Valley Vista Nursing: Oxygen Tube Found in Resident's Mouth - CA
The inspection at Valley Vista Nursing and Transitional Care LLC, conducted on August 13 and 14, 2025, documented what investigators found when they walked into Resident 1's room at 12:16 in the afternoon. The resident was asleep. Her nasal cannula, the flexible tube her doctor had ordered to deliver continuous oxygen, was not in her nose. It was in her mouth.
The certified nursing assistant, identified in the report as CNA 1, was standing near her bed. When an inspector asked where the nasal cannula was, he pointed to her mouth.
CNA 1 told inspectors he understood the tube needed to be in the resident's nose for her to receive oxygen. He said that if a cannula was found out of place, the right move was to notify the charge nurse. He had not done that.
Resident 1 depended entirely on staff for eating, dressing, personal hygiene, and using the toilet. Her care plan, dated July 1, 2025, noted she had the potential for episodes of shortness of breath and required continuous oxygen via nasal cannula. Her doctor's orders, dated August 1, 2025, called for oxygen at two liters per minute every shift, with instructions to increase it to five liters if necessary.
A nasal cannula in the mouth delivers nothing to the lungs.
The licensed vocational nurse on duty, LVN 1, told inspectors what happens when a cannula is misplaced: oxygen saturation drops. The nurse said the correct response, upon finding the tube in a resident's mouth, was to check the resident's oxygen levels, confirm the doctor's order, and reposition the cannula. None of that had happened before inspectors arrived.
The Director of Nursing told inspectors the next day that professional standards for respiratory care require nursing staff, every time they enter a resident's room, to check the resident's position, confirm the call light is within reach, and verify the nasal cannula is correctly placed. The Director of Nursing said the consequence of improper placement was that the resident is deprived of oxygen, which can lead to desaturation. The director also said that if a doctor has ordered oxygen, it needs to be followed.
The facility's own oxygen administration policy, last revised in October 2010, describes the nasal cannula as a tube placed approximately one-half inch into the resident's nose.
CMS rated the harm level for this violation as minimal, with potential for actual harm affecting few residents. But Resident 1's underlying conditions made the stakes specific. Congestive heart failure leaves the heart unable to pump enough blood to meet the body's needs, causing fluid to back up into the lungs. Pleural effusion adds excess fluid between the lung and the chest wall. Respiratory failure means the lungs are already struggling to exchange oxygen and carbon dioxide. For a resident carrying all three diagnoses, continuous oxygen is not a comfort measure. It is a clinical requirement.
The inspection was triggered by a complaint. The report does not say how long the nasal cannula had been in the resident's mouth before the inspector walked in, or how long before that CNA 1 had first entered the room. He said he had been there maybe ten minutes. What happened in the time before that, while Resident 1 slept and her oxygen tube sat in her mouth, the report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley Vista Nursing and Transitional Care LLC from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC in NORTH HOLLYWOOD, CA was cited for violations during a health inspection on August 14, 2025.
Her nasal cannula, the flexible tube her doctor had ordered to deliver continuous oxygen, was not in her nose.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.