Huntington Park Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4), who had a sacrococcygeal (tailbone) wound, received the treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan by failing to ensure the topical medication ordered by the physician was administered by a licensed nursing personnel and was not left at the bedside, unattended. This failure had the potential for Resident 4's wound to worsen and placed other residents at risk for accidental ingestion, leading to complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician for one of five sampled residents (Resident 4), who had a purple skin discoloration on the right upper arm. This deficient practice resulted in the physician being unaware of the resident's condition and had the potential to delay the care and services the resident will need.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents ' (Resident 2) pain medication was reordered from the pharmacy at least seven (7) days in advance, as indicated in the facility ' s policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy. This deficient practice placed Resident 2 without the pain medicine available when needed resulting in the resident ' s discomfort and risk for severe pain. This deficient practice had the potential to affect in maintaining the resident ' s highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices for 84 out of 84 residents when: 1. The inside gasket of the kitchen ice machine was not clean. 2. One container of gelatin mix powder was not labeled with use-by date and content. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (any illness resulting from eating contaminated/spoiled foods) in all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents' (Resident 45) call light was within reach. This deficient practice had the potential to result in a delay and the inability for Resident 45 to obtain care and services from the facility's staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four sampled residents' (Residents 33, 70, and 32) low air loss mattresses (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) were accurately set to their weight. This deficient practice had the potential to cause the avoidable development and/or worsening of pressure ulcers (PU, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and the complications associated with impaired skin integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective infection prevention control program for three out of four sampled residents (Residents 21, 70, and 242) when the facility failed to: 1. Ensure Resident 21 did not reuse an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag. 2. Change Resident 70's oral suction (procedure involving the removal of secretions from the mouth using a suction device) cannister (container to collect fluids and secretions removed from the mouth). 3. Ensure Resident 242's indwelling urinary catheter drainage bag and tubing did not touch the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly notify the physician and the responsible party (RP) of a significant change in condition (COC), related to decline in mobility and ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) for one of six sampled residents (Resident 72). This deficient practice had the potential to result in a delay in medical assessment and treatment for Resident 72 and placing the resident at risk of significant decline in functional status, including total dependency for mobility, and increased dependency in ([ADLs]- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool), for two of six sampled residents (Residents 9, and 3) was accurately coded to reflect Residents 9 and 3's oral and/or dental status. This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 9 and 3's dental status and had the potential to negatively affect residents' care plan and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for one of 11 residents (Resident 7) by failing to keep Resident 7's fingernails clean and neat. This failure had the potential to result in a negative impact on Resident 7's quality of life and self-esteem. This failure also had the potential for the development of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician order for physical therapy ([PT]- healthcare specialty focuses on restoring, maintaining, and improving a resident ability to move and function) and occupational therapy ([OT]- a healthcare specialty that helps a resident improve the ability to perform daily activities) services were implemented timely for one of six sampled residents (Resident 72). This deficient practice had the potential to result in a significant decline in Resident 72's functional status, including total dependency for mobility, and increased dependency in activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a two-person assist when utilizing the electric stand-up lift (battery-powered device to provide assistance from a sitting to standing position) for one of two sampled residents (Resident 64). This deficient practice had the potential to result in Resident 64 becoming unsteady on the electronic stand-up lift resulting in a fall and/or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of two residents (Resident 80), who required hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), a dialysis emergency kit (e-kit) at bedside. This failure had the potential for Resident 80 to receive delayed intervention in managing dialysis site complications such as bleeding.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's physician (Physician 1) conducted an initial comprehensive assessment (a thorough evaluation of person's health, including their physical, mental, and social factors) for one of six sampled residents (Resident 45) after Resident 45 was readmitted to the facility. This deficient practice resulted in the delay of a comprehensive assessment of Resident 45's health and status, which could negatively affect the delivery of necessary care and services for Resident 45.

Inspectors wroteBased on interview and record review, the facility failed to follow up on an order for consultation with an Ear, Nose, and Throat (ENT - medical doctor who specializes in the medical and surgical treatment of conditions affecting the ears, nose, throat, head, and neck region) doctor for Resident 82. This failure had the potential to result in worsening left ear pain and left ear hearing loss for Resident 82.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' food preferences were respected and alternatives were provided for one of six sampled residents (Resident 42). This deficient practice had the potential to result in decreased meal intake, and alter Resident 42's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the renal diet (specialized diet designed to help people with kidney disease or kidney failure to manage their condition) menu for one of four sampled residents (Resident 21). This deficient practice had the potential to result in the buildup of waste products that Resident 21's kidneys could not filter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and properly store food brought by family/ visitors for three out of three residents (Residents 40, 66, and 52) in accordance with the facility's Policy and Procedure (P&P) titled, Use and storage for foods brought in by family or visitors. These deficient practices had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) for Residents 40, 66, and 52, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and could lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician order for physical therapy ([PT]- healthcare specialty focuses on restoring, maintaining, and improving a resident ability to move and function) and occupational therapy ([OT]-a healthcare specialty that helps a resident improve the ability to perform daily activities) evaluation and a wheelchair was carried out for one of six sampled residents (Resident 72). This deficient practice resulted in delayed treatment and services for Resident 72 and placed the resident at higher risk for further functional and mobility decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 3 sampled residents ' (Resident 1) personal wheelchair was accounted for, in the resident ' s inventory list (a document where a resident ' s personal belongings are listed/ added when received), as indicated in the facility ' s policy and procedure (P&P) titled, Inventory List, Resident ' s Personal. This failure had the potential to result in Resident 1 ' s wheelchair lost or stolen.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a comprehensive, resident-centered care plan was developed for one of three sampled residents (Resident 1), who was admitted high risk for fall. This failure resulted in a total of three falls (2/20/2024, 3/25/2024 and 7/16/2024) within 5 months and had the potential to cause harm and injury to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the call light was in reach for five of 92 facility residents (Resident 27, 70, 7, 9, and 79). This deficient practice increased the risk for residents to be unable to call for staff assistance or express their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments and services to prevent and/or limit a decline in range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility (ability to move) for two of six sampled residents (Residents 78 and 29) with identified ROM and mobility concerns by failing to: a. Provide treatment and services to maintain and prevent a decline in mobility and ROM of Resident 78's legs. b. Provide a right knee extension splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to Resident 78's right leg in accordance with Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) recommendations on 2/14/2023. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 37) did not receive unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) when: 1. Lorazepam (brand name Ativan, used to act on the brain and nerves to produce a calming effect) was administered for behaviors not indicated in the physician order or resident's care plan. 2. Certified Nursing Assistant (CNA) observations were used for clinical justification in determining whether to attempt a gradual dose reduction (GDR, the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Resident 37's lorazepam order. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure expired Ozempic (once-weekly injection to manage blood glucose levels) was removed and discarded for one out of three residents (Resident 51) medications reviewed in two of two inspected medication carts (Middle Station Medication Cart). 2. Ensure medication remaining at the facility after two of two residents (Resident 55 and 88) was discharged from the facility was removed from active supply, marked discontinued and securely stored until destroyed in accordance with the facility's Policy and Procedure (P&P) titled, Discontinued Medications, dated 8/2019. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure all food items stored in the kitchen and dry food storage room were labeled and dated, and failed to ensure safe food preparation practices in the kitchen were followed. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness for residents who received food from kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure enhanced barrier precautions (EBPs, an infection control intervention used to reduce transmission of multidrug-resistant organisms [MDROs, organisms resistant to at least one or more classes of antimicrobial agents]) were implemented for 16 of 16 sampled residents (Residents 59, 70, 94, 46, 25, 74, 92, 71, 48, 38, 40, 69, 26, 2, 62, 247). This deficient practice increased the risk for spread of MDROs to vulnerable facility residents, and the potential incidence of preventable infection.

Inspectors wroteBased on interview and record review, the facility failed to offer advance directives for one of three residents (Resident 44). This deficient practice had the potential to cause conflict with Resident 44's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 92 resident's (Resident 37 and 41) beds were not positioned against the wall. This deficient practice reduced the residents' ability to get out of bed freely and also increased the risk for entrapment and subsequent injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions to improve, maintain, or prevent a further decline in range of motion (ROM, full movement potential of a joint) and mobility for one of six sampled residents (Resident 78) who was identified as having decreased mobility and ROM limitations in the right leg. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 78, and had the potential to lead to contracture (loss of motion of a joint) development and a decline in overall physical functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately monitor and record the total amount of calories received via enteral feeding (nutrition that bypasses the mouth and delivers via the stomach) for one of three residents (Resident 2). This deficient practice had the potential to result in Resident 2 not receiving an adequate amount of calories which could potentially lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor one out of three residents' food preferences (Resident 65). This deficient practice had the potential for Resident 65 experience discomfort due to indigestion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Occupational Therapy (OT, provides services to increase and/or maintain a person's capability to participate in everyday life activities) services to one of six sampled residents (Resident 78) who had activities of daily living (ADL, basic activities such as eating, dressing, toileting) and functional mobility (ability to move around and perform daily tasks) concerns. This deficient practice prevented Resident 78 from receiving skilled therapy services to maintain or achieve the highest practicable level of function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of three Residents (Resident 74) understood and received the arbitration agreement in a language (Spanish) Resident 74 could understand when entering a binding contract. This deficient practice had the potential to result in harm for Resident 74 by waiving his right to a jury trial when taking legal action without his knowledge.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy to one of five sampled residents (Resident 2), when providing right foot wound care. This deficient practice violated the resident's right to privacy and had the potential to affect the psychosocial well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan to reflect safety measures in caring for one of five sampled residents (Resident 1), who was at risk for spontaneous fractures (broken bone) due to brittle bones. This deficient practice had the potential to place Resident 1 at risk for further injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment was conducted on the lower extremities for one of three sampled residents (Resident 1). This failure had the potential that proper interventions necessary for an individualized care plan will not be identified and had the potential to provide poor quality care to the affected resident. Findings During a review of Resident 1's admission record, dated 3/28/2024, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of lower end of left femur (thigh), fracture of lower end of right femur, and osteoporosis (a condition in which bones become weak and brittle). During a review of Resident 1's History and Physical (H&P), dated 8/26/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate documentation was available in the medical record for 1 of 4 sampled residents, Resident 1. Resident 1 who had an insurance managed by a Health Management Organization (HMO, a health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO), and was changed to Medicare (united states federal health insurance program for people aged 65 years or older and people with certain disabilities). This failure resulted in Resident 1 ' s family member verbalizing feelings of mistrust, accusations of false documentation and doubting the care the facility staff provided.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 2 monitored and supervised one of three sampled residents (Resident 1) after being medicated and agitated 10 minutes prior to the incident. As a result of this failure, Resident 1 suffered a fall to the ground from a wheelchair and sustained a subdural hematoma (a type of brain bleed), subarachnoid hemorrhage (bleeding in the space that surrounds the brain), compression fracture of the fourth lumbar vertebra (a type of break in bones to the back that stack up on from the spine), right eleventh rib fracture (break in bone of the rib), and right temporal bone fracture (break in bone that forms part of the side and base of the skull).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach and accessible for one of three sampled residents (Resident 3). This deficient practice had the potential to result in a fall, accidents and delay in meeting the needs for Resident 3.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide reasonable accommodation to meet the resident's needs by not ensuring: A. the resident's call lights were within reach for Five of Five sampled residents (Residents 56, 67, 2, 41 and 35) B. ensure bed's are working properly for one of three sampled residents (Resident 20). These deficient practicse had the potential to negatively impact the psychosocial well-being of the residents or result in delayed provision of services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled Residents (#56 and # 269), received the professional standard of care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 56 and Resident 269 not receiving fingernail care and had the potential to negatively impact Resident 56's and Resident 269's quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label four insulin pens with a pharmacy label for Resident 23, in accordance with medication labeling requirements, in one of 2 inspected medication room (Medication Room Miles Station). 2. Indicate open date on a multi-dose Tuberculin Purified Protein Derivative (Mantoux) Tubersol Vaccine, Gabapentin Solution, Albuterol Sulfate in one of two inspected medication room (Medication Room Miles Station). 3. Indicate an open date on Morphine Sulfate concentrate, Geri-tussin DM, 5 dietary supplements, multi-dose Heparin vial and Breo Ellipta, in accordance with medication labeling requirements and manufacturers' requirements and facility policies, in one of two inspected medication carts (Medication Cart Miles in Yellow zone). 4. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store and prepare food under sanitary conditions in one (1) of 1 kitchen, by failing to: A. Ensure the facility used pasteurized ( have gone through a process that kills germs in foods and drinks ) eggs when preparing fried over-easy eggs( (egg gets fried on both sides, but it's not cooked for very long on the second side, so the yolk remains runny and uncooked) egg for 6 of 6 residents sampled, B. Ensure the jelly sandwiches were not stored in the dry storage area. These deficient practices had the potential to result in contamination of food items placing residents at a high risk for food borne illness that can lead to a decline in health, hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of infections for two of two sampled residents (29, 1 and 17) by failing to: a. Ensure treatment nurse 1 (TN 1) performed hand hygiene and used clean gloves while rendering wound care treatment for Resident 29 and Resident 1. b. Staff covered Resident 17's toothbrush before storing it on top of the bathroom sink for Resident 17 These deficient practices placed Residents17 and 29 at risk for contracting an infectious disease that could lead to illness and hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to provide 1 out of 7 residents (Resident 23), and or their responsible parties, with written information on how to formulate an Advanced Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential for violating Resident 23 choices about their medical care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident's belongings, update inventory list, and verify missing items for one of two sampled residents (Resident 6), resulted in Resident 6 feeling uncomfortable wearing clothes that do not belong to him. This deficient practice resulted in violating Resident 6's rights and has the potential to cause negative effect on resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized resident-centered plan of care with measurable objectives, timeframe, and interventions to meet Resident 56 who has pacemaker (a small device that is implanted in the chest to help control heartbeat) needs.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure Resident 8 received the necessary care and services needed to attain the highest practicable level of physical, mental, and psychosocial well-being, by not ensuring facility staff tended to Resident 8's needs. This deficient practice had the potential to result in Residents 8 not receiving the care that was needed to maintain Resident 8's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs, for three of three sampled residents, as evidenced by: a. Failing to properly implement safety precaution for Resident 10 who needed proper positioning and suctioning. This deficient practice has the potential to result in aspiration (inhalation of foreign materials) and resident choking on her saliva. b. Failing to provide proper turning for a Resident 1who needed assistance with repositioning and care. This deficient practice resulted in worsening of the left hip wound.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of one sampled residents (Resident 268) was assessed upon arrival to the facility when she returned from outpatient dialysis (procedure to remove waste products and excess fluid from the blood). This deficient practice resulted in a delay in addressing Resident 268's complaint of dizziness, and this could have been detrimental to her health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to follow policy for count of controlled substances on change-of-shift documentation in the medication cart in the red zone. This deficient practice has the potential for the facility staff to not secure and safeguard-controlled medications as well as not be able to monitor those medications were administered to the residents safely and accurately.

Inspectors wroteBased on interview and record review, the facility failed to act on the consultant pharmacist's recommendation in the Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) in a timely manner for three out of nine sampled residents (Residents 13, 45, and 53). This deficient practice resulted in recommended blood test not performed on time for Residents 13, 45, and 53, with potential for adverse drug reaction for the following: a. Resident 13- Digoxin (medication to treat heart failure) level for the months of November and December b. Resident 45- Liver Function Test (blood test to diagnose and monitor liver disease) for the month of December c. [...]