F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure an accurate assessment was conducted on the
lower extremities for one of three sampled residents (Resident 1).
Residents Affected - Few
This failure had the potential that proper interventions necessary for an individualized care plan will not be
identified and had the potential to provide poor quality care to the affected resident.
Findings
During a review of Resident 1's admission record, dated 3/28/2024, the admission record indicated
Resident 1 was admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of lower
end of left femur (thigh), fracture of lower end of right femur, and osteoporosis (a condition in which bones
become weak and brittle).
During a review of Resident 1's History and Physical (H&P), dated 8/26/2023, the H&P indicated Resident
1 did not have the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening
tool, dated 9/5/2023, the MDS indicated Resident 1 understood and was able to be understood by others.
The MDS indicated Resident 1 had impairments on both lower extremities. The MDS indicated Resident 1
was dependent on staff for rolling left and right, sitting to lying, and lying to sitting on edge of bed.
During a review of Resident 1's N Adv-Skilled Evaluation (Evaluation), dated 11/3/2023, the evaluation
indicated Resident 1 was able to move all extremities with no impairment to the upper extremity (arms)
range of motion and had a check mark next to amputation.
During a review of Resident 1's N Adv-Skilled Evaluation (Evaluation), dated 11/4/2023, the evaluation
indicated Resident 1 was able to move all extremities with no impairment to the upper extremity and lower
extremity (legs) range of motion and had a check mark next to amputation.
During a review of Resident 1's N Adv-Skilled Evaluation (Evaluation), dated 11/5/2023, the evaluation
indicated Resident 1 was able to move the right and left upper extremities with no impairment to the upper
extremity range of motion and impairment on both lower extremities range of motion and had a check mark
next to amputation.
During a concurrent interview and record review of Resident 1's Evaluations with the MDS nurse (MDSN)
on 3/28/2024 at 2:19 p.m., the MDSN stated the documentation of the assessment was inconsistent
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
056144
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2024
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
and it was based on whoever assessed the resident at the time. The MDSN stated at the time he performed
the MDS assessment, Resident 1 had impairments on both lower extremities.
During a concurrent phone interview and record review of Resident 1's Evaluations with the Director of
Nursing (DON) on 4/3/2024, the DON stated a check mark meant the selection applied. The DON stated it
meant that Resident 1 had an amputation. The DON stated he did not think Resident 1 had an amputation
and the evaluation was not correct. The DON stated the evaluation were an assessment of the resident and
if the assessment were not correct, it can lead to improper interventions for the resident.
During a review of the facility's policy and procedure (P&P), titled Care Plan, Comprehensive, dated 2018,
the P&P indicated the care plan is based on using information gathered by the MDS, resident assessment
protocols (RAP protocols) and information gathered through regular observation and assessment. The P&P
indicated the care plan becomes tool for the interdisciplinary team to use as a reference for resident
specific problems and approaches to establish guidance on meeting the individual needs of the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056144
If continuation sheet
Page 2 of 2
