The resident, admitted in August with chronic respiratory failure and obstructive pulmonary disease, required continuous oxygen at 5 liters per minute through nasal tubing. Federal inspectors found the oxygen tubing completely unlabeled during a January 28 visit, making it impossible to determine when it was last changed.
The resident's nebulizer tubing, used to deliver liquid medication as an inhalable mist, was labeled January 5 but hadn't been replaced by the inspection date. Facility policy required the equipment be changed every seven days, meaning it should have been replaced by January 19.
"There was no way to know when the tubing's were last changed since there was no date or documentation," Registered Nurse 1 told inspectors while observing the unlabeled oxygen equipment in the resident's room.
The nurse acknowledged both violations during the inspection. She stated the oxygen tubing "was not labeled and should be labeled weekly to ensure the tubing was changed to prevent infection." Regarding the nebulizer, she said it "should have been changed since not changing the nebulizer tubing would increase the risk of infection."
Licensed Vocational Nurse 1 confirmed during a concurrent interview that "oxygen tubing must be dated to ensure staff know when to change the tubing next."
The resident, described in assessment records as cognitively intact and capable of making decisions, requires moderate assistance with daily activities including personal hygiene and dressing. The facility's own policies, dating to 2010 and 2011, specifically address these infection control requirements.
The oxygen administration policy requires staff to document "the date and time the procedure was performed" in the resident's medical record after completing oxygen setup. The respiratory therapy policy mandates changing "the oxygen cannula and tubing every seven days, or as needed" with documentation of when the therapy was performed.
Inspectors found no such documentation in the resident's medical records.
The facility's respiratory therapy policy, established in November 2011, states its purpose is "to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff."
During the inspection, both nurses observed the equipment alongside inspectors in the resident's room. The violations were discovered during a complaint investigation on January 28, when inspectors examined two residents receiving respiratory therapy services.
Federal inspectors classified the violations as having "minimal harm or potential for actual harm" but noted the deficient practices "had the potential to increase the risk and spread of infections."
The resident has been at the facility since August, receiving continuous oxygen therapy since a December 25 physician's order. Assessment records from November indicated the resident remains cognitively intact, able to understand and make decisions appropriately.
Oxygen tubing and nebulizer equipment create direct pathways into residents' respiratory systems. When left unchanged beyond recommended intervals, the equipment can harbor bacteria and other pathogens that cause pneumonia and other serious respiratory infections.
The facility's own policies recognize these risks, requiring weekly equipment changes and documentation to track compliance. Yet inspectors found staff had abandoned both requirements for this resident's care.
The registered nurse's admission that there was "no way to know" when equipment was changed highlights a broader breakdown in the facility's infection control systems. Without proper labeling and documentation, staff cannot ensure equipment is changed on schedule or identify when residents may be at increased risk.
For a resident already struggling with chronic respiratory failure, contaminated breathing equipment poses serious additional health risks that facility policies were designed to prevent.
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.