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 (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: 555574 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 555574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stoney Point Healthcare Center 21820 Craggy View St. Chatsworth, CA 91311 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)