Rinaldi Convalescent Hospital: Oxygen Safety Failure - CA
The resident, identified in inspection records as Resident 11, had been living at the facility since December 2024. Their diagnoses included metabolic encephalopathy, muscle weakness, difficulty swallowing, and failure to thrive. By early 2026, a formal assessment found their cognition moderately impaired. They required substantial help with eating and personal hygiene. For oral care and toileting, staff did everything.
Since October 2025, a physician had ordered continuous oxygen at two liters per minute through a nasal cannula, with the goal of keeping blood oxygen levels above 90 percent.
On the morning of March 28, 2026, at 8:40 a.m., an inspector walked into Resident 11's room and found the resident lying in bed with their mouth open, the nasal cannula sitting inside their mouth rather than in their nostrils.
Six minutes later, a Registered Nurse Case Manager entered the room alongside the inspector. The cannula was still in the resident's mouth. The nurse repositioned it, placing the prongs into the resident's nostrils where they belonged. The nurse told the inspector that the cannula was not in the right place and should not have been in the resident's mouth.
Nobody else had caught it before the inspector arrived.
That afternoon, the facility's Assistant Director of Nursing described what can happen when a resident doesn't receive the oxygen their physician ordered. Dizziness. An elevated heart rate. Shortness of breath. The ADON acknowledged that proper nasal placement is necessary for residents to actually receive the oxygen they're prescribed.
Resident 11, with moderate cognitive impairment and complete dependence on staff for personal care, could not have repositioned the tube themselves or reliably communicated that something was wrong. The inspection record does not indicate how long the cannula had been misplaced before the inspector's arrival.
The facility's own oxygen administration policy, reviewed as recently as January 2026, describes a nasal cannula as a tube placed approximately one-half inch into the resident's nose. The gap between that written standard and what inspectors found in Resident 11's room that morning was not a matter of interpretation.
CMS rated the violation at the lowest level of harm, citing minimal harm or potential for actual harm. That classification reflects the regulatory framework's assessment of documented injury, not a judgment about what could have happened to a resident with compromised cognition, swallowing difficulties, and no ability to self-correct a device meant to keep their blood oxygenated.
Rinaldi Convalescent Hospital is located at 16553 Rinaldi Street in Granada Hills. The inspection was completed March 29, 2026.
Resident 11 remained at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rinaldi Convalescent Hospital from 2026-03-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
RINALDI CONVALESCENT HOSPITAL in GRANADA HILLS, CA was cited for violations during a health inspection on March 29, 2026.
The resident, identified in inspection records as Resident 11, had been living at the facility since December 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.