The woman told state inspectors during a September interview that she routinely took off her nasal cannula and placed the oxygen tubing on her bed when she left to smoke cigarettes. When she returned, the tubing was still there on the bed, uncovered and unprotected.
She also turned off her nebulizer machine herself and placed the mouthpiece on her bedside table after breathing treatments. The resident said staff had never told her to notify them when she removed the nasal cannula or nebulizer equipment.
The facility's Director of Nursing acknowledged the violations during an interview on September 30. She told inspectors that oxygen tubing and respiratory items should have been stored in a bag when not in use, not left exposed on the bed.
"If respiratory items were dirty or contaminated, the risk to the resident was infection," the nursing director stated.
The breathing treatment equipment presented particular problems. Licensed Vocational Nurse B explained during a telephone interview that the resident received nebulizer treatments three times daily. Sometimes the woman turned off the nebulizer before completing a treatment and placed the mouthpiece on the bedside table, leaving it exposed to contamination.
The nursing director said whoever administered medication should ensure the nebulizer mouthpiece was placed in a bag after each breathing treatment. If left exposed, it should be replaced and placed in a clean bag.
LVN B emphasized that monitoring the resident was crucial to ensure respiratory items were bagged for infection control. But that monitoring clearly wasn't happening consistently.
The facility's own policies revealed the scope of the failure. Their Administering Medications through a Small Volume Nebulizer policy, revised in October 2010, specifically required storing nebulizer equipment "in a plastic bag with the resident's name and date on it."
However, inspectors discovered a gap in the facility's oxygen safety protocols. The Oxygen Administration and Oxygen Safety policy, revised as recently as July 23, 2025, failed to include instructions for storing oxygen tubing when not in use.
This oversight became particularly problematic given the resident's smoking routine. She consistently removed her oxygen equipment to go outside, creating repeated opportunities for contamination when the tubing was left unprotected on her bed.
The nursing director promised inspectors that the facility would provide in-service training related to monitoring residents to ensure respiratory items were stored properly when not in use.
But the violations highlighted a broader breakdown in basic infection control practices. Respiratory equipment requires careful handling to prevent contamination that could lead to serious lung infections, particularly dangerous for residents already dependent on oxygen therapy.
The resident's case illustrated how seemingly small lapses in protocol can create ongoing health risks. Each time she placed her oxygen tubing on the bed or left her nebulizer mouthpiece on the bedside table, the equipment was exposed to bacteria and other contaminants.
For a resident requiring multiple daily breathing treatments and continuous oxygen therapy, contaminated equipment could introduce harmful bacteria directly into her respiratory system. The risk was compounded by her routine of removing and replacing the equipment multiple times each day for smoking breaks.
The facility received a citation for failing to ensure residents were free from accident hazards and received adequate supervision and assistance devices to prevent accidents. Inspectors determined the violations caused minimal harm or potential for actual harm, affecting few residents.
The inspection revealed that basic infection control measures weren't being followed consistently, despite clear policies requiring proper storage of respiratory equipment. Staff failed to monitor the resident's handling of her oxygen and nebulizer equipment, allowing unsafe practices to continue unchecked.
The woman continued using her oxygen tubing and nebulizer mouthpiece after repeated exposure to potential contamination, while staff remained unaware of the ongoing violations until state inspectors arrived to investigate.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Ridge Rehabilitation and Healthcare Center from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
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