Federal inspectors found nebulizer masks and tubing left exposed throughout Bel Air at Teravista during a November complaint investigation. The equipment, used to deliver medication directly to residents' lungs, was stored in drawers or left "anywhere" by residents without protective bags to prevent contamination.
Four residents were affected by the infection control breakdown. The facility's director of nursing acknowledged the widespread failure during interviews with investigators.
"It was a common practice that the residents used nebulizers by themselves and left them anywhere," the director told inspectors on November 6. When investigators informed him that no protective bags were available in any of the residents' rooms, he explained "the usual practice at the facility was storing them in a drawer."
The admission revealed a systemic problem with respiratory care at the 120-bed facility. Federal guidelines require nebulizer equipment to be stored in clean, dry plastic bags between uses to prevent the spread of germs, particularly when treating residents with respiratory conditions.
LVN A, the charge nurse responsible for three residents using nebulizers, told inspectors the storage failure "was her mistake." She acknowledged not ensuring the masks were protected from contamination despite understanding "it was essential to minimize the risk of infection, especially respiratory infection."
The nurse said she relied on her professional knowledge about infection control but could not remember attending any facility training on proper nebulizer storage procedures.
LVN B, who worked with another affected resident, described how the patient "handled the nebulizer independently and had the habit of keeping it anywhere." The nurse admitted she did not know if the resident was ever supervised to ensure safe storage or educated about the importance of protective covers.
"It was the responsibility of the nurse to make sure it was done appropriately," LVN B told investigators. Like her colleague, she could not recall receiving any facility training on nebulizer storage protocols.
The director of nursing's comments to inspectors revealed the scope of the problem. He stated that "technically the nebulizer masks were to be cleaned and safely stored in the protective bags provided, however, in reality, this rarely happened."
More troubling, he admitted "there was no system in place to ensure the nurses were doing this properly."
The facility's own policy, titled Oxygen Administration and dated October 2010, failed to address the storage requirements. The 15-year-old policy did not mention the necessity for storing oxygen and nebulizer equipment in protective bags when not in use.
Federal health guidelines are explicit about respiratory equipment storage. The National Heart, Lung, and Blood Institute instructs facilities to store nebulizer parts in dry, clean plastic storage bags between uses. When equipment is shared among multiple residents, each person's medicine cup, mouthpiece, mask and tubing should be kept in separate, labeled bags to prevent germ transmission.
The contamination risk is particularly serious for nursing home residents, who often have compromised immune systems and underlying respiratory conditions. Nebulizers deliver medication directly to the lungs through a fine mist, making sterile equipment essential for preventing respiratory infections.
Inspectors found the infection control failures affected multiple residents simultaneously. The investigation did not specify whether any residents developed infections as a result of the contaminated equipment, but documented the potential for harm.
The director of nursing told investigators he wanted to ensure staff would be "diligent in this practice in the future." However, his acknowledgment that proper storage "rarely happened" and that no oversight system existed suggests the problems were longstanding.
The facility's approach of storing respiratory equipment in drawers without protective barriers contradicts basic infection control principles. Drawers in healthcare settings can harbor bacteria and other contaminants that pose risks to vulnerable residents requiring respiratory treatments.
The November inspection occurred in response to a complaint, though the specific nature of the complaint was not detailed in the available records. Federal investigators classified the violation as causing minimal harm or potential for actual harm to some residents.
For residents requiring daily nebulizer treatments, the contaminated equipment represented a daily exposure to potential infection. The failure to maintain basic sterile storage protocols left some of the facility's most vulnerable residents at unnecessary risk during their respiratory treatments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bel Air At Teravista from 2025-11-21 including all violations, facility responses, and corrective action plans.