Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Huntington Park Nursing Center during CMS and state inspections, most recent first.
A resident with an unstageable sacral PU, DM, HTN, and moderate cognitive impairment had a physician order for Calmoseptine to be applied to the sacrococcygeal area. Instead, a medicine cup with the topical cream was found uncovered at the bedside, and the resident said an unidentified nurse had given it to her about a week earlier and told her to apply it daily. An LVN stated it was not acceptable to leave the medication with the resident, and another LVN stated topical meds must be applied by licensed nursing staff and supervised even when self-administration is possible.
A resident with DM, HTN, and CHF, who had intact cognition and required assistance with ADLs, was observed with a purple bruise over an inch in size on the upper arm, with no clear cause identified. The resident reported that staff had not applied any treatment and was unsure if nurses were aware of the bruise. The care plan and skin policy required daily body checks, CNA reporting of discolorations, and licensed nurse assessment, documentation, and MD notification for new skin changes. An LVN confirmed she had not been informed of the bruise, had not notified the MD, and that the expected assessment and follow-up for the bruise had not been completed.
A resident with chronic pain and a severe pressure ulcer did not receive prescribed Hydrocodone-Acetaminophen as needed because staff failed to reorder the controlled medication from the pharmacy at least seven days in advance, as required by facility policy. The resident reported pain and was informed by nursing staff that the medication was unavailable and had to be reordered, resulting in discomfort until the medication was delivered.
Surveyors identified that the facility did not maintain sanitary conditions in the kitchen, as the ice machine had visible buildup inside the gasket and a container of gelatin mix powder was not labeled with a use-by date or contents. The Dietary Supervisor and Maintenance Manager both acknowledged these lapses, which were not in accordance with facility policy.
A resident with cognitive and physical impairments was repeatedly observed in bed without access to their call light, despite care plans and facility policy requiring it to be within reach. Staff interviews confirmed the call light was moved during care and not returned, leaving the resident unable to call for assistance.
Three residents with significant immobility and risk for pressure ulcers were found lying on low air loss mattresses (LALMs) that were set at weights much higher than their actual body weights. Staff and the DON confirmed that the LALMs should have been set according to each resident's weight, as required by facility policy and the manufacturer's instructions. The incorrect settings resulted in mattresses that were too firm, potentially reducing the effectiveness of pressure redistribution for these residents.
A resident with severe cognitive impairment and hypertension was administered hydralazine 24 times outside of physician-ordered blood pressure hold parameters. Nursing staff failed to follow the specified guidelines, as confirmed by MAR review and staff interviews, resulting in medication being given when blood pressure readings indicated it should have been held.
Surveyors found that the facility did not follow infection prevention protocols for three residents, including improper reuse and handling of urinary catheter drainage bags, failure to change oral suction cannisters daily, and allowing catheter bags and tubing to touch the floor. These actions were inconsistent with facility policy and staff knowledge, and were confirmed through observation and staff interviews.
A resident with dementia, Alzheimer's disease, diabetes, and muscle weakness experienced a significant decline in mobility and increased dependency in ADLs, progressing from walking with assistance to requiring a wheelchair and mechanical lift. Despite these changes, there was no timely assessment or notification to the physician or responsible party, as confirmed by interviews with therapy and nursing staff, the responsible party, and the physician. Facility policy required such notifications, but documentation and communication were lacking.
Two residents with significant medical histories were inaccurately assessed in the MDS as having no oral or dental issues, despite both reporting problems with missing or broken dentures and difficulty chewing. Observations and interviews confirmed the discrepancies, and the MDS nurse acknowledged the coding errors, which did not reflect the residents' actual oral and dental conditions.
A resident who required maximal assistance with personal hygiene was repeatedly observed with long, dirty fingernails containing a yellow and brown substance. Staff interviews and photographic evidence confirmed the lack of proper nail care, despite facility policies and care plans requiring staff to maintain resident cleanliness and grooming.
A resident with dementia, Alzheimer's, diabetes, and muscle weakness experienced a significant decline in mobility and ADL function after PT and OT services were discontinued. Despite a physician's order for PT/OT evaluation and a wheelchair, nursing staff failed to assess the decline, notify therapy, or implement the order, resulting in delayed care and treatment.
A CNA transferred a resident with severe cognitive impairment and muscle weakness using an electric stand-up lift without the required second staff member, contrary to the resident's care plan and facility policy. Staff interviews and training records confirmed that two-person assistance was necessary for safe transfers, but the CNA performed the transfer alone.
A resident dependent on hemodialysis did not have a required dialysis emergency kit (e-kit) at the bedside, as confirmed by multiple observations and staff interviews. The resident's care plan and physician orders specified the need for an e-kit to manage bleeding risks, but the kit was not present or accessible, contrary to facility policy and standard practice.
A resident with cognitive and physical impairments was readmitted, but the attending physician did not complete a required comprehensive assessment or provide a current H&P as mandated by facility policy. The only available H&P was from a prior hospitalization, and staff confirmed that the physician did not see the resident or establish a new baseline after readmission.
A resident with multiple chronic conditions experienced ongoing left ear pain and hearing loss, and although an ENT consultation was ordered, facility staff did not follow up to ensure the consultation occurred. Interviews confirmed that neither nursing nor social services took action to arrange the specialist visit, resulting in unmet medical needs.
A resident with multiple medical conditions and intact decision-making capacity was not provided with meals that matched their documented food preferences, including a preference for boiled meats and a dislike of milk. Despite care plans and dietary orders specifying these preferences, the resident was repeatedly served grilled fish and a milk-based supplement, and was not offered appropriate substitutes or snacks. Staff and dietary supervisor interviews confirmed that the resident's preferences were not honored, in violation of facility policy.
A resident with ESRD, spina bifida, and neurogenic bladder was not consistently provided the prescribed renal diet, receiving incorrect menu items including Italian crusted fish and double protein portions instead of the required baked fish. The dietary supervisor confirmed the error, and the DON acknowledged the importance of adhering to therapeutic diets for residents with kidney failure.
Three residents were found with perishable food items, such as opened ranch dressing, lemonade, and jalapenos, at their bedsides that were not labeled with names or dates and were not refrigerated as required. Staff did not ensure these items were properly stored or labeled, despite facility policy and manufacturer instructions indicating the need for refrigeration after opening.
A resident with dementia, Alzheimer's disease, diabetes, and muscle weakness experienced a significant decline in mobility and self-care abilities. Although a physician's order was written for PT/OT evaluation and a wheelchair, the order was not communicated to or carried out by the therapy department. Nursing and therapy staff were unaware of the order, resulting in delayed treatment and services for the resident.
A resident's personal wheelchair was not documented in the facility's inventory list, contrary to policy. Despite the resident's capacity to make decisions and the presence of identifying information on the wheelchair, staff interviews revealed that the inventory list was not updated to include the wheelchair, nor was it signed by the resident or their representative. This oversight had the potential to result in the wheelchair being lost or stolen.
A resident with a high fall risk experienced three falls over five months due to the facility's failure to implement a comprehensive, resident-centered care plan. Despite the resident's history of falls and muscle weakness, the care plan lacked necessary monitoring and supervision. The facility's policy emphasized individualized care plans and supervision for high-risk residents, but these were not effectively implemented.
The facility failed to ensure call lights were within reach for five residents, including those with muscle weakness, Alzheimer's disease, and hemiplegia. Observations revealed call lights on the floor or under pillows, leaving residents unable to call for assistance. Staff confirmed that call lights should be within reach to prevent delays in care and reduce fall risks.
The facility failed to provide treatments and services to prevent a decline in ROM and mobility for two residents. One resident did not receive a recommended knee splint or restorative nursing services, leading to decreased mobility and ROM. Another resident missed multiple days of scheduled ambulation exercises, risking functional decline.
A resident received lorazepam for behaviors not indicated in the care plan, with CNA observations improperly used for clinical justification and no documented risk-benefit analysis from the physician for continued use beyond 14 days.
The facility failed to remove expired Ozempic for a resident and did not properly store medications for two discharged residents. The expired medication was used beyond its recommended period, and the medications for discharged residents were mixed with current residents' medications, creating a potential for errors and drug diversion.
The facility failed to label and date food items in the kitchen and dry storage room, including milk, juice, cooked beans, apple sauce, margarine, sausages, rice, and dry beans. Cook 1 admitted to not knowing the preparation dates and acknowledged the importance of labeling for safety. The Dietary Staff Manager confirmed the requirement for labeling to prevent cross-contamination and ensure food safety.
The facility failed to implement enhanced barrier precautions (EBPs) for 16 residents, increasing the risk of MDRO transmission. Observations revealed no EBP signage or PPE outside the rooms of residents with conditions requiring EBP, such as wounds and indwelling medical devices. The Infection Preventionist Nurse confirmed that EBP was not being implemented, despite the facility's policy requiring it.
The facility failed to offer advance directives to a resident with severe cognitive impairment and multiple diagnoses, as required by their policy. This oversight was confirmed through interviews and record reviews, revealing a lack of documentation in the resident's chart.
The facility failed to ensure that two residents' beds were not positioned against the wall, restricting their ability to get out of bed freely and increasing the risk of entrapment and injury. Both residents had cognitive impairments and required assistance for repositioning, but there was no documented preference or care plan for the bed positioning. The DON confirmed that this practice posed a high risk for entrapment and was considered a restraint.
The facility failed to develop and implement an individualized care plan for a resident with decreased mobility and ROM limitations in the right leg. Despite the resident's diagnoses and MDS indicating functional limitations, no care plan was created to address these needs, resulting in the resident not receiving necessary interventions such as physical therapy or leg exercises.
The facility failed to accurately monitor and record the total amount of calories received via enteral feeding for a resident with dementia, gastrostomy, and dysphagia. Discrepancies in the administration and recording of the enteral feeding led to the resident not receiving the prescribed amount of nutrition, as confirmed by observations, interviews, and record reviews.
A resident with GERD and chronic gastritis was served food containing bell peppers despite having informed the Dietary Staff Manager to avoid such ingredients. The dietary staff failed to accurately document and honor the resident's food preferences, leading to potential digestive discomfort.
A resident with significant ADL and functional mobility concerns was discharged from OT services due to the end of insurance coverage, despite continued need for skilled therapy. The facility failed to explore alternative means to continue therapy, leading to a deficiency in care.
A resident with stage renal disease and dependence on renal dialysis signed an arbitration agreement in English, despite only understanding Spanish. The facility's policy required that such agreements be presented in a language the resident understands, but this was not followed, leading to a potential waiver of the resident's right to a jury trial without his knowledge.
A resident did not receive privacy during a wound care procedure, as the curtains were not completely closed, exposing the procedure to staff and visitors. The resident expressed discomfort, and facility staff acknowledged the importance of providing privacy to maintain dignity.
The facility failed to revise the care plan for a resident with osteoporosis, who required substantial assistance with ADLs and transfers. The care plan lacked specific safety interventions, leading to an incident where a CNA moved the resident's knee too hard, causing pain and the need for a splint. Staff confirmed that the care plan should have included measures to prevent injuries.
A facility failed to ensure an accurate assessment of a resident's lower extremities, leading to inconsistent documentation and potential improper interventions. The resident had fractures in both femurs and osteoporosis, and the assessments varied, with some indicating impairments and others not. The DON confirmed the inaccuracies, emphasizing the importance of correct evaluations for proper care planning.
Topical wound medication left at bedside and not administered by licensed nurse
Penalty
Summary
The facility failed to ensure that a physician-ordered topical medication for a resident with a sacrococcygeal wound was administered by licensed nursing personnel and not left unattended at the bedside. Resident 4 was admitted with diagnoses including an unstageable sacral pressure ulcer, DM, and HTN, and the care plan directed wound care per treatment order. The resident’s MDS indicated moderate cognitive impairment and dependence or partial dependence for several ADLs. The physician ordered the sacrococcygeal area to be cleansed with NS, patted dry, and Calmoseptine applied every day shift for 30 days. During observation, a medicine cup containing a thick pink cream was found on the resident’s bedside table, and the resident stated a nurse had given the cream about one week earlier and instructed her to apply it daily. The resident also stated she kept the cup uncovered on the bedside table. An LVN observed the cup at the bedside and stated it was not acceptable to leave the medication with the resident or unattended, and another LVN stated licensed nurses were responsible to apply topical creams and that even residents capable of self-administration must be supervised during medication administration. The facility policy stated medications should be administered only by licensed nursing personnel in accordance with written orders.
Failure to Notify MD of New Bruising and Skin Change
Penalty
Summary
The facility failed to notify the physician of a change in condition for one resident who was observed with a purple skin discoloration on the right upper arm. During an observation and interview in the resident’s room, the discoloration measured more than an inch, and the resident reported not knowing the cause, speculating it might have occurred when going to the bathroom. The resident stated she was unsure if nursing staff were aware of the bruise and that nothing had been applied to it. Review of her records showed she had diagnoses of diabetes mellitus, hypertension, and congestive heart failure, had intact cognition and decision-making capacity, and required assistance with ADLs including dressing, toileting, personal hygiene, transfer, and mobility. The resident’s care plan for potential skin breakdown, related to thin fragile skin, directed staff to perform daily body checks and to monitor, document, and report to the physician any changes in skin status, including bruises or discolorations, and to notify the nurse of new areas of skin breakdown noted during care. In an interview, an LVN stated she had not been informed of the resident’s arm bruise and confirmed the physician had not been notified. The LVN also stated the bruise should have been assessed for size, redness, hardness, and possible blood thinner use, and the cause should have been identified. Facility policy on Skin and Wound Monitoring and Management required licensed nurses to assess and document skin issues and obtain and implement treatment orders as appropriate, and required CNAs to report skin discolorations to licensed nurses, but this process did not occur for the resident’s arm bruise.
Failure to Timely Reorder Pain Medication Resulting in Resident Discomfort
Penalty
Summary
The facility failed to ensure that a resident's pain medication, Hydrocodone-Acetaminophen, was reordered from the pharmacy at least seven days in advance, as required by the facility's policy and procedure for medication ordering and receiving. The resident, who had chronic pain, a stage 4 pressure ulcer, and acute osteomyelitis, was admitted with intact cognition and required substantial assistance with activities of daily living. The physician's order specified the use of Hydrocodone-Acetaminophen for moderate to severe pain. On the day in question, the authorization form for the pain medication refill was faxed to the resident's physician, but the physician was unavailable to sign until several days later. The refill authorization was eventually received and sent to the pharmacy, but the medication was not delivered or available for administration on the day the resident requested it. The Medication Administration Record confirmed that the resident did not receive the pain medication on that day. Interviews with the resident and nursing staff confirmed that the resident experienced pain and was informed by staff that the medication was unavailable and needed to be reordered. Staff acknowledged the importance of timely medication ordering and the negative impact of pain on the resident's well-being. The facility's policy required controlled substances to be reordered at least seven days in advance, but this was not followed, resulting in the resident being without necessary pain medication.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage practices for all residents. Specifically, the inside gasket of the kitchen ice machine was found to have yellow and white buildup, which the Dietary Supervisor acknowledged as water residue that should not be present and could cause contamination. The Maintenance Manager confirmed responsibility for cleaning the inside of the ice machine and stated that the buildup was not supposed to be there, indicating a lapse in regular cleaning and maintenance as required by facility policy. Additionally, a container of gelatin mix powder in the kitchen's dry storage room was found without a use-by date or content label. The Dietary Supervisor confirmed that the container should have been labeled with both the received and use-by dates, and acknowledged that the expiration date was not visible. This failure to properly label food items was contrary to the facility's policy and could result in the use of expired or unidentified food products.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
Staff failed to ensure that a resident's call light was within reach, as required by the resident's care plans and facility policy. The resident, who had diagnoses including cognitive communication deficit, generalized muscle weakness, and dementia, was assessed as having moderately impaired cognition and required moderate to total assistance with daily activities such as hygiene, toileting, and dressing. Multiple care plans for the resident specifically directed staff to keep the call light within reach to minimize fall risk, support communication, and anticipate needs. During several observations, the resident was found lying in bed with the call light either hanging behind the bed or clipped to an overhead light, both out of the resident's reach. Staff interviews confirmed that the call light was not accessible and that it had been moved during care and not returned to the resident's reach. Staff acknowledged that the resident would be unable to call for assistance in this situation. Facility policy also required staff to ensure call lights were within reach and secured as needed.
Failure to Set Low Air Loss Mattresses to Resident Weight
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs) for three of four sampled residents were set according to each resident's actual weight, as required by both facility policy and the manufacturer's instructions. Observations and interviews revealed that the LALMs for these residents were set at weights significantly higher than the residents' actual weights, resulting in mattresses that were too firm. This practice was confirmed by both the treatment nurse and the director of nursing, who acknowledged that the mattresses should be set to match the resident's weight to provide appropriate pressure redistribution. One resident, with a history of hemiplegia, hemiparesis, respiratory failure, and dementia, was observed on a LALM set at 350 lbs despite weighing only 123 lbs. Another resident, who had hemiplegia, hemiparesis, and a stage four pressure ulcer, was also found on a LALM set at 350 lbs while weighing 159 lbs. A third resident, diagnosed with quadriplegia and diabetes, was observed on a LALM set at 230 lbs, though his weight was 156-157 lbs. In each case, staff confirmed that the LALM settings were incorrect and not in accordance with the residents' actual weights. The facility's own policy and the LALM manufacturer's manual both require that the mattress pressure be adjusted based on the patient's weight to prevent skin breakdown and pressure ulcers. Staff interviews indicated awareness of the importance of correct LALM settings, yet the deficiency persisted across multiple residents. The incorrect settings had the potential to compromise the effectiveness of the pressure redistribution, as noted by the staff and the director of nursing during interviews.
Failure to Follow Hold Parameters for Antihypertensive Medication
Penalty
Summary
Licensed nursing staff failed to administer hydralazine according to the physician-ordered hold parameters for a resident with a history of hemiplegia, hemiparesis, and essential hypertension. The resident was cognitively impaired and dependent on staff for all activities of daily living. The medication order specified that hydralazine should be held if the systolic blood pressure was less than 110 mm Hg or the diastolic blood pressure was less than 60 mm Hg. Despite these clear instructions, the medication was administered 24 times over a period of approximately five weeks when the resident's blood pressure readings met the criteria for holding the medication. The MAR and interviews confirmed that the licensed nurse was responsible for following the hold parameters but did not do so, resulting in the resident receiving hydralazine outside of the prescribed safety limits. The DON acknowledged that the failure to follow hold parameters put the resident at risk. Facility policy required medications to be administered in accordance with physician orders, but this was not followed in the case of this resident.
Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement an effective infection prevention and control program for three residents, resulting in multiple deficiencies related to the handling of urinary catheters and oral suction equipment. For one resident with an indwelling urinary catheter, the drainage bag and tubing were repeatedly disconnected and reconnected between a bedside drainage bag and a leg bag. The tubing tip was left uncapped and exposed to air or tucked inside a dignity bag, and the same drainage bag was reused daily for up to a month. Staff interviews confirmed awareness of this practice, which was inconsistent with facility policy requiring a new drainage bag and tubing whenever the closed system is compromised. Another resident, who was dependent on staff for all care and required frequent oral suctioning, had a suction cannister at the bedside that was not changed daily. The cannister, containing oral secretions, was observed to have been in use for over a week, with staff confirming that the cannister and tubing should be disposed of daily. The facility did not have a policy specifying the required frequency for changing suction equipment, but staff and the infection preventionist stated that best practice was to change it every 24 hours to prevent bacterial growth. A third resident with a chronic indwelling urinary catheter was observed multiple times with the catheter bag and tubing touching the floor. The infection preventionist confirmed that the bag and tubing should be kept off the floor to prevent contamination, and the facility's policy also required this. Despite these requirements, the issue persisted over several observations, and staff acknowledged responsibility for ensuring the catheter bag was properly positioned.
Failure to Notify Physician and Responsible Party of Resident's Decline in Mobility and ADLs
Penalty
Summary
The facility failed to promptly notify the physician and responsible party of a significant change in condition for a resident who experienced a decline in mobility and increased dependency in activities of daily living (ADLs). The resident, who had diagnoses including dementia, Alzheimer's disease, diabetes mellitus, and muscle weakness, was initially able to walk independently or with a walker and required only moderate assistance with ADLs. Over time, the resident became increasingly dependent, eventually requiring a wheelchair and mechanical lift for transfers, and was no longer able to stand or walk. Despite this notable decline, there was no documented evidence in the electronic medical record of a timely assessment or physician notification regarding the resident's change in condition. Interviews with therapy staff, nursing staff, and the responsible party confirmed that the decline was observed but not communicated to the physician or responsible party as required. The responsible party reported noticing the resident spending more time in bed and sleeping more, but stated that these changes were not discussed with him by the facility. Therapy staff were also unaware of the resident's current status and had not been referred for reassessment. The facility's policy required documentation of assessment findings and prompt notification of the physician and responsible party in the event of a change in condition. However, both the MDS nurse and DON confirmed that the significant decline in the resident's functional status was not properly assessed or communicated, and the physician stated he was not aware of the change. This lack of timely notification and assessment constituted the deficiency identified by surveyors.
Inaccurate MDS Coding of Oral/Dental Status for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents accurately reflected their oral and dental status. For one resident with diagnoses including Parkinson's disease, dementia, diabetes mellitus, and dysphagia, the MDS indicated no oral or dental issues, despite the resident stating difficulty chewing due to lack of natural teeth and broken dentures. Observation confirmed the resident was eating breakfast and expressed these concerns directly. The MDS nurse acknowledged that the MDS was incorrectly coded and did not reflect the resident's actual oral and dental condition. Similarly, another resident with dementia, diabetes mellitus, dysphagia, and muscle weakness was assessed in the MDS as having no oral or dental issues. However, during observation and interview, the resident reported having no natural teeth and experiencing difficulty chewing due to loose dentures. The MDS nurse confirmed that this resident's MDS was also inaccurately coded, failing to represent the true oral and dental status. The facility's policy required the interdisciplinary team to ensure MDS accuracy, but this process was not followed in these cases.
Failure to Maintain Resident Nail Hygiene and Personal Grooming
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and personal hygiene for one resident by not ensuring the resident's fingernails were kept clean and neat. Multiple observations over three consecutive days revealed that the resident's fingernails were long and had a yellow and brown substance underneath. Interviews with staff, including a CNA and the Infection Preventionist Nurse, confirmed that the resident's fingernails were dirty and required cleaning, and that it was the responsibility of the nursing staff to ensure residents' fingernails were clean as part of infection control and personal hygiene. The resident involved had a history of ulcerative colitis and dementia, was dependent on staff for most activities of daily living, and required maximal assistance with personal hygiene. The resident's care plan included a goal to keep the resident clean, dry, and well-groomed. Facility policy and the CNA job description both specified that nail care was part of routine hygiene responsibilities. Despite these requirements, the resident's fingernails remained unclean over several days, as documented by both direct observation and photographic evidence.
Failure to Implement Timely PT/OT Orders for Resident with Declining Mobility
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician's order for physical therapy (PT) and occupational therapy (OT) services in a timely manner for a resident with a history of dementia, Alzheimer's disease, diabetes mellitus, and muscle weakness. The resident was initially admitted with the ability to walk independently or with a walker and received PT and OT services upon admission. These therapy services were discontinued after the resident achieved maximum potential, and the resident was discharged from therapy with an order for the Restorative Nursing Assistance (RNA) program. However, as the resident's mobility declined over several months, no further referrals for PT or OT were made, and the RNA program was not re-initiated for PT. Despite a significant decline in the resident's mobility and increased dependency in activities of daily living (ADLs), there was no documented assessment or intervention by nursing staff. The resident's responsible party reported noticing the decline and requested more therapy, but therapy services were not resumed. Nursing progress notes and physician orders did not reflect any assessment or action regarding the resident's mobility decline, and there was no evidence that the physician's order for a PT/OT evaluation and wheelchair was communicated to or carried out by the therapy department. Multiple staff interviews confirmed that the order for PT/OT evaluation, written and signed by the physician, was overlooked and not implemented. The PT and OT staff were unaware of the order and the resident's current functional status until the issue was brought to their attention during the survey. The facility's policies and job descriptions required that physician orders be carried out promptly and that referrals to therapy be made as needed, but these procedures were not followed, resulting in delayed care and treatment for the resident.
Failure to Provide Required Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) transferred a resident using an electric stand-up lift without the required assistance of a second staff member. The CNA entered the resident's room alone and used the lift to transfer the resident from a wheelchair to the bed, despite facility policy and the resident's care plan both specifying that a two-person assist was necessary for such transfers. The resident involved had multiple sclerosis, generalized muscle weakness, and severely impaired cognition, and was assessed as needing maximal assistance with transfers and mobility. Interviews with facility staff, including the CNA, Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that two staff members were required to safely operate the electric stand-up lift. The CNA acknowledged being alone during the transfer and stated awareness of the two-person requirement. Facility training records showed the CNA had received in-service education on proper transfer procedures, which included the need for assistance from another staff member. The facility's policy emphasized the resident's right to a safe environment, including safe support for daily living activities.
Failure to Provide Dialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to provide a dialysis emergency kit (e-kit) at the bedside for a resident who required hemodialysis. The resident, admitted with chronic kidney disease requiring hemodialysis, anemia, and hypertension, had physician orders for hemodialysis three times a week and a care plan identifying a high risk for bleeding. The care plan specifically required that an e-kit be available at all times to manage potential bleeding events. Multiple observations on different occasions confirmed that there was no e-kit present in the resident's room, either pinned to the wall, on the nightstand, or inside the bedside drawer. The resident also confirmed not having seen an e-kit in the room. Interviews with staff, including an LVN and the DON, confirmed that the e-kit should always be at the resident's bedside and checked daily to ensure it is stocked. The facility's policy required ongoing assessment and oversight for residents receiving hemodialysis, including monitoring for complications and implementing appropriate interventions. Despite these requirements, the absence of the e-kit at the bedside represented a failure to follow the care plan and facility policy for providing safe and appropriate dialysis care.
Physician Failed to Complete Required Assessment After Resident Readmission
Penalty
Summary
The facility failed to ensure that a resident's attending physician conducted an initial comprehensive assessment following the resident's readmission. Specifically, after being readmitted, the resident—who had diagnoses including cognitive communication deficit, generalized muscle weakness, and dementia—did not have a History and Physical (H&P) completed by the attending physician within the required timeframe. The only H&P available in the resident's record was from a prior hospitalization, and there was no documentation of a new, facility-based assessment after readmission. Interviews with the Medical Records Director and the Director of Nursing confirmed that the physician did not provide a current H&P after the resident's return, as required by facility policy. The Director of Nursing stated that the physician is supposed to physically see the resident and complete a comprehensive assessment to establish a baseline for care. The absence of this assessment delayed the establishment of the resident's current health status, which is essential for guiding care and services.
Failure to Follow Up on ENT Consultation Order
Penalty
Summary
The facility failed to follow up on a physician's order for an Ear, Nose, and Throat (ENT) consultation for a resident who was experiencing left ear pain and hearing loss. The resident, who had multiple diagnoses including end stage renal disease, anemia, hypertension, diabetes mellitus, and peripheral vascular disease, reported ongoing left ear pain and difficulty hearing for over a month. Despite a documented order for an ENT consultation and treatment for the resident's left ear pain, there was no evidence in the medical record that the consultation was scheduled or followed up by nursing staff, social services, or administration. Interviews with the resident, Social Services Director, and Director of Nursing confirmed that no follow-up calls or actions were taken to ensure the ENT consultation occurred after it was ordered. The Social Services Director acknowledged that no contact had been made with the ENT provider, and the Director of Nursing stated that the resident's needs were not being met due to the lack of follow-up. The facility's social worker job description indicated responsibilities for communication and intervention, but these were not fulfilled in this case.
Failure to Honor Resident Food Preferences and Provide Alternatives
Penalty
Summary
The facility failed to honor a resident's food preferences and provide appropriate meal alternatives as required by the resident's care plan and dietary orders. The resident, who had diagnoses including dementia, diabetes mellitus, dysphagia, and muscle weakness, was cognitively intact and able to make decisions regarding their care. Documentation indicated that the resident should be offered choices for snacks and that staff should honor food and fluid preferences. However, the resident reported not liking the meals provided, specifically grilled chicken and fish, and stated that no substitutes or snacks were offered. The resident also expressed a dislike for milk, which was not accommodated. Observations confirmed that the resident was served grilled fish and Ensure, despite the diet ticket specifying a preference for boiled meats and a dislike of milk. Staff interviews revealed that while there was a process for requesting meal substitutes, boiled beef was not offered as an option. The Dietary Supervisor acknowledged that the meal provided did not align with the resident's documented preferences and that the facility's policy required satisfaction of resident tastes and provision of food substitutions. This failure to provide preferred foods and alternatives was directly observed and confirmed through interviews and record reviews.
Failure to Provide Prescribed Renal Diet to Resident with ESRD
Penalty
Summary
The facility failed to follow the prescribed renal diet for a resident diagnosed with end stage renal disease (ESRD), spina bifida, and neurogenic bladder. The resident was admitted with orders for a renal diet, regular texture, and thin consistency fluids, as documented in the medical record and care plan. Despite these orders, the resident reported occasionally receiving incorrect menu items during mealtimes. On one observed occasion, the resident was served Italian crusted fish instead of the baked fish specified for the renal diet, and received a double portion of protein per his request. The dietary supervisor confirmed that the Italian crusted fish was not appropriate for the renal diet and that the resident should have received baked fish with simple seasonings. The dietary supervisor acknowledged responsibility for checking plates before food carts left the kitchen and before nursing staff distributed meals, but failed to ensure the correct meal was served. The director of nursing confirmed that not following the therapeutic diet could negatively impact the resident's health, especially given the resident's ESRD and need for dialysis. The facility's policy required all special diets to be prepared and served as planned, but this was not followed in the resident's case.
Failure to Label and Properly Store Perishable Food Brought by Visitors
Penalty
Summary
The facility failed to follow its policy and procedure regarding the labeling and storage of food items brought in by family or visitors for three residents. In each case, perishable food items that required refrigeration after opening were found at the residents' bedsides, unlabeled and undated, and not stored in a refrigerator as required by the manufacturer's instructions and facility policy. Staff did not ensure that these food items were properly labeled with the resident's name and date, nor did they offer to store the items in a refrigerator. One resident with diabetes mellitus and end stage renal disease was observed with an opened, unlabeled bottle of ranch dressing at the bedside, which indicated it should be refrigerated after opening. The resident stated that staff did not offer to store the bottle in the refrigerator and could not recall when it was opened. Another resident with dementia and diabetes had two bottles of lemonade at the bedside, both labeled to be kept refrigerated, but neither was labeled with the resident's name or date. The resident and a CNA were unaware of how long the lemonade had been at the bedside. A third resident with diabetes and a local skin infection had an opened, unlabeled, and undated jar of jalapenos at the bedside. The resident reported receiving the jar the previous day, and staff confirmed that there was no labeling or dating on the item. The facility's dietary supervisor and infection preventionist both acknowledged that the facility did not have a refrigerator for residents' food items and that perishable foods should be consumed immediately or discarded. However, staff did not ensure compliance with these procedures, resulting in the presence of potentially perishable and improperly stored food items in resident rooms.
Failure to Implement Physician Order for PT/OT Evaluation and Wheelchair
Penalty
Summary
The facility failed to ensure that a physician's order for physical therapy (PT) and occupational therapy (OT) evaluation, as well as a wheelchair, was carried out for a resident with significant mobility and self-care deficits. The resident, who had diagnoses including dementia, Alzheimer's disease, diabetes mellitus, and muscle weakness, was initially able to ambulate with a walker and perform some activities of daily living (ADLs) with moderate assistance. Over several months, the resident experienced a decline in mobility, becoming increasingly bedbound and eventually requiring a wheelchair and mechanical lift for transfers. Despite a physician's order dated 10/23/2024 for PT/OT evaluation and a wheelchair, there was no documented evidence that the order was communicated to or carried out by the therapy department. Interviews with therapy staff revealed they were unaware of the order and had not reassessed the resident after the initial therapy discharge. Nursing staff also confirmed that the order was not implemented or communicated, and the resident's decline in function was not addressed with appropriate therapy referrals or interventions. The facility's own policies and job descriptions required that physician orders be carried out promptly and that referrals to other departments, such as therapy, be completed as needed. However, the failure to implement the physician's order resulted in delayed treatment and services for the resident, as confirmed by multiple staff interviews and record reviews.
Failure to Account for Resident's Personal Wheelchair
Penalty
Summary
The facility failed to ensure that a resident's personal wheelchair was accounted for in the resident's inventory list, as required by the facility's policy and procedure. The resident, who was admitted with a diagnosis of hemiplegia following a stroke, had the capacity to understand and make decisions. During an observation, the resident's identifying information was found on a tag attached to the wheelchair, confirming it as the resident's personal property. However, the inventory list did not reflect the presence of the wheelchair, and it lacked the necessary signature from the resident or their representative. Interviews with facility staff, including a Licensed Vocational Nurse and the Assistant Director of Rehabilitation, revealed that the inventory list should have been updated to include the wheelchair. The facility's policy indicated that all durable medical equipment must be listed and signed for, but this was not done. The Social Services Director confirmed that the inventory list should have been updated when the resident received the wheelchair, as indicated by a Standard Written Order. The failure to update the inventory list had the potential to result in the wheelchair being lost or stolen, as it was not documented as the resident's property within the facility.
Failure to Implement Comprehensive Fall Prevention Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident who was admitted with a high risk for falls. The resident experienced three falls over a five-month period, which were not adequately addressed in the care plan. The initial care plan included interventions such as assessing toileting needs, encouraging the use of a call light, and providing non-skid footwear, but did not include continuous monitoring or supervision, which was crucial given the resident's condition. The resident's history included falls, muscle weakness, impaired gait, and forgetfulness of limitations, indicating a high fall risk. Despite these risk factors, the care plan was not updated to include necessary monitoring or supervision after the first fall, which resulted in a bump and abrasion on the head. The interdisciplinary team recommended continued use of non-skid footwear and reminders to use the call light, but these measures were insufficient to prevent further falls. Subsequent falls occurred at an outside clinic and within the facility, with the resident attempting to ambulate without assistance. The facility's policy on fall prevention emphasized the need for individualized care plans and supervision for high-risk residents, but these were not implemented effectively. Interviews with staff revealed that the care plan lacked interventions for monitoring, and the Director of Nursing acknowledged that continuous monitoring might not have been considered necessary, despite the resident's high fall risk.
Call Lights Not Within Reach for Multiple Residents
Penalty
Summary
The facility did not ensure that the call lights were within reach for five residents, increasing the risk of residents being unable to call for staff assistance or express their needs. Resident 27, who was admitted with generalized muscle weakness and osteoarthritis, was observed multiple times with the call light on the floor, out of reach. Despite calling out for help, no staff were present to assist. CNA 1 confirmed that the call light should have been within reach to prevent the resident from attempting to get up unassisted and potentially falling. Resident 70, admitted with generalized muscle weakness and difficulty walking, was also found with the call light on the floor, out of reach. Similarly, Resident 7, who has muscle weakness and spina bifida, was observed with the call light under the pillow and later on the floor, unable to call for assistance. Resident 7 was calling for help and asking for water but could not locate the call light. Resident 9, diagnosed with Alzheimer's disease and other conditions, was observed with the call light under the bed and out of reach on two separate occasions. LVN 1 confirmed that the call lights should be within reach to prevent delays in resident care and reduce the risk of falls. Resident 79, with hemiplegia and a history of falls, was found in a wheelchair leaning to one side and unable to reach the call light. The Infection Preventionist Nurse confirmed that the call light should have been within reach. The Director of Nursing reiterated that call lights should always be within reach to ensure resident safety.
Failure to Provide ROM and Mobility Services
Penalty
Summary
The facility failed to provide treatments and services to prevent and/or limit a decline in range of motion (ROM) and mobility for two residents with identified concerns. For Resident 78, the facility did not provide a right knee extension splint as recommended by Physical Therapy (PT) and did not implement a Restorative Nursing Program (RNP) to maintain mobility and ROM after discharge from PT services. This led to a decline in Resident 78's mobility and left knee ROM, with the resident experiencing stiffness and an inability to straighten both knees. The Director of Rehabilitation (DOR) confirmed that there was no monitoring system in place to detect changes in a resident's ROM and mobility, and the rehabilitation department was unaware of Resident 78's functional decline because they were not notified by nursing staff. For Resident 29, the facility failed to implement the RNP for ambulation five times a week as recommended by PT upon discharge from PT services. The RNA Documentation Survey Reports for February, March, and April 2024 indicated multiple days where Resident 29 did not receive the scheduled RNA services. The Director of Staff Development (DSD) confirmed that Resident 29 missed several days of scheduled RNA services and stated that missed sessions could place residents at risk for a functional decline. The Director of Nursing (DON) acknowledged that the purpose of the RNA program was to maintain a resident's current level of function and that missed RNA treatments could potentially cause a decline in overall function, mobility, and ROM. The facility's policies and procedures indicated that assistive devices and RNA services should be provided to maintain or improve a resident's abilities. However, the facility did not have policies and procedures specifically for maintaining a resident's ROM and mobility and contracture management. The lack of adherence to PT recommendations and the failure to implement RNA services as established led to the decline in physical functioning and quality of life for Residents 78 and 29.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident did not receive unnecessary psychotropic medications. Lorazepam was administered to the resident for behaviors not indicated in the physician order or care plan. The resident's care plan specified that lorazepam should be administered for repetitive motions, but the resident did not exhibit this behavior during the months reviewed. Despite this, the resident received lorazepam multiple times over several months without the appropriate behavioral indications being documented. Certified Nursing Assistant (CNA) observations were improperly used for clinical justification in determining whether to attempt a gradual dose reduction (GDR) for the resident's lorazepam order. The facility's Director of Nursing (DON) confirmed that CNA observations should not be used for clinical justification, as it is outside their scope of practice. The Psychotropic Behavior Summary GDR Form used to review the resident's lorazepam orders included general mood/behavior episodes without specifying the behaviors relevant to the medication's administration. The resident's attending physician did not document the risk-benefit analysis for the continued administration of lorazepam beyond the federal guideline of 14 days. The facility's policy requires that PRN psychotropic drug orders be limited to 14 days unless accompanied by supporting documentation from the prescribing practitioner. The physician's progress notes lacked this necessary documentation, leading to the continued use of lorazepam without proper justification.
Failure to Properly Manage and Store Medications
Penalty
Summary
The facility failed to ensure expired Ozempic was removed and discarded for one resident. Resident 51, who had Type 2 diabetes mellitus and chronic kidney disease, had an Ozempic pen that was used beyond its 56-day expiration period. The medication was last administered on a date that exceeded the manufacturer's recommended usage period, and the Licensed Vocational Nurse (LVN) acknowledged that the medication should have been discarded and reordered. The Director of Nursing (DON) was unaware of the specific expiration guidelines for Ozempic, and the facility's policy indicated that outdated medications should be immediately removed and disposed of properly. The facility also failed to remove and securely store medications for two residents who were discharged. Medications for Resident 55 and Resident 88 were found mixed with current residents' medications in the Middle Station Medication Cart. Resident 55 had been transferred to a hospital and was on bedhold, while Resident 88 had been discharged from the facility. The LVN stated that there were no markings on the medication packs to indicate the residents were transferred, and she was not instructed on how to store bedhold medications. The DON confirmed that the medications should have been removed from the cart and stored in a designated location in the medication room. The facility's policy on discontinued medications indicated that medications should be marked as discontinued and destroyed when a resident is transferred or discharged. However, the facility did not have a specific policy for handling bedhold medications. The DON stated that controlled medications should be given to the DON as soon as possible when orders are changed or residents are discharged. The failure to properly store and manage medications for discharged residents created a potential for medication errors and drug diversion.
Failure to Label and Date Food Items in Kitchen and Storage
Penalty
Summary
The facility failed to ensure all food items stored in the kitchen and dry food storage room were labeled and dated, and did not follow safe food preparation practices. During an initial tour of the kitchen, surveyors observed multiple food items in the refrigerator, including glasses of milk and juice, containers of cooked beans and apple sauce, and cartons of milk, all without dates. Additionally, a large box of margarine and bags of uncooked sausages were found without dates. On the kitchen table, containers of previously cooked rice were also undated, and in the dry storage room, a container of dry uncooked beans was found unlabeled and undated. During an interview, Cook 1 admitted to not knowing when the undated food items were prepared and acknowledged the importance of labeling and dating food for safety and quality. Cook 1 mentioned that the margarine and sausages were delivered the previous week but were not labeled due to being busy. The Dietary Staff Manager confirmed that all foods should be labeled and dated to prevent cross-contamination and ensure food safety. The facility's policy on food safety in receiving and storage requires food containers to be labeled with the contents and the date they were transferred to the container.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for 16 residents, increasing the risk of transmission of multidrug-resistant organisms (MDROs). Observations revealed that there was no signage indicating EBP, and no personal protective equipment (PPE) was available outside or near the rooms of the affected residents. This was noted for residents with various conditions, including cellulitis, pressure ulcers, surgical incisions, end-stage renal disease, and dependence on renal dialysis, among others. These residents had wounds, indwelling medical devices, or were receiving treatments that required EBP according to the facility's policy and procedure (P&P) dated March 2023. For instance, Resident 59 had a Stage II pressure ulcer and cellulitis but did not have orders for EBP, and no PPE was observed outside their room. Similarly, Resident 70, who had a surgical incision on the left foot, also lacked EBP orders and PPE outside their room. Resident 94, with end-stage renal disease and extended spectrum beta-lactamase resistance, was observed without EBP signage or PPE outside their room. These observations were consistent across multiple dates and times, indicating a systemic issue in the facility's infection control practices. The Infection Preventionist Nurse (IPN) confirmed that EBP was not being implemented for any facility residents, despite the facility's P&P requiring it for residents with wounds and indwelling medical devices. The IPN acknowledged that the lack of EBP could increase the risk of infection within the facility. The facility's P&P clearly stated that PPE should be available immediately near or outside the resident's room and that orders for EBP should be obtained for residents with specific conditions, which was not adhered to in these cases.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to offer advance directives to Resident 44, who was admitted with diagnoses including metabolic encephalopathy and dementia. A review of Resident 44's records indicated severe cognitive impairment and a complete dependence on assistance for daily activities. Despite these conditions, there was no documentation in the resident's electronic medical record indicating that advance directives were offered or acknowledged. Interviews with the Social Services Director and the Administrator confirmed that the process of offering advance directives and documenting them was not followed in this case. The facility's policy and procedure, dated November 2016, required informing new residents of their right to establish an advance directive and having them or their responsible party sign an acknowledgment form. However, this procedure was not adhered to for Resident 44, as evidenced by the lack of documentation in the resident's chart. This oversight had the potential to cause conflict with Resident 44's healthcare wishes, as the resident's severe cognitive impairment necessitated clear documentation of their healthcare preferences.
Improper Bed Positioning Leading to Entrapment Risk
Penalty
Summary
The facility failed to ensure that two residents' beds were not positioned against the wall, which restricted their ability to get out of bed freely and increased the risk of entrapment and injury. Resident 37, who had severe cognitive impairment and required maximal assistance for repositioning, was observed with her bed against the wall without any documented preference or care plan indicating this arrangement. The resident's family member confirmed that the bed had been against the wall for a while and was not informed that it should not be positioned that way. The facility's policy indicated that such positioning is considered a physical restraint. Similarly, Resident 41, who had moderate cognitive impairment and required partial assistance for repositioning, was also observed with her bed against the wall. The resident's care plan did not indicate any preference for this arrangement. The Director of Nursing confirmed that beds should not be placed against the wall unless documented as a resident's preference, and acknowledged that this practice posed a high risk for entrapment and was considered a restraint. The facility's policy on a restraint-free environment supported this stance.
Failure to Develop and Implement Individualized Care Plan for Resident with Mobility and ROM Limitations
Penalty
Summary
The facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for a resident identified as having decreased mobility and range of motion (ROM) limitations in the right leg. The resident, who was admitted with diagnoses including an acquired absence of the right leg below the knee, right knee contracture, and a chronic left ankle ulcer with necrosis, did not have a care plan addressing these issues. The resident's Minimum Data Set (MDS) indicated functional limitations in ROM in one leg and required extensive assistance for various activities of daily living, yet no care plan was created to address these needs. During an observation and interview, the resident was found lying in bed with both knees bent and unable to straighten them. The resident reported not having received help with leg exercises for about a year and never having had a splint for the right leg. The MDS Director confirmed that a care plan should have been created to include interventions such as physical therapy, occupational therapy, and/or restorative nursing assistant services to maintain or prevent a decline in the resident's mobility and ROM. The lack of a care plan meant that the resident did not receive the appropriate treatment and services required. The Director of Nursing (DON) also confirmed that comprehensive care plans should be developed for all residents identified as having ROM and mobility limitations. The facility's policy and procedure indicated that care plans should be individualized, realistic, and have measurable goals and timeframes. However, in this case, the facility failed to adhere to its own policy, resulting in the resident not receiving the necessary care to maintain or improve their physical functioning.
Failure to Accurately Monitor and Record Enteral Feeding
Penalty
Summary
The facility failed to accurately monitor and record the total amount of calories received via enteral feeding for Resident 2. Resident 2, who was diagnosed with dementia, gastrostomy, and dysphagia, was dependent on staff for all activities of daily living, including eating. The physician's orders specified that Resident 2 was to receive Jevity 1.2 at a rate of 50 ml per hour for 20 hours daily, starting at 2 p.m. However, observations and interviews revealed discrepancies in the administration and recording of the enteral feeding, leading to Resident 2 not receiving the prescribed amount of nutrition. On multiple occasions, the enteral feeding pump was turned off earlier than the prescribed time, and the total volume fed did not match the physician's orders. For instance, on 4/29/2024, the pump was turned off at 10:00 a.m., and Resident 2 had only received 786 ml of Jevity 1.2 since the previous day. Similar discrepancies were observed on 4/30/2024 and 5/1/2024, where the total volume fed did not align with the prescribed 1000 ml. The nurses involved were unsure of the total amount of nutrition Resident 2 actually received, and the documentation in the medication administration record (MAR) did not reflect the actual times the feedings were administered. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the enteral feeding orders were not being followed accurately. The DON stated that the total volume fed and the rate of feeding should be set on the pump by the nurse and reset after the total volume was administered. However, the discrepancies in the total volume fed and the timing of the feedings indicated that Resident 2 was at risk of not receiving adequate nutrition, potentially leading to weight loss. The facility's policy on enteral nutritional therapy required documentation of the date, time, type, and amount of feeding administered, which was not consistently followed in this case.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of one resident, identified as Resident 65, who had specific dietary needs due to gastro-esophageal reflux disease (GERD), constipation, and chronic gastritis. Despite Resident 65's clear communication to the Dietary Staff Manager (DSM) about avoiding bell peppers and spicy foods due to stomach irritation, the resident was served Spanish rice containing bell peppers. This occurred even though the DSM had updated the resident's food preferences, which were supposed to be reflected on the tray tickets. However, the dietary aide and cook did not ensure that these preferences were followed, leading to the resident experiencing discomfort and potential digestive irritation. During interviews, the DSM acknowledged that Resident 65 had requested to avoid bell peppers and spicy foods, and that the Spanish rice served should have been replaced with an alternative. Cook 1 confirmed that the diet slip did not specify no bell peppers, only no spicy foods, and did not consider bell peppers as spicy. The facility's policy required the Food and Dining Services Manager to document specific food preferences within 48 hours of admission and ensure that dining staff were aware of these preferences. The failure to accurately document and honor Resident 65's food preferences led to the deficiency identified in the report.
Failure to Provide Necessary Occupational Therapy Services
Penalty
Summary
The facility failed to provide necessary Occupational Therapy (OT) services to a resident who had significant activities of daily living (ADL) and functional mobility concerns. The resident, who had an amputation below the right knee, a right knee contracture, and a chronic left ankle ulcer, was admitted with a requirement for OT services. Despite an OT evaluation indicating the resident's need for therapy to address a decline in strength, balance, activity tolerance, and safety awareness, the resident was discharged from OT services when insurance coverage ended, without exploring alternative means to continue the therapy. This discharge occurred despite the resident's continued need for skilled OT services to prevent further decline and immobility, as noted in the OT evaluation and discharge summary. The Director of Rehabilitation (DOR) and Occupational Therapist (OT 1) confirmed that the resident was discharged from OT services due to the end of insurance coverage, even though the resident still required skilled therapy. OT 1 admitted that she did not inform the DOR, case manager, or business office to request re-authorization or explore alternate ways of obtaining services. The Social Services Director (SSD) and the Director of Nursing (DON) both stated that the facility should have ensured the resident received the necessary services regardless of payment source, by requesting re-authorization or exploring alternative means of providing the services. The Administrator (ADM) also acknowledged that the facility was responsible for providing the required care and services regardless of payment source. The failure to continue OT services for the resident, despite the clear need and potential for further decline, highlights a significant deficiency in the facility's process for managing therapy services when insurance coverage ends. The facility did not have policies in place for Rehabilitation Services, maintaining ADLs, and maintaining mobility, which contributed to the oversight and subsequent deficiency in care for the resident.
Failure to Provide Arbitration Agreement in Resident's Language
Penalty
Summary
The facility failed to ensure that a resident (Resident 74) understood and received the arbitration agreement in a language he could understand when entering a binding contract. Resident 74, who only speaks, reads, and writes in Spanish, signed an arbitration agreement in English. The Admission Coordinator acknowledged that the arbitration agreement should have been provided in Spanish. The resident did not remember signing the agreement and stated he was probably not fully aware when he signed it. Resident 74 was admitted to the facility with diagnoses including stage renal disease and dependence on renal dialysis. The resident had the capacity to understand and make decisions, as indicated in his History and Physical. The facility's policy required that arbitration agreements be presented in a language the resident understands, but this was not followed in Resident 74's case, leading to a potential waiver of his right to a jury trial without his knowledge.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to provide privacy to Resident 2 during a right foot wound care procedure. Resident 2, who was admitted with a diagnosis that included surgical wound dressing changes and diabetes, had the mental capacity to understand and make medical decisions. During an observation, a Licensed Vocational Nurse (LVN) was seen performing wound care on Resident 2 without completely closing the curtains, thereby exposing the procedure to staff and visitors passing by. This lack of privacy was confirmed by Resident 2, who expressed discomfort about the situation. Interviews with the Social Services Department and the Assistant Director of Nursing (ADON) confirmed that the facility's policy required providing privacy during resident care. The ADON acknowledged that failing to close the curtains during the procedure was a dignity issue and could make Resident 2 feel embarrassed and disrespected. The facility's policy on promoting and maintaining resident dignity emphasized the importance of protecting resident rights and treating each resident with respect and dignity.
Failure to Revise Care Plan for Resident with Osteoporosis
Penalty
Summary
The facility failed to revise the care plan to reflect safety measures for a resident at risk for spontaneous fractures due to brittle bones. The resident, diagnosed with dementia, age-related osteoporosis, and unilateral primary osteoarthritis of the right knee, required substantial assistance with activities of daily living (ADLs) and was dependent on staff for transfers and bed mobility. Despite these needs, the care plan did not include specific interventions to ensure the resident's safety and prevent injuries, such as gentle handling during transfers and ADL care. This omission was highlighted during an interview with the resident, who recounted an incident where a CNA moved their knee too hard, resulting in pain and the need for a splint. Interviews with the facility's staff, including a registered nurse and the assistant director of nursing, confirmed that the care plan should have included safety interventions tailored to the resident's condition. The facility's policy on comprehensive care plans mandates the development of person-centered care plans that address the resident's medical, nursing, and psychosocial needs. However, the care plan for this resident did not meet these requirements, as it lacked specific measures to prevent injuries related to osteoporosis.
Inaccurate Assessment of Resident's Lower Extremities
Penalty
Summary
The facility failed to ensure an accurate assessment was conducted on the lower extremities for one resident. The resident was admitted with diagnoses including fractures of both femurs and osteoporosis. The Minimum Data Set (MDS) indicated the resident had impairments on both lower extremities and was dependent on staff for various movements. However, subsequent evaluations showed inconsistencies, with some indicating no impairments and others indicating impairments or even an amputation, which was not accurate according to the Director of Nursing (DON). The MDS nurse confirmed that the documentation was inconsistent and based on whoever assessed the resident at the time. During interviews, both the MDS nurse and the DON acknowledged the inconsistencies in the assessments. The DON specifically noted that the incorrect evaluations could lead to improper interventions for the resident. The facility's policy and procedure for care planning emphasized the importance of accurate assessments to develop individualized care plans. The failure to ensure accurate assessments had the potential to result in poor quality care for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7,102 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Huntington Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenfield Care Center Of South Gate | 1.6 mi | ★★★★★ | 10 | 0 |
| Maywood Skilled Nursing & Wellness Centre | 1.7 mi | ★★★★★ | 25 | 0 |
| Bell Convalescent Hospital | 2.4 mi | ★★★★★ | 31 | 0 |
| Los Angeles Comm Hospital | 3.1 mi | ★★★★★ | 15 | 1 |
| Briarcrest Nursing Center | 3.2 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Huntington Park Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.