Huntington Park Nursing Center

F-F688

Findings:

During a review of Resident Admission Record (Face Sheet), the Face Sheet indicated Resident 72 was admitted to the facility on [DATE REDACTED] with diagnoses which included dementia, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness (loss of muscle strength).

During a review of Resident 72's Minimum Data Set (MDS - a resident assessment tool), dated 6/10/2024,

the MDS indicated Resident 72's cognitive (the ability to think and process information) skills for daily decision making was severely impaired. The MDS indicated Resident 72 required moderate (helper does less than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). The MDS indicated Resident 72 required moderate assistance from staff for sitting to standing and transfer from bed to chair.

The MDS indicated Resident 72 was not assessed for walking due to medical conditions or safety concerns.

During a review of Resident 72's care plan titled Resident with self-care deficit ., initiated 6/10/2024, the care plan indicated the facility would monitor, document, and report any changes for self-care deficit and declines

in Resident 72's function.

During a telephone interview on 5/6/2025 11:25 a.m., with Resident 72's Responsible Party (RP) 1, RP 1 stated he visited Resident 72 daily since the resident's admission to the facility. RP 1 stated Resident 72 was able to walk independently and sometimes used a walker (a mobility aid). RP 1 stated he noticed over the last four months Resident 72 increasingly began to spend more time in bed and was sleeping more. RP 1 stated he wanted the facility to get Resident 72 out of bed more often and provide therapy. RP 1 stated Resident 72 was receiving therapy upon admission to the facility but the facility discontinued therapy services on 9/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 45 056144 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056144 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Huntington Park Nursing Center 6425 Miles Avenue Huntington Park, CA 90255

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 During a concurrent interview and record review on 5/8/2025 at 9:15 a.m., with Occupational Therapy Assistant (OTA) 1, Resident 72's occupational therapy treatment encounter notes, dated 6/6/2024 to Level of Harm - Minimal harm or 9/12/2024, were reviewed. The notes indicated Resident 72's initial assessment was performed on 6/6/2024 potential for actual harm and Resident 72 required moderate assistance from staff for ADLs. OTA 1 stated Resident 72 received OT services from 6/6/2024 to 9/12/2024 and the resident achieved maximum potential (highest level of functional Residents Affected - Few abilities). OTA 1 stated Resident 72 was discharged from therapy on 9/12/2024 with an order for the Restorative Nursing Assistance ([RNA]- certified nursing aide program that helps residents to maintain or improve their physical function) program. OTA 1 stated Resident 72 was not referred again for occupational therapy and she was not aware of the resident's current functional status.

During a concurrent interview and record review on 5/8/2025 at 9:25 a.m., with Physical Therapist (PT) 1, Resident 72's physical therapy treatment encounter notes, dated 6/6/2025 to 7/31/2024, were reviewed. The notes indicated Resident 72's initial assessment was performed on 6/6/2024 and Resident 72 was able to ambulate (walk) five feet using a two-wheeled walker (a mobility aid). PT 1 stated Resident 72 received PT services from 6/6/2024 to 7/30/2024 and reached a high level of mobility (ambulate independently). PT 1 stated Resident 72 was discharged from therapy on 7/31/2024 and did not require the RNA program. PT 1 stated Resident 72 had no need for a wheelchair during PT treatment and/or upon discharge from PT services. PT 1 stated Resident 72 was not referred again for PT after being discharged on [DATE REDACTED]. PT 1 stated he was not aware Resident 72 was now wheelchair bound. PT 1 stated if there was a decline in a resident's mobility, the nurses were responsible for notifying the physician for an order and referral for therapy.

During a concurrent observation and interview on 5/8/2025 at 10:00 a.m., in Resident 72's room, with Certified Nursing Assistant (CNA) 3, CNA 3 was observed transferring Resident 72 from a shower chair to

the bed using a mechanical lift (a device used to assist in lifting transferring residents with limited mobility). CNA 3 stated Resident 72 was no longer able to stand up on her feet or walk and now required staff assistance for transfers. CNA 3 stated Resident 72 was able to stand and walk when first admitted to the facility but can no longer due to a decline in mobility and increased need for physical support.

During a concurrent interview and record review on 5/8/2025 at 10:15 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 72's Electronic Medical Records (EMR) was reviewed. The EMR indicated Resident 72 was able to stand and walk short distances with a walker upon admission to the facility but now required a wheelchair. LVN 2 stated Resident 72's decline in mobility and ADLs should have been assessed and an order for PT/OT evaluation and treatment obtained. LVN 2 stated she was not aware if there was a current PT/OT order and was unable to locate an order in the EMR.

During an interview on 5/8/2025 at 12:19 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated if

the nurse received a written and signed order from the physician, the order would be put in resident's order summary report and carried out immediately. RNS 1 stated if a PT/OT order was received the nurse would communicate with the rehabilitation department so the therapists would be aware to carry out the order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 45 056144 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056144 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Huntington Park Nursing Center 6425 Miles Avenue Huntington Park, CA 90255

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 During a concurrent interview and record review with RNS 1, Resident 72's EMR was reviewed. RNS 1 stated there was a written and signed physician's order dated 10/23/2024 which indicated Resident 72 Level of Harm - Minimal harm or required PT/OT evaluation and wheelchair for mobility. RNS 1 stated there was no documented evidence the potential for actual harm order was carried out and/or communicated to the therapy department. RNS 1 stated not carrying out the PT/OT order timely placed Resident 72 at risk for delayed treatment, services, and for further functional and Residents Affected - Few mobility decline.

During a concurrent interview and record review on 5/8/2025 at 1:20 p.m., with PT 1, Resident 72's physician order dated 10/23/2024, was reviewed. PT 1 stated the physician order indicated Resident 72 required PT/OT evaluation for a wheelchair. PT 1 stated he was not aware of the order. PT 1 stated the nurses were responsible for getting an order from the physician and communicating with the rehabilitation department. PT 1 stated he was not aware Resident 72 had an order for a PT/OT evaluation and wheelchair until 5/8/2025. PT 1 stated the nurses should have notified the rehabilitation department that there was a physician order for

a PT/OT evaluation and treatment so Resident 72 would be assessed and provided with necessary services and treatment as necessary.

During an interview on 5/8/2025 at 2:20 p.m., with the Director of Nursing (DON), the DON stated the physician's orders should be completed and implemented immediately after they were received. The DON stated the facility staff overlooked Resident 72's physician order for a PT/OT evaluation for a wheelchair, which resulted in delayed care and treatment. The DON stated this could place Resident 72 at risk for mobility and ADL decline.

During a review of the facility's policy and procedure P&P titled Physician Orders and Telephone Orders, dated 1/2004, the P&P indicated physician's orders would be obtained prior to the initiation of any treatment.

The P&P indicated all orders must be complete and carry out without any questions.

During a review of the facility's Registered Nurse (RN) Job Description, undated, the job description indicated RNs duties included but not limited to take, transcribe, and carry out complete orders. The job description indicated RNs would complete appropriate referrals to other departments, including therapy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 45 056144 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056144 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Huntington Park Nursing Center 6425 Miles Avenue Huntington Park, CA 90255

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47679 potential for actual harm Based on observation, interview, and record review, the facility failed to implement an effective infection Residents Affected - Some 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.

These deficient practices had the potential to result in the spread of bacteria through Resident 21 and 242's urinary catheter to result in a urinary tract infection ([UTI], an infection in the bladder/urinary tract). These deficient practices had the potential to result in Resident 70 developing a respiratory infection.

Findings:

a. During a review of Resident 21's Admission Record (Face Sheet), the Face Sheet indicated Resident 21 was admitted to the facility on [DATE REDACTED]. Resident 21's diagnoses included spina bifida (a condition that occurs when the spine and spinal column do not form properly), end stage renal disease ([ESRD], irreversible kidney failure), and neuromuscular dysfunction of the bladder (also known as neurogenic bladder, when damage to the brain, spinal cord, or nerves disrupts the communication between the brain and the bladder, leading to a loss of bladder control).

During a review of Resident 21's Minimum Data Set ([MDS], a resident assessment tool), dated 3/6/2025,

the MDS indicated Resident 21's cognition (process of thinking) was intact. The MDS indicated Resident 21 required setup assistance with eating and oral hygiene and required moderate assistance (helper does less than half the effort) with toileting, bathing, and upper body dressing. The MDS indicated Resident 21 had an indwelling urinary catheter

During a review of Resident 21's History and Physical (H&P), dated 2/19/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions.

During a review of Resident 21's Order Summary Report, dated 5/8/2025, the Order Summary Report indicated for Resident 21 to have an indwelling urinary catheter, 16 French (unit of measure of the diameter of the catheter) with 5 milliliter (mL, unit of fluid measurement) balloon, connected to a drainage bag for neurogenic bladder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 45 056144 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056144 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Huntington Park Nursing Center 6425 Miles Avenue Huntington Park, CA 90255

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of Resident 21's care plan titled, Resident with a Foley (indwelling urinary catheter) for Urinary Detention (the inability to fully or partially empty the bladder of urine), dated 3/3/2025, the care plan Level of Harm - Minimal harm or indicated staff were to maintain a closed drainage system (drainage tubing that is connected to a sterile potential for actual harm collection container).

Residents Affected - Some During an observation on 5/5/2025 at 11:23 a.m., inside Resident 21's room, Resident 21 was not present in

the room. A dignity bag (bag specifically designed to cover and conceal a urinary catheter drainage bag) with

the urinary catheter drainage bag inside was tied to Resident 21's bed frame. The tip (end) of the drainage tubing, without a cap and exposed to air, was hanging outside of the dignity bag.

During an interview on 5/5/2025 at 1:10 p.m., with Resident 21, Resident 21 stated when in bed, his urinary catheter was connected to the drainage bag on the side of the bed frame. Resident 21 stated when he transfers to his wheelchair, he would disconnect the urinary catheter from the drainage tubing then connect

the urinary catheter to the drainage tubing of the leg bag (a sterile urine drainage bag designed to attach securely to the leg). Resident 21 stated once he returned to bed, he would disconnect the urinary catheter from the leg bag, then reconnect the urinary catheter to the drainage tubing at the side of his bed frame. Resident 21 stated the drainage bag tubing at the side of his bedframe would be reused daily and only changed once a month. Resident 21 stated the tip of the drainage tubing was not capped when he switched to the leg bag. Resident 21 stated the nursing staff were aware he switched from the two drainage bags.

During an observation on 5/6/2025 at 1:47 p.m., inside Resident 21's room, Resident 21 was not present in

the room. Resident 21's urinary catheter drainage bag was inside the dignity bag at the side of Resident 21's bed frame. The tip of the drainage bag, without a cap, was tucked inside the dignity bag.

During an interview on 5/7/2025 at 7:37 a.m., with Resident 21, Resident 21 stated on 5/6/2025 he left the facility for his dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) appointment. Resident 21 stated prior to his appointment he switched to the leg bag and upon his return to the facility, he switched back to the same drainage bag in the dignity bag.

During a concurrent observation and interview on 5/7/2025 at 11:14 a.m., with Treatment Nurse (TN) 1, inside Resident 21's room, Resident 21 was not present in the room. Resident 21's urinary catheter drainage bag was observed inside the dignity bag at the side of Resident 21's bed frame. The tip of the drainage bag, without a cap, was tucked into the dignity bag. TN 1 stated Resident 21's drainage bag should not be kept at

the bedside once disconnected from Resident 21. TN 1 stated whenever Resident 21 switched from the drainage bag to the leg back, the disconnected tubing and drainage bag should be disposed. TN 1 stated once Resident 21 was ready to switch from the leg bag to the drainage bag, Resident 21 should have been provided with a new drainage bag. TN 1 stated the urinary drainage bag should not be kept at the bedside

after being disconnected due to the high chance of bacteria entering through the tip of the drainage tubing. TN 1 stated if bacteria were to enter the tubing and was reconnected to Resident 21's urinary catheter, the bacteria would enter Resident 21's bladder and cause a UTI.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 45 056144 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056144 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Huntington Park Nursing Center 6425 Miles Avenue Huntington Park, CA 90255

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 5/7/2025 at 1:42 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated urinary catheters can be disconnected from the drainage tubing and bag, however, those parts should never Level of Harm - Minimal harm or be reconnected. The IPN stated a new drainage tubing and bag should be connected to the urinary catheter potential for actual harm to prevent bacteria from entering the urinary catheter. The IPN stated the urinary catheter was a direct passage to Resident 21's bladder and any bacteria introduced could cause Resident 21 to develop a UTI Residents Affected - Some and experience symptoms such as burning during urination.

During a review of the facility's policy and procedure (P&P) titled, Catheter Associated Urinary Tract Infection (CAUTI) Prevention, undated, the P&P indicated to change the indwelling catheter and/or drainage bag when

the closed system is compromised.

b. During a review of Resident 70's Admission Record (Face Sheet), the Face Sheet indicated Resident 70 was admitted to the facility on [DATE REDACTED]. Resident 70's diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the right dominant side following

a cerebral infarct (also known as stroke, a loss of blood flow to a part of the brain), respiratory failure (when

the lungs do not work well enough to get enough oxygen into the blood) with hypoxia (low oxygen level in the body's tissues), and dementia (a progressive state of decline in mental abilities).

During a review of Resident 70's MDS, dated [DATE REDACTED], the MDS indicated Resident 70's cognition was severely impaired. The MDS indicated Resident 70 was dependent on staff's assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and rolling left and right. The MDS indicated Resident 70 was receiving oxygen therapy.

During a review of Resident 70's H&P, dated 5/4/2024, the H&P indicated Resident 70 did not have the capacity to understand and make decisions.

During a review of Resident 70's Order Summary Report, dated 5/7/2025, the Order Summary Report indicated to suction Resident 70 four times a day and as needed for increased oral secretions.

During a review of Resident 70's Medication Administration Record ([MAR], a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/1/2025 through 4/30/2025, the MAR indicated from 4/27/2025 through 4/30/2025, Resident 70 had oral secretions suctioned 13 times.

During a review of Resident 70's MAR, dated 5/1/2025 through 5/31/2025, the MAR indicated from 5/1/2025 through 5/5/2025, Resident 70 had oral secretions suctioned 17 times.

During an observation on 5/5/2025 at 9:51 a.m., inside Resident 70's bedroom, an oral suction cannister containing approximately 250 ml of clear fluid was on top of Resident 70's nightstand. The lid of the suction cannister was dated 4/27/2025 and the two suction tubing connected to the cannister were dated 5/4/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 45 056144 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056144 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Huntington Park Nursing Center 6425 Miles Avenue Huntington Park, CA 90255

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 5/7/2025 at 11:07 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 70 had the tendency to have oral secretions that required oral suctioning from the licensed nurse. Level of Harm - Minimal harm or LVN 1 stated after the suction cannister, and tubing were used, those items were to be disposed of daily. potential for actual harm LVN 1 stated oral secretions had the potential to grow bacteria and the bacteria could enter Resident 70's respiratory system through the Yankauer suction tip (an oral suctioning tool). Residents Affected - Some

During an interview on 5/7/2025 at 1:44 p.m., with the IPN, the IPN stated once the suction tubing and suction cannister were used, the licensed nurse was responsible for disposing the used tubing and cannister and putting together a new set up for the following shift. The IPN stated Resident 70's suction cannister with oral secretions should not have been kept at the bedside from 4/27/2025 through 5/5/2025. The IPN stated Resident 70 was at risk for respiratory infection, which could manifest as a fever, cough, or increased secretions.

During an interview on 5/7/2025 at 2:37 p.m., with the Director of Nursing (DON), the DON stated the facility did not have a policy that indicated when a used suction cannister and tubing were to be changed. The DON stated the best practice was to dispose and change the suction cannister and tubing after 24 hours. The DON stated secretions in the cannister and tubing at the bedside could grow bacteria that would be harmful to the residents and the staff.

During a review of the facility's P&P titled, Infection Prevention Program Overview, undated, the P&P indicated the goal of the infection prevention program was to decrease the risk of infection to residents and personnel.

49900

c. During a review of Resident 242's Admission Record, the record indicated Resident 242 was admitted to

the facility on [DATE REDACTED]. Resident 242's diagnoses included candidal cystitis and urethritis (a fungal urinary tract infection [UTI] in the urinary bladder and/or urethra [tube-like structure that carried urine from the bladder to the outside of the body]) and dermatitis (inflammation of the skin).

During a review of Resident 242's MDS, dated [DATE REDACTED], the MDS indicated Resident 242's cognition was intact. The MDS indicated Resident 242 required setup assistance with eating and oral hygiene, and maximal assistance (helper did more than half the effort) with toileting hygiene, showering/ bathing self, and chair/bed-to-chair transferring.

During a review of Resident 242's H&P, dated 4/13/2025, the H&P indicated Resident 242 had a chronic (lasting for a long time or recurring frequently) indwelling urinary catheter.

During a review of Resident 242's care plan titled Enhanced Barrier Precautions, dated 4/17/2025, the care plan indicated the goal was for Resident 242 to be free of signs and symptoms of infection.

During an observation on 5/5/2025 at 9:56 a.m. in Resident 242's room, Resident 242 was observed lying on

the bed. Resident 242's urinary catheter bag and tubing were touching the floor.

During an observation on 5/6/2025 at 8:06 a.m. in Resident 242's room, Resident 242 was observed lying on

the bed. Resident 242's urinary catheter bag and tubing were touching the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 45 056144 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056144 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Huntington Park Nursing Center 6425 Miles Avenue Huntington Park, CA 90255

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation on 5/6/2025 at 10:12 a.m. in Resident 242's room, Resident 242 was observed lying

on the bed. Resident 242's urinary catheter bag and tubing were touching the floor. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and picture review of Resident 242's urinary catheter bag and tubing on 5/6/2025 at 2:29 p.m. with the IPN, the pictures dated 5/5/2025 at 9:56 a.m., 5/6/2025 at 8:06 a.m., and Residents Affected - Some 5/6/2025 at 10:12 a.m. were reviewed. The pictures showed Resident 242's urinary catheter bag and tubing were touching the floor. The IPN stated the urinary catheter bag and tubing should be away from the floor to prevent microorganisms from entering the resident's body. The IPN stated it was a part of the infection control program. The IPN stated it put Resident 242 at risk of infection and Resident 242 might experience burning sensation, pain, and fever. The IPN stated everyone was responsible for ensuring the urinary catheter bag was off the floor by checking throughout the shift.

During a review of the facility's P&P titled Catheter Associated Urinary Tract Infection (CAUTI) Prevention, undated, the P&P indicated, Keep the collection bag and tubing off the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 45 056144