Health inspection·September 5, 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 interview and record review, the facility failed to provide respiratory care services consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure high concentration oxygen (a compressed gas cylinder containing oxygen at a high-pressure level, delivering pure oxygen with very high purity [up to 99.5 percent {%}] for medical use) was administered and correct oxygen delivery device (a piece of medical equipment that provides supplemental oxygen [a medical treatment that provides additional oxygen to the body when the air we normally breathe doesn't contain enough for organs to function correctly] to a resident who is unable to get enough oxygen on their own) was used when on 8/30/2025 at 9:20 a.m., Resident 1 had an oxygen saturation level (amount of oxygen that is circulating in the blood, normal range: 95% to 100%) of 80 % while receiving oxygen via nasal cannula (a medical device, typically a thin, flexible tube with two prongs, that delivers supplemental oxygen to a person's nostrils). This deficient practice had the potential to result in inadequate oxygenation which could lead to increased respiratory distress (a severe symptom of a medical emergency characterized by trouble breathing, including a sudden, intense feeling of shortness of breath, rapid, labored breathing [breathing is unusually quick , requires significant effort], and potentially a bluish tint to the lips or nails due to low blood oxygen), hypoxia (low levels of oxygen in body tissues) and other complications. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/9/2025 with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own), malignant neoplasm (a cancerous growth of cells) in the prostate (a gland in the male reproductive system) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/16/2025, the MDS indicated that Resident 1 was sometimes able to make self-understood and sometimes able to understand others. The MDS indicated Resident 1's cognition (ability to think and make decisions) was severely impaired. The MDS further indicated that Resident 1 required moderate assistance from staff with eating and oral hygiene, and required maximum assistance from staff with toileting, lower body dressing, personal hygiene and mobility (movement). During a review of Resident1's Weights and Vital Signs (measurements that indicate a person's basic physiological functions and overall health) Summary, including oxygen saturation level dated 8/30/2025, the summary indicated that on 8/30/2025 at 9:20 a.m., Resident 1had an oxygen saturation level of 80% while receiving oxygen via nasal cannula. During a review of Resident 1's Physician's Order dated 8/15/2025, the Physician's Order indicated to administer oxygen at two (2) to five (5) liters per minute (LPM - unit of measure) via nasal cannula, titrate (gradually adjust) oxygen level less than (<) 90% as needed. During a review of Resident 1's Physician's Order dated 8/30/2025, timed at 9:17 a.m., the Physician's Order indicated to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) via paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital). During a Residents Affected - Few Page 1 of 2 555574 555574 09/05/2025 Stoney Point Healthcare Center 21820 Craggy View St. Chatsworth, CA 91311

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review of Resident1's Progress Notes dated 8/30/2025, timed at 9:58 a.m., the Progress Notes indicated that on 8/30/2025 at 9:58 a.m. an order was received from Medical Doctor 1 (MD 1) to transfer Resident 1 to the hospital (GACH 1) via 911 (emergency telephone number for immediate assistance from police, fire or emergency medical services [EMS - refers to a system that provides immediate medical care to individuals experiencing medical emergencies]) for comfort measures. The Progress Notes indicated that on 8/30/2025 at 9:30 a.m., paramedics arrived and took over resident care. The Progress Notes indicated that on 8/30/2025 at 9:58 a.m., Resident 1 left the facility and was transferred to GACH 1. During a concurrent interview and record review on 9/5/2025 at 4:07 p.m., with the Director of Nursing (DON), Resident 1's Progress Note dated 8/30/2025 timed at 9:58 a.m. was reviewed. The DON stated that there was no documented evidence found in Resident 1's medical records indicating that oxygen flow rates (refers to the volume of supplemental oxygen delivered to a patient, measured in LPM) were increased to address Resident 1's oxygen saturation level of 80% on 8/30/2025 at 9:20 a.m., or that high concentration oxygen tank was administered using a non-rebreather mask (a single-use medical device that delivers a high concentration of oxygen to a patient with moderate to severe shortness of breath, with a typical oxygen flow rate of 10 to 15 LPM) prior to the arrival of paramedics. During a phone interview on 9/8/2025 at 10:12 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that on 8/30/2025 at 9:20 a.m. Resident 1 was receiving oxygen at five (5) LPM via NC until paramedics arrived. RN 1 further stated that Resident 1 was not administered high concentration supplemental oxygen via a non-rebreather mask prior to the paramedics' arrival. During a review of Resident 1's Paramedics Patient Care Report dated 8/30/2025, the Paramedics Patient Care Report indicated that on 8/30/2025 the paramedics arrived on scene (at the facility) at 9:42 a.m. and found Resident 1 with an oxygen saturation level of 83% on four (4) LPM via nasal cannula, heart rate of 122 beats per minute and respiratory rate of 41 breaths per minute. The Paramedics Patient Care Report indicated that when facility staff (staff not indicated) was asked why Resident 1 wasn't placed on oxygen therapy no answer was given. The Paramedics Patient Care Report indicated Resident 1 was then placed on oxygen at 15 LPM via non-rebreather mask and given fluids for hypotension (low blood pressure). During a review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 1/21/2025, the P&P indicated, The purpose of the procedure is to provide guidelines for safe oxygen administration. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record. The rate of oxygen flow, route, and rationale. All assessment data obtained before, during, and after the procedure. 555574 Page 2 of 2