The resident, who suffers from chronic respiratory failure and obstructive pulmonary disease, requires continuous oxygen at 5 liters per minute through nasal tubing. Federal inspectors found the facility's infection control failures put the patient at increased risk during a January complaint investigation.
When inspectors examined the resident's room on January 28, they discovered oxygen tubing with no date marking whatsoever. The resident's breathing nebulizer tubing was dated January 5 — meaning it had gone 23 days without replacement when facility policy required weekly changes.
A Licensed Vocational Nurse told inspectors that oxygen tubing "must be dated to ensure staff know when to change the tubing next." But this resident's tubing carried no such marking.
The registered nurse on duty acknowledged the failures directly. "The oxygen tubing was not labeled and should be labeled weekly to ensure the tubing was changed to prevent infection," the RN told inspectors. She confirmed the nebulizer tubing dated January 5 "should have been changed since not changing the nebulizer tubing would increase the risk of infection."
The RN calculated that the nebulizer equipment should have been replaced by January 19 under the facility's seven-day policy. Instead, it remained in use nearly a week past that deadline.
"There was no way to know when the tubing's were last changed since there was no date or documentation to indicate when Resident 1's oxygen tubing was changed," the registered nurse admitted to inspectors.
The resident, admitted in August with multiple respiratory conditions, is cognitively intact and capable of understanding their medical situation. They require moderate assistance with daily activities like personal hygiene and dressing, making them dependent on staff to maintain their breathing equipment properly.
Federal inspectors found the facility violated its own written policies on respiratory therapy equipment. The facility's Oxygen Administration policy from October 2010 requires staff to document the date and time oxygen setup procedures are performed in the resident's medical record. No such documentation existed for this resident.
The facility's Respiratory Therapy policy from November 2011 specifically mandates changing oxygen cannula and tubing every seven days "or as needed" and documenting when respiratory therapy is performed. Staff failed on both requirements.
Breathing equipment that goes unchanged beyond recommended timeframes can harbor bacteria and other pathogens, particularly dangerous for residents with compromised respiratory systems. The resident's chronic respiratory failure means their lungs already struggle to get adequate oxygen — contaminated equipment compounds that medical vulnerability.
The nebulizer device converts liquid medication into fine mist for inhalation, making it a direct pathway to the resident's respiratory system. Equipment that should have been sterile and fresh was instead weeks old, creating what inspectors termed "potential to increase the risk and spread of infections."
Despite the facility having detailed written procedures for respiratory equipment maintenance, staff demonstrated they either didn't follow the policies or failed to understand their importance. The registered nurse's acknowledgment that unchanged tubing increases infection risk suggests awareness of the medical consequences, making the oversight more concerning.
The inspection found these failures affected few residents, but for those impacted, the stakes were significant. Respiratory patients depend on clean, properly maintained equipment for every breath.
Staff couldn't provide basic information about when critical medical equipment was last changed, leaving inspectors — and presumably the resident — unable to determine how long contaminated tubing had been in use. The complete absence of documentation meant no accountability system existed to prevent similar lapses.
The resident continues requiring continuous oxygen support for their chronic respiratory failure, now relying on a facility that demonstrated it cannot consistently maintain the basic infection control measures their breathing equipment demands.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Griffith Park Healthcare Center from 2026-01-29 including all violations, facility responses, and corrective action plans.