Health inspection·January 11, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement its infection control policy by failing to ensure nasal cannula (oxygen [a colorless, odorless, and tasteless gas] tubing - a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) and humidifier (medical devices used to humidify supplemental oxygen) was changed and labeled with the date of change for one of four sampled residents (Resident 1). Residents Affected - Few This deficient practice had placed Resident 1 at risk for infection. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 4/22/2021 with diagnoses including hemiplegia (paralysis that affects only one side of your body), sequelae (an aftereffect of a disease, condition, or injury) of cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and difficulty in walking. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 1/3/2024, indicated Resident 1 was severely impaired and could not make decisions. A review of the Physician ' s Order for Resident 1, dated 5/8/2021, indicated the following: - Oxygen during each shift oxygen (O2) 2 liters per minute (LPM- the flow of oxygen you receive from your oxygen delivery device) via nasal canula continuously to keep O2 greater than 92%. - Oxygen Tubing: Clean filter and change tubing during night shift weekly on Mondays. A review of Resident 1 ' s Care Plan, developed on 4/4/2023, for Resident 1 ' use of continuous oxygen therapy of 2 LPM via nasal canula indicated interventions including assess status and response to oxygen therapy and administer oxygen as ordered. During a concurrent observation and interview on 1/11/2024 at 10:15 a.m., with Certified Nursing Assistant 1 (CNA 1) at the bedside of Resident 1. CNA 1 stated nursing is the one that changes the oxygen tubing and humidifier. CNA1 verified date on Resident 1 ' s nasal canula tubing as 12/31/2023 and CNA 1 stated humidifier did not have a date on it. During an interview on 1/11/2024 at 3 p.m. with the Director of Nursing (DON) stated nasal cannulas are changed weekly and as needed, and the humidifiers as needed. The DON stated both the nasal canula and the humidifier must have documentation of the date it was changed, it is for safety, and the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055192 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence St Elizabeth Care Center 10425 Magnolia Blvd North Hollywood, CA 91601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)