Federal inspectors found staff at ARC at Cincinnati repeatedly violated infection control protocols by failing to store respiratory equipment in protective bags. The violations affected residents with severe breathing conditions including chronic obstructive pulmonary disease, asthma, and sleep apnea.
Resident 06, who suffers from a respiratory infection, required nebulizer treatments with albuterol every six hours and sodium chloride twice daily. Inspectors observed the resident's nebulizer machine sitting on an over-the-bed table with medication canisters and connectors lying exposed on December 15, 16, 17, 18, and 19.
No plastic bag protected the equipment during any of the five observation periods.
Licensed Practical Nurse 02 acknowledged the equipment should be stored in plastic bags. "There was not a plastic bag in the room, and she meant to get one to put the resident's nebulizer equipment in but got busy with something else and forgot," according to the inspection report.
The Director of Nursing confirmed respiratory equipment should be covered when not in use for infection control reasons. She stated nurses should not have left nebulizer equipment sitting on tables.
Similar storage failures affected Resident 37, who has severe cognitive impairment with a mental status score of seven out of 15. The resident uses a CPAP machine for obstructive sleep apnea and has multiple respiratory conditions including COPD, asthma, and congestive heart failure.
Inspectors found the resident's CPAP mask lying uncovered on a dresser during observations on December 15, 20, and 21. The equipment remained exposed without protective storage throughout the inspection period.
Certified Nursing Assistant 29 verified he routinely placed CPAP masks on top of dressers when residents weren't using them. The practice contradicted facility expectations and infection control standards.
Multiple staff members confirmed proper storage protocols during interviews. CNA 31 verified CPAP masks should be stored in plastic bags when not in use. LPN 10 stated the same requirement.
Yet the facility lacked written policies governing CPAP mask storage. The Director of Nursing admitted during a December 22 interview that no formal policy existed, though she expected staff to store masks in bags rather than on dressers or in drawers.
The Administrator stated she expected staff to store CPAP masks in bags when not in use, confirming the gap between facility expectations and actual practice.
The violations occurred during a complaint investigation at the 180-bed facility on Rosslyn Drive. Both affected residents required respiratory equipment multiple times daily for serious breathing conditions that make them particularly vulnerable to infections.
Resident 06's treatment schedule called for nebulizer medications at midnight, 6 a.m., noon, and 6 p.m. daily, plus sodium chloride treatments every 12 hours. The frequent use made proper equipment storage critical for preventing contamination between treatments.
The exposed equipment violated federal infection prevention and control requirements. Inspectors classified the violations as causing minimal harm or potential for actual harm to some residents.
Staff acknowledged knowing proper storage procedures but failed to follow them consistently. The Licensed Practical Nurse's admission that she "got busy with something else and forgot" to provide protective storage highlighted systemic compliance failures.
The facility's lack of written CPAP storage policies compounded the problem. Without clear protocols, staff relied on informal expectations that proved insufficient to ensure consistent infection control practices.
Respiratory equipment contamination poses serious risks for residents with compromised lung function. Both affected residents had multiple conditions that could worsen with respiratory infections, including COPD, asthma, and existing respiratory infections.
The inspection revealed a pattern of equipment left exposed across multiple days and different shifts, indicating widespread rather than isolated compliance failures. The violations affected residents who depend on the equipment for basic breathing support.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arc At Cincinnati from 2025-12-23 including all violations, facility responses, and corrective action plans.