Griffith Park Healthcare Center

Based on observation, interview and record review, the facility failed to implement infection control practices in accordance with the facility's Policy and Procedure (P&P) titled Oxygen Administration and Departmental (Respiratory Therapy) for a one of two sampled residents ( Resident 1) by failing to : Ensure Resident 1's oxygen tubing (a flexible plastic tube, often green, that delivers supplemental oxygen from a tank or concentrator to a patient via nasal prongs) was labeled with a date the oxygen tubing was last changed.Ensure Resident 1's breathing nebulizer (a device that converts liquid medication into a fine mist for inhalation) was changed within seven (7) days.

The nebulizer was last dated 1/5/2026.Document oxygen set- up, which included the date and time the procedure was performed in Resident 1's medical record.

These deficient practices had the potential to increase the risk and spread of infections.

Findings: During a review of Residents 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 08/08/2026, with a diagnosis of chronic respiratory failure (lungs can't get enough oxygen), obstructive pulmonary disease (blocked airways, hard to breathe out) and delusional disorders (false beliefs).

During a review of Resident 1's History and Physical (H&P), dated 8/11/2026, the H&P indicated Resident 1 has the capacity to understand and make decisions.

During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/15/2025, indicated resident is cognitively intact (can understand, remember and make decisions appropriately) and requires moderate assistance (helper does less than half the effort) with Activities of Daily living ( ADLS) such as personal and oral hygiene, and dressing.

During a review of Resident 1' s Order Summary Report, the report indicated an order start date of 12/25/2025 for oxygen at 5 liters per minute(lpm) by nasal canula (small tub in the nose that gives extra oxygen) to be administered continuously (all the time) every shift.

During an observation on 1/28/2026 at 10:30AM in Resident 1's room, Resident 1's oxygen tubing was observed without a date or time to indicate when the tubing was last changed and breathing nebulizer tubing was dated 1/5/2026.

During a concurrent observation and interview on 1/28/2026 at 11 AM with Licensed Vocation Nurse (LVN) 1 in Resident 1's room, Resident 1's oxygen tubing and breathing nebulizer was observed. LVN 1 stated oxygen tubing must be dated to ensure staff know when to change the tubing next.

During a concurrent observation and interview on 1/28/2026 at 11:45 AM with Registered Nurse ( RN1), Resident 1's oxygen tubing and nebulizer was observed. RN 1 stated the oxygen tubing was not labeled and should be labeled weekly to ensure the tubing was changed to prevent infection. RN1 stated the nebulizer tubing was dated 1/5/2026 and that the tubing should have been changed since not changing the nebulizer tubing would increase the risk of infection. RN 1 stated 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. RN 1 stated that the nebulizer tubing was last changed on 1/5/2026, since that date was indicated on the label, and that the nebulizer tubing should have been changed every 7 days, which would have been last changed on 1/19/2026.

During a review of the facility's policy and procedure (P&P) titled Oxygen Administration dated October 2010, indicated the purpose of the P&P is to provide guidelines for safe oxygen administration and documentation.

The policy requires that, after completing oxygen se-up, the date and time the procedure was performed be documented in the resident's medical record.

During a review of the facility's P&P titled Departmental ( Respiratory Therapy)dated November 2011 indicated the purpose of the P&P is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators , among residents and staff.

The P&P indicates to change the oxygen cannula and tubing every seven ( 7) days, or as needed and to document the following information in the resident's medical record, the date and time the respiratory therapy was performed.

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