Health inspection·July 31, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/27/2023 at 3:41 p.m., with the Director of Respiratory Services (DRS), the DRS stated the facility's policy was to change the suction tip once a week. The DRS stated he thought the suction tip had just been misdated by the Respiratory Therapist (RT). When asked if he could prove that the suction tip had been changed recently, the DRS could not provide an answer. When asked, if assuming the suction tip had been misdated, why the following assigned RTs had not changed it out after seeing an old date, the DRS stated the RTs store the suction tip and its plastic covering inside a black bag and just pull it out without the plastic covering when they need to use it. The DRS stated that was probably why the RTs did not see the date written. The DRS stated that the purpose of changing the suction tip weekly and as needed was to prevent infection to the resident. During an interview on 7/31/2023 at 11:10 a.m., with the Director of Nursing (DON), the DON stated it was the facility's policy to change the suction tip once a week or as needed. When asked if the RTs were checking the dates on the suction tips, the DON stated she could not answer because they are stored in a plastic covering inside a black bag, and the RT pulls it out of the bag without removing the entire plastic covering with it. The DON stated it would be good practice for the RT to check the date on it to ensure that the suction tip was being changed regularly. The DON stated the purpose of changing the suction tip was to ensure that it was clean, so that organisms would not be introduced to the resident. A review of the facility's policy and procedure titled, Changing of Respiratory Equipment, last reviewed on 1/26/2023, indicated that disposable equipment is for single resident use and will be changed regularly and on an as needed (PRN) basis to minimize the risk of nosocomial infections (infections acquired during the process of receiving health care that was not present during the time of admission). Yankauer suction tips will be changed weekly and PRN. b. A review of Resident 1's admission Record indicated the facility originally admitted the resident on 4/22/2023 and readmitted the resident on 6/8/2023 with diagnoses that included chronic respiratory failure with hypoxia, tracheostomy, dependence on ventilator, pneumonia, and encounter for attention to gastrostomy (the creation of an artificial external opening into the stomach for nutritional support). A review of Resident 1's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. During a concurrent observation and interview on 7/29/2023 at 8:38 a.m., with Respiratory Therapist 3 (RT 3), observed Resident 1's oxygen tubing and the end of Resident 1's disconnected g-tube tubing on the floor. RT 3 stated the oxygen tubing and the g-tube tubing should not be on the floor because they can become contaminated, which can cause infection to the resident. During an interview on 7/29/2023 at 9:41 a.m., with the DON, the DON stated the facility did not have a specific policy indicating that oxygen tubing and g-tube tubing should not be on the floor. During an interview on 7/31/2023 at 11:10 a.m., with the DON, the DON stated it was important to ensure that oxygen tubing and the connecting end of the g-tube feeding was off the floor because it was important to ensure that anything connected to the resident was clean to prevent infection. A review of the facility's policy and procedure titled, Changing of Respiratory Equipment, last reviewed on 1/26/2023, indicated that disposable equipment is for single resident use and will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete changed regularly and on an as needed (PRN) basis to minimize the risk of nosocomial infections (infections acquired during the process of receiving health care that was not present during the time of admission). A review of the facility's policy and procedure titled, Infection Control Precautions - Standard, last reviewed on 1/26/2023, indicated it is the policy of the facility to utilize standard precautions when caring for patients/residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Handle used patient/resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other patients/residents and environments. Event ID: Facility ID: 056092 If continuation sheet Page 3 of 3