Health inspection·April 30, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility staff failed to ensure one of three sampled residents (Resident 1) received two (2) liters (a unit of measurement) of oxygen continuously according to the physician's order. Residents Affected - Few This deficient practice had the potential to result in Resident 1 not receiving sufficient oxygen levels in the body, shortness of breath, difficulty with speaking, confusion, and decreased quality of life. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 4/7/2025 with diagnoses that included cerebral palsy (a group of conditions that affect movement and posture), chronic pulmonary edema (an abnormal buildup of fluid in the lungs), and bronchopneumonia (infection in the upper part of the airway). During a review of Resident 1's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 4/10/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely cognitively impaired. Resident 1 required maximum assistance from staff with eating and dependent on staff for activity of daily living (ADL-routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). During a review of Resident 1's physician orders dated 4/7/2025, physician orders indicated an order to administer oxygen at two (2) liters per minute via nasal cannula (a medical device used to deliver additional oxygen or increased airflow to a person) continuously. During a review of Resident 1's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, Oxygen Therapy, dated 4/8/2025, the care plan indicated a goal that Resident 1 will have no signs or symptoms of poor oxygen absorption. Interventions included to explain the importance of keeping oxygen at the prescribed setting .give medications as ordered by physician. During a concurrent observation and interview on 4/29/2025 at 11:00 a.m., with Resident 1 in the activities room, observed Resident 1 sitting in a chair without oxygen in place and no oxygen administration supplies located near Resident 1. Resident 1 stated that he was unsure why he did not have Page 1 of 2 056137 056137 04/30/2025 The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402

F 0695 his oxygen on. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 4/29/2025 at 11:10 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 1 in the activity room. LVN 1 confirmed by stating that Resident 1 did not have oxygen being administered at that time. LVN 1 stated that Resident 1 did have a physician order for oxygen at two (2) liters per minute via nasal cannula. Residents Affected - Few During an interview on 4/30/2025 at 11:00 a.m., with the Director of Nursing (DON), the DON stated that Resident 1 did have a physician order for continuous oxygen at two (2) liters per minute via nasal cannula at the time of the observation (4/29/2025). The DON stated that the correct process for Resident 1 at the time of observation was to have two (2) liters of continuous oxygen being administered via nasal cannula. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, with a review date of 11/6/2024, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed .Place the appropriate oxygen device on the resident. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 056137 Page 2 of 2