Resident #6 told inspectors on September 10 that he wore his nasal cannula oxygen tubing "all the time because if he did not, he could get short of breath." He believed his oxygen tubing was properly connected to the machine and used his portable oxygen daily when leaving his room.
But inspectors observed the oxygen tubing lying on the floor behind the oxygen tank, exposed to air without any protective bag or covering. The tubing in the resident's nose was not actually connected to the oxygen machine.
RN A discovered the contamination during the inspection. When asked what she observed about Resident #6's portable oxygen tank setup, she told inspectors "the O2 tank had tubing that was on the floor, and the tubing should have been in a bag for infection control reasons."
The nurse explained that oxygen tubing should be bagged "to prevent bacteria from getting into line." She immediately replaced both the oxygen machine and portable oxygen tank tubing, telling inspectors: "Because they were contaminated and, on the floor, and anything that touched the floor needs to be replaced."
The facility's Director of Nursing confirmed proper oxygen tubing storage protocols during a September 17 interview. Tubing should be kept in "special bags for it, with a string hang over the concentrator [oxygen machine] above the floor, on the bed. Always in a bag when not in use."
When asked about concerns with oxygen tubing touching floors or other contaminated surfaces, the Director of Nursing said the solution was to "throw it away and replace" and prevent it from reaching "the floor again."
The violation affected multiple residents. Inspectors documented similar oxygen tubing contamination issues with Residents #3 and #8, though specific details about their cases were not included in the available inspection narrative.
Avir at Schertz's own infection control policy, revised in September 2022, requires that "resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments."
The policy also mandates that "reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed" and that "single use items are properly discarded."
For Resident #6, who depended on supplemental oxygen to prevent shortness of breath, the contaminated tubing posed infection risks precisely when he was most vulnerable. The resident's belief that his oxygen was properly connected while breathing through floor-contaminated tubing highlighted both the infection control failure and potential communication breakdown about his medical equipment.
The immediate replacement of contaminated tubing by nursing staff during the inspection demonstrated the facility's awareness of proper protocols, raising questions about how the violation occurred and persisted until inspectors arrived.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting some residents at the facility. The September 17 complaint investigation focused specifically on infection control practices related to respiratory equipment storage and handling.
The case illustrates how seemingly routine equipment management failures can compromise resident safety, particularly for those with chronic conditions requiring continuous medical devices. For residents like #6, who rely on oxygen therapy to maintain basic respiratory function, contaminated tubing represents both an immediate infection risk and potential respiratory compromise if the equipment fails to function properly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Schertz from 2025-09-17 including all violations, facility responses, and corrective action plans.