Federal inspectors responding to a complaint on October 16, 2025, found that Licensed Vocational Nurse A, who cared for two of the residents, was "not aware that the oxygen tubing and the prefilled humidifier bottles were not dated." She told inspectors she "usually checked the oxygen tubing to make sure they were dated."
The nurse explained that oxygen tubing and prefilled humidifiers "were changed every week on Sunday night" and that dating all equipment was crucial "so that everyone track when the tubing was last changed." She acknowledged receiving training on infection control and oxygen tubing care.
Licensed Vocational Nurse B, responsible for the third resident, similarly told inspectors she "was not aware that Resident #3's oxygen tubing and the prefilled humidifier bottle were not dated." She said she "usually checked the oxygen tubing and prefilled humidifier bottlers to make sure they were dated."
Both nurses understood the importance of the dating system. LVN B explained that "the importance of dating oxygen tubing was to track its age so it could be replaced according to the recommended schedule."
The Director of Nursing told inspectors her expectation was that "the nurse assigned should be check the oxygen tubing and prefilled humidification bottles as part of overall assessment make sure it was properly functioning." She confirmed that all oxygen equipment "should be dated" and "should be stored in a plastic bag."
When asked about risks to residents, the Director of Nursing said undated or improperly stored tubing posed "infection control" dangers. She confirmed that nurses had received training on infection control and oxygen tubing care.
Millbrook's own policies require strict adherence to dating protocols. The facility's Oxygen Equipment policy, revised in May 2017, states that "pre-filled humidifiers, when used, are to be dated and replaced every (7) days, according to manufacturers' recommendations, or as needed."
The policy specifies that tubing, masks, and cannulas must be replaced weekly. It warns that when equipment is used continuously or intermittently, tubing must be "routinely changed to prevent the build-up of respiratory secretions, mucous, and bacterial growth."
The facility's Infection Control policy, reviewed in July 2022, aims to "decrease the risk of infection to patients and personnel" and "monitor for the occurrence of infection and implement appropriate control measures."
Despite these written protocols and staff training, the dating system failed for multiple residents. The policy requires oxygen masks, nasal cannulas, and tubing to be used for one resident only, with equipment covered loosely when not in use "to prevent contamination from airborne microorganisms."
Proper equipment tracking becomes critical for residents dependent on supplemental oxygen, who often have compromised respiratory systems. The seven-day replacement schedule exists specifically to prevent bacterial buildup in tubing that comes into direct contact with residents' airways.
The inspection found that while nurses understood the importance of dating equipment and had received appropriate training, the actual implementation of safety protocols broke down at the bedside level. Both LVNs claimed they usually checked for proper dating but missed the violations in their assigned residents.
The facility allows flexibility in equipment changes, with the Director of Nursing explaining that while changes typically occur on night shift, "if the night shift were busy then any shift could change." This system requires clear documentation to track when equipment was last replaced, making the dating violations more significant.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm" affecting "some" residents. The finding represents a breakdown in basic infection control practices that the facility's own policies recognize as essential for patient safety.
The three residents continued to receive oxygen through equipment of unknown age, with no clear timeline for when their tubing and humidifier bottles had last been changed or cleaned.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Millbrook Healthcare and Rehabilitation Center from 2025-12-01 including all violations, facility responses, and corrective action plans.
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