Health inspection·January 8, 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 failed to ensure oxygen tanks were safely stored in the oxygen storage room for one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to place the resident at risk for injury due to a fire hazard. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility 7/30/2024 with diagnoses including pulmonary fibrosis (a lung disease that causes scarring in the lungs, making it difficult to breathe) and hemiplegia (paralysis on one side of the body). During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 11/7/2024, the MDS indicated Resident 1 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with bathing and dressing. During a concurrent observation and interview on 1/8/2025 at 9:02 a.m., with Resident 1 in Resident 1 ' s room, Resident 1 had two oxygen tanks standing upright next to his chair. Resident 1 stated he did not feel comfortable with the oxygen tanks sitting in his room because he has seen them fall over and shoot through a wall in the past. During an interview on 1/8/2025 at 9:52 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when oxygen tanks are no longer being used, they are put back in the oxygen storage room. LVN 1 stated if the oxygen tanks are not put back in the oxygen storage room, it can be unsafe for the residents and staff if they fall over. During an interview on 1/8/2025 at 10:01 a.m. with Certified Nurse Assistant (CNA), the CNA verbally confirmed there were two oxygen tanks sitting up in Resident 1 ' s room. The CNA stated she was busy and did not tell her charge nurse about the oxygen tanks in Resident 1 ' s room but should have done so because it was dangerous. The CNA stated the oxygen tanks can fall over and explode. During an interview on 1/8/2025 at 10:39 a.m. with Registered Nurse Supervisor (RNS), the RNS stated oxygen tanks should be placed in the oxygen storage room when not in use and not in a residents room. The RNS stated leaving an oxygen tank in a residents room was unsafe because it was a fire hazard and can fall over and explode. (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: 555070 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 555070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southland 11701 Studebaker Road Norwalk, CA 90650 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)