Health inspection·November 19, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some at 9:28 AM with the Director of Nursing (DON) inside Resident 1's room, the DON saw Resident 1's oxygen tubing with the cannula on top of resident's chest. The DON asked Resident 1 if why was her nasal cannula on top of her chest. Resident 1 stated it came off this morning. During an observation and interview on 11/18/2025 at 11:30 AM, inside Resident 1's room, Resident 1 was observed not wearing her oxygen cannula, which was resting on the resident's chest. The oxygen concentrator was observed to be on and set at 2.5 lpm.During a concurrent observation and interview on 11/18/2025 at 11:31 AM inside Resident 1's room, the DON observed and confirmed Resident 1's oxygen tubing with the cannula was resting on top of Resident 1's chest. The DON stated Resident 1's oxygen concentrator was set up at 2.5 lpm which was the incorrect setting. The DON stated Resident 1 can experience low oxygen saturation. The DON added Resident 1 should be administered oxygen continuously per order. During a concurrent observation and interview on 11/18/2025 at 11:44 AM with Licensed Vocational Nurse 1 (LVN 1) inside Resident 1's room, LVN 1 stated Resident 1's oxygen concentrator was set up at 2.5 lpm which was the incorrect setting. LVN1 stated, The oxygen concentrator should be at 3 lpm. The resident will not get enough oxygen, and her oxygen saturation can go lower than 90%. During a record review of facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised 10/2010, the P&P indicated,1. Review the physician's orders or facility protocol for oxygen administration.13.Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record:3. The rate of oxygen flow, route, and rationale.4. The frequency and duration of the treatment. 2. During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] Resident 2's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), iron deficiency anemia (which occurs when your body does not have enough iron {helps make red blood cells [provide oxygen to body tissue]}) and dementia. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 has modified independence (some difficulty in new situations only) cognitive skills for daily decision making. The MDS indicated Resident 2 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in shower/ bathe self, lower body dressing, putting on/ taking off footwear, and personal hygiene. During a record review of Resident 2's Order Summary, dated 3/10/2025, the Order Summary indicated: Oxygen at 2 lpm via nasal cannula continuously. Diagnosis: Respiratory Failure every shift. Monitor Oxygen Saturation every shift. Notify MD if Oxygen Saturation was less than 92%. During a review of Resident 2's Medication Administration Record (MAR) dated 10/1/2025 to 10/31/2025 indicated Resident 2's oxygen saturation level indicated, On 10/4/2025, during 7-3 shift, Resident 2's oxygen saturation was 91%. On 10/11/2025, during 7-3 shift, Resident 2's oxygen saturation was 91%. On 10/15/2025, during 3-11 shift, Resident 2's oxygen saturation was 91%. During a concurrent interview and record review on 11/18/2025 at 12:53 PM with the DON, Resident 2's Medication Administration Record (MAR) from 10/1/2025 to 10/31/2025 was reviewed. The DON stated Resident 2's oxygen saturation level was below 92% on 10/4/2025, 10/11/2025 and 10/15/2025. During a concurrent interview and record review on 11/18/2025 at 12:55 PM with DON, Resident 2's Situation, Background, Assessment, Recommendation (SBAR, is a verbal or written communication tool that helps provide essential, concise information, usually during crucial situation) for the month of 10/2025 was reviewed. The DON stated there was no documentation on 10/4/2025, 10/11/2025 and 10/15/2025 that the MD was notified regarding Resident 2's oxygen saturation below 92%. During a concurrent interview and record review on 11/18/2025 at 12:59 PM with the DON, Nurses Progress Notes for 10/1/2025 to 10/31/2025 were reviewed. The DON stated there was no licensed nurse's documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055376 If continuation sheet Page 2 of 3 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 055376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Huntington Drive Health and Rehabilitation Center 400 W. Huntinton Dr. Arcadia, CA 91007 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete that the MD was notified of Resident 2's oxygen saturation being below 92%. The DON stated if there was no documentation in the progress notes, that means the licensed staff did not call the MD about the resident's oxygen saturation below 92%. The DON stated the licensed nurses should have notified the MD anytime Resident 2's oxygen saturation is below 92%. During an interview on 11/18/2025 at 12:59 PM with the DON, the DON stated it was important to monitor vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate) and oxygen saturation to make sure that residents who were receiving oxygen were comfortable, were receiving enough oxygen, and their oxygen saturation were within normal levels. During a record review of facility's P&P titled, Oxygen Administration, revised 10/2010, the P&P indicated, after completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record:6. All assessment data obtained before, during, and after the procedure.The P&P also indicated in Reporting. 2. Report other information in accordance with facility policy and professional standards of practice. Event ID: Facility ID: 055376 If continuation sheet Page 3 of 3