Health inspection·May 30, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for two of four sampled residents (Resident 2 and Resident 3) by failing to: Residents Affected - Few 1. Ensure Resident 2 and Resident 3's oxygen tubings were dated when it was changed. 2. Ensure Resident 2's oxygen tubing was free from kinks. These deficient practices had the potential for the residents to receive less oxygen needed in the body and develop respiratory diseases or infections. Findings: a. A review of Resident 2's admission Record indicated the facility admitted the resident on 4/4/2024 with diagnoses that included interstitial pulmonary disease (a large group of diseases that cause scarring of the lungs), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/11/2024, indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills was severely impaired. A review of the Physician Orders, dated 4/4/2024, indicated an order to administer oxygen at two to five liters per minute via nasal cannula (is a device that delivers extra oxygen through a tube and into your nose continuously) to maintain oxygen saturation (measures how much oxygen is carried by the hemoglobin [a protein in red blood cells that carries oxygen] in your blood) above 90 percent (%-unit of measurement) as needed for shortness of breath. On 5/30/2024 at 10:22 a.m., during a concurrent observation and interview with Registered nurse 1 (RN 1), Resident 2's oxygen cannula was observed on the resident's chest under the blanket. RN 1 stated that Resident 2's nasal cannula should be on the resident's nose. Resident 2's oxygen tubing connecting the oxygen concentrator (a medical device that separates nitrogen from the air so a person can breathe up to 95% pure oxygen) to the humidifier (a device that release water vapor or steam) was observed to be kinked. RN 1 stated that a kinked oxygen tubing had the potential for Resident 2 to receive less than required oxygen. Resident 2's oxygen tubing and oxygen cannula were not labeled with the date the supplies were replaced. Resident 2 did not have an oxygen supplies bag at bedside. RN 1 stated that Resident 2's oxygen tubing and cannula should be dated and there should be a dated (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: 555012 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 555012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606 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)