Health inspection·December 20, 2023

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 interview, and record review, the facility failed to provide oxygen therapy for one (1) of three (3) sampled residents (Resident 1). Resident 1 had a change of condition, on 11/27/2023 at 8:08 a.m., and staff did not provide oxygen to Resident 1 prior to the arrival of Emergency Medical Services (EMS, 911). Residents Affected - Few This deficient practice resulted in Resident 1 not receiving oxygen therapy until Emergency Medical Services (911) arrived on 11/27/2023 at 8:14 a.m. (resulting in 6 minutes delay of oxygen therapy). Findings: A review of Resident 1's Physician Note by Medical Doctor 1 (MD 1), dated 11/25/2023, indicate Resident 1 was admitted at the facility on 11/22/223 at 19:35 (7:35 p.m.) with diagnosis that included right MCA (mid cerebral [brain] artery) stroke and had nasogastric tube (NGT, tube inserted in the nose to the stomach and used for feeding and medication administration). A review of Resident 1's Physician Orders of Life-Sustaining Treatment (POLST), signed by MD 1 on 12/25/2023 and signed by Family Member 1 (FM 1), on 12/22/2023, indicated Resident 1 was Do Not Attempt Resuscitation (life-saving treatment [chest compression])/DNR ([Do Not Resuscitate] Allow to Natural Death). Resident 1's POLST indicated medical interventions was Selective Treatment - goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV (intravenous, medication given into the vein) antibiotics, and IV fluids as indicated. Do not intubate (tube inserted into the mouth to the trachea [windpipe] to assist with breathing. May use non-invasive positive airway pressure (oxygen therapy to help keep the lung open). A review of Resident 1's Progress Note, written by Registered Nurse (RN 3), dated 11/27/2023 at 8:08 a.m., indicated RN 3 created Resident 1's progress note. The Progress Note indicated, on 11/27/2023 at 8:14 a.m., RN 3, Assumed care for patient (Resident 1) this morning and patient seemed restless. N A (Nurse Assistant) unable to obtain vital signs. Extremities were cold. Attempted paging doctor but no answer. CRN (Charge Registered Nurse) informed. Called 911. EMS arrived and called son over the phone. Son agreed to transfer patient to little company main hospital. The record did not indicate oxygen was administered to Resident 1. A review of Resident 1's Internal Medicine Discharge Summary, by MD 1, dated 11/27/2023 created at 13:23 (1:23 p.m.), indicated under the Discharge Summary notes, Event 11/27: patient (Resident 1) found by nurse to have low BP and restless, could not obtain vitals here, EMS called . The noted indicated, On transfer to ER, had lost of pulse in ambulance bay. Patient passed prior to triage in ER. (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: 056499 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 056499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Little CO of Mary Transitional Care Ctr 4320 Maricopa Street Torrance, CA 90503 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)