessments stayed away from the room.
The portable oxygen tanks the nursing assistants brought to the room suggest they understood the gravity of the situation better than LPN #1. Oxygen concentrators, which extract oxygen from room air, can malfunction or provide insufficient oxygen flow for residents in respiratory distress. Portable tanks deliver concentrated oxygen at higher flow rates.
But portable tanks are temporary measures. They require monitoring, flow rate adjustments, and clinical assessment to determine whether emergency intervention is needed.
For nearly three hours, Resident #2 received none of that clinical oversight.
The inspection occurred as part of a complaint investigation, suggesting someone — likely a family member or staff member — reported concerns about the resident's death to state health officials.
Federal inspectors classified the violation as causing "actual harm" to "few" residents, the second-highest severity level in the Medicare inspection system. The finding triggers automatic scrutiny of the facility's clinical practices and could result in monetary penalties or other sanctions.
The facility is required to submit a plan of correction detailing how it will prevent similar deaths in the future.
But for Resident #2's family, those systemic changes come too late. Their loved one died not from the underlying respiratory condition, but from a nurse's decision to ignore a medical emergency for three hours.
The nursing assistants who first recognized the crisis and brought oxygen tanks to the room followed their training. The nurse practitioner who ran to help when finally alerted responded appropriately.
LPN #1 alone chose to look away while a resident suffocated.
The inspection report provides no explanation for why LPN #1 avoided assessing a resident in obvious respiratory distress, why she lied to her supervisor about needing help, or why she allowed nearly three hours to pass before the medical team learned of the emergency.
What it documents is a preventable death caused by a single nurse's abandonment of basic professional duties while other staff members tried desperately to keep a resident alive.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Advanced Center For Nursing & Rehabilitation from 2025-10-02 including all violations, facility responses, and corrective action plans.
Additional Resources
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