NORTH HOLLYWOOD, CA - Valley Vista Nursing and Transitional Care LLC was cited for multiple serious violations during an April 2025 inspection, including failure to properly administer medications and maintain basic sanitation standards for a vulnerable resident with chronic obstructive pulmonary disease and other serious medical conditions.
Critical Medication Failures Put Resident at Risk
The most serious violations centered on the facility's failure to provide essential respiratory medications to a resident with chronic obstructive pulmonary disease (COPD), a condition that causes severe breathing difficulties and requires consistent treatment to prevent life-threatening complications.
Inspection records revealed that staff failed to administer prescribed breathing treatments on multiple occasions in March 2025. The resident's Albuterol sulfate nebulizer treatments - critical medications that help open airways and ease breathing - were not given on March 28 at 5 p.m. and 10 p.m. Additionally, Symbicort inhalation aerosol, an anti-inflammatory medication that helps prevent breathing episodes, was missed on March 28 at 9 p.m.
The facility also failed to provide ordered Aquaphor ointment treatments for nasal dryness on four separate dates in March - the 9th, 16th, 23rd, and 30th. While this may seem minor, nasal dryness can significantly impact oxygen delivery effectiveness for COPD patients who rely on continuous oxygen therapy.
During the inspection, the affected resident told surveyors she felt "frustrated because she was not receiving timely breathing treatments and skin treatment as ordered by the physician." A Licensed Vocational Nurse acknowledged that "the failure to administer medications could have potentially caused Resident 1 to experience shortness of breath."
Dangerous Oxygen Supply Shortages During Medical Appointments
Beyond missed medications, inspectors discovered the facility was providing inadequate oxygen supplies during the resident's medical appointments. The resident, who requires 4-5 liters of oxygen per minute continuously, was given only a single oxygen tank for clinic visits that lasted longer than the tank's capacity.
According to the facility's oxygen provider, the E-tanks provided contain enough oxygen to last approximately two hours for someone using 4-5 liters per minute. However, the resident reported that during "several clinic appointments, the facility provided Resident 1 with one oxygen tank which did not contain enough oxygen to last until Resident 1 returned to the facility causing shortness of breath."
This practice creates significant medical risks. When oxygen levels drop below prescribed levels, COPD patients can experience respiratory distress, increased strain on the heart, and potentially life-threatening complications. The Director of Nursing acknowledged that the "facility's failure to provide Resident 1 with enough oxygen to last during clinic visits could have potentially endangered Resident 1's life."
Serious Sanitation Failures Create Infection Risks
Inspectors documented alarming sanitation failures in the resident's living space that violated basic infection control standards. During an April 2025 inspection, surveyors found food debris scattered on the floor next to the resident's bed, including a plastic spoon with brown residue, a glass jar with brown residue, an upside-down plate, and orange peels.
More concerning, inspectors observed ants inside the glass jar and on the floor. A Certified Nursing Assistant present during the inspection confirmed that "there were ants inside the glass jar and on the floor" and acknowledged that "it is important to keep Resident 1's room clean and prevent infection."
Additionally, dried fecal residue was found on the resident's bedside commode, which had not been properly cleaned. The nursing assistant stated that "the bedside commode should have been cleaned to prevent spread of infection."
These sanitation failures are particularly dangerous for residents with compromised immune systems or chronic conditions like COPD, who face elevated risks from bacterial infections that could lead to pneumonia or other serious complications.
Medical Context and Standards of Care
For residents with COPD, consistent medication administration is essential for maintaining stable respiratory function. Missing even a single dose of bronchodilators like Albuterol can trigger breathing episodes that may require emergency intervention. Anti-inflammatory medications like Symbicort help prevent airway inflammation that can lead to severe breathing difficulties.
Federal nursing home regulations require facilities to administer medications exactly as prescribed by physicians and maintain detailed documentation of all treatments. The facility's own policy states that "medications are administered in a safe and timely manner, and as prescribed" with proper documentation required.
Regarding infection control, nursing homes must maintain environments that prevent disease transmission, particularly crucial for vulnerable populations with chronic respiratory conditions who face heightened infection risks.
Care Plan Implementation Failures
The inspection also revealed that the facility failed to properly implement the resident's care plan regarding weight monitoring. Despite the care plan requiring notification of the physician when the resident refused weight measurements between December 2024 and March 2025, no documented communication with the physician occurred.
The Director of Nursing admitted the facility "could not provide documented evidence of physician communication regarding Resident 1's weight measurement refusal" and acknowledged this "could have potentially experienced a change in her condition and weight loss that was not identified."
Additional Issues Identified
The inspection revealed additional deficiencies including failure to maintain a homelike environment due to unsanitary conditions, inadequate care plan implementation, and lack of policies addressing oxygen provision during resident transportation. The facility also lacked proper documentation procedures for care plan compliance and physician communication protocols.
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 2025-04-04 including all violations, facility responses, and corrective action plans.
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