Health inspection·September 29, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for one sampled resident (Resident 1), Resident 1's oxygen delivery via tubing was secured and maintained. Residents Affected - Few This deficient practice had the potential to result in Resident 1 suffering from hypoxemia (low level of oxygen in the blood) and may lead to the resident's deterioration of medical condition. Findings: A review of Resident 1's History and Physical (H&P), dated [DATE], indicated Resident 1 was found down by family members. Cardiopulmonary Resuscitation ([CPR] is an emergency lifesaving procedure performed when the heart stops beating) was initiated prior to Emergency Medical Services ([EMS] is a system that responds to emergencies in need of highly skilled pre-hospital clinicians) arrival. The patient was intubated (a tube has been placed inside a patient's trachea through the mouth to keep airways open in an emergency setting) for airway protection. In addition the H&P indicated Resident 1's Computed Tomography ([CT] scan is an imaging test that helps healthcare providers detect diseases and injuries) scan of the head showed a large intracranial (Within the cranium, the bony dome that houses and protects the brain) and intraventricular (within the ventricles of the brain) hemorrhage (bleeding) with developing hydrocephalus (the buildup of fluid in cavities called ventricles deep within the brain). During an interview on [DATE], at 8:24 A.M., with the Nurse Manager (NM), the NM confirmed that on [DATE], Resident 1's oxygen tubing was found disconnected by the resident's family member (FM). Resident 1's FM immediately informed Staff Nurse 1 (SN1), who was with another patient in the same room. The NM stated SN1 was not sure why oxygen tubing was disconnected. The NM added there was a similar event in the past involving Resident 1, where the oxygen tubing was found disconnected. These incidents may have been the result of how staff reposition residents. During an interview on [DATE], at 9:12 A.M., with the NM, the NM stated Resident 1 was brought back from activity room to bed by Certified Nurse Assistant 1 (CNA 1) on [DATE] between the hours of 12:30 p.m. and 1:00 p.m. CNA 1 went back around 4:30 p.m. to 5:00 p.m. to reposition Resident 1. Resident 1's FM found the oxygen tubing disconnected sometime after 5:00 p.m. In the same interview, the NM stated on investigation CNA 1 did not check if oxygen tubing was connected to Resident 1 after repositioning Resident 1. The NM stated the staff should do environmental check before leaving the patient. The NM stated CNA 1 informed her that after repositioning Resident 1, CNA 1 did not check if the oxygen tubing was connected to the patient. (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: 555074 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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)