The September incident at Agility Health and Rehabilitation illustrates broader oxygen safety failures that federal inspectors documented during a complaint investigation. Two residents with chronic obstructive pulmonary disease received improper oxygen therapy, with staff unable to explain dosing errors and equipment running without required humidifiers.
Resident 9 needed oxygen at 2 liters per minute to keep blood oxygen levels above 90 percent, according to February physician orders. But when inspectors observed the patient on September 24, Staff G, the licensed practical nurse, found the concentrator running at 4.5 liters per minute.
"The oxygen was running at 4.5 lpm, and was supposed to be at 2 lpm," Staff G told inspectors.
The patient had been receiving oxygen therapy for months. Review of treatment records showed consistent documentation that staff followed oxygen orders, but the actual equipment settings told a different story.
During multiple visits in September, inspectors found Resident 9's oxygen concentrator running without a humidifier bottle. The equipment was set at 4 liters per minute on September 19, when the patient sat in a wheelchair watching television. Five days later, it was running at the even higher 4.5-liter rate that the nurse acknowledged was wrong.
Resident 8 faced similar problems with oxygen equipment maintenance. The patient, who used a CPAP machine at night and experienced shortness of breath when lying flat, received oxygen through nasal cannula tubing dated September 15. But the humidifier bottle was dated September 8 and completely empty when inspectors arrived on September 19.
"COPD was a new diagnosis for them," Resident 8 told inspectors, adding they had trouble keeping the CPAP on at night but "when it was able to stay on, they woke up feeling great."
The facility's own orders required weekly changes of oxygen tubing and humidifier bottles every Sunday night shift. Staff documented completing these tasks on September 7 and September 14, but the empty humidifier bottle suggested the maintenance wasn't actually performed.
Staff E reviewed the documentation during a September 24 interview and insisted nurses changed the tubing, not the bottle. Staff F, the Resident Care Manager, said the maintenance tasks "needed to be separated into different orders."
But the documentation problems went deeper than unclear orders. A February physician directive required staff to check oxygen saturation levels every shift, maintaining readings between 90 and 98 percent. Nurses documented taking these measurements every shift, but failed to indicate whether they measured oxygen levels with or without supplemental oxygen — a critical distinction for monitoring COPD patients.
Staff B, the Director of Nursing, acknowledged the systemic problems during a September 24 interview, stating "they needed to change how the orders were written."
The violations occurred despite detailed care plans for both residents. Resident 8's March care plan noted the use of 2-liter oxygen via nasal cannula, nighttime CPAP, and increased nasal saline gel for dryness caused by oxygen with humidifier. Resident 9's August care plan directed staff to "administer O2 as ordered."
Staff F confirmed during interviews that "oxygen tubing and humidifiers should be changed weekly, and residents should receive oxygen at a rate ordered by the provider." The gap between policy and practice put vulnerable COPD patients at risk.
Both residents required continuous oxygen support due to their chronic lung conditions. Resident 8 experienced shortness of breath with exertion and when lying flat. Resident 9 needed oxygen to maintain safe blood oxygen levels above 90 percent.
The inspection findings reveal how equipment maintenance failures and dosing errors can compromise respiratory care for nursing home residents who depend on precise oxygen delivery to breathe safely.
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.