Health inspection·April 18, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide privacy to one of five sampled residents (Resident 2), when providing right foot wound care. This deficient practice violated the resident's right to privacy and had the potential to affect the psychosocial well-being of the resident. Findings: A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE], with a diagnosis that included encounter for change or removal of surgical wound dressing, diabetes (abnormal blood sugar levels), and encounter for orthopedic aftercare following surgical amputation (aftercare following surgical amputation) A review of Resident 2's history and physical (H&P) dated 3/16/2004, indicated Resident 2 had the mental capacity to understand and make medical decisions. A review of Resident 2's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 3/20/2024, indicated Resident 2's cognitive skills (thought process) was independent and could understand and be understood by others. The MDS indicated Resident 2 required supervision or touching assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). A review of Resident 2's physician orders dated 3/17/2024, indicated Resident 2 had an order for right great toe, status post big toe amputation, surgical incision treatment order to cleanse with normal saline, pat dry, apply iodine (antiseptic agent) dressing, cover with conventional dry dressing kerlix (type of dressing) every two days for 21 days. During an observation on 4/5/2024 at 11:00 a.m., by residents' room [ROOM NUMBER] bed b, Licensed Vocational Nurse 2 (LVN2) was observed performing wound care on Resident 2 with curtains not completely closed, exposing patient care procedure to staffs and visitors passing by room [ROOM NUMBER] and it was not providing the resident privacy. During an interview on 4/5/2024 at 12:50 p.m., with Resident 2 in Resident 2's room. Resident 2 stated wound dressing changes are done every other day. Resident 2 stated, it's not good if everybody saw the dressing change being done. Page 1 of 4 056144 056144 04/18/2024 Huntington Park Nursing Center 6425 Miles Avenue Huntington Park, CA 90255

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/5/2024 at 3:46 p.m., with Social Services Department (SSD), the SSD stated Resident 2 had the right for privacy and Resident 2 may feel uncomfortable that all the people are aware of his wound. During an interview on 4/8/2024 at 12:42 p.m., with Assistance Director of Nursing (ADON), the ADON stated, the nurses need to provide privacy by closing the resident curtains when performing resident care. The ADON stated providing privacy is a dignity matter. ADON stated, Resident 2 will feel embarrassed and disrespected. ADON stated, nurses need to protect Resident 2's privacy. A review of the facility's policy and procedure (P&P) titled, Promoting/ Maintaining Resident Dignity , dated 10/22/20222, indicated it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 056144 Page 2 of 4 056144 04/18/2024 Huntington Park Nursing Center 6425 Miles Avenue Huntington Park, CA 90255

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the care plan to reflect safety measures in caring for one of five sampled residents (Resident 1), who was at risk for spontaneous fractures (broken bone) due to brittle bones. This deficient practice had the potential to place Resident 1 at risk for further injuries. Findings: A review of Resident 1's admission record, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included dementia (impairment of memory and abstract thinking), age-related osteoporosis (a condition in which bones become weak and brittle), and unilateral primary osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down) of right knee. A review of Resident 1's history and physical (H&P) dated 4/18/2023, indicated Resident 1 does not have the mental capacity to understand and make medical decisions. A review of Resident 1's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 3/26/2024, indicated Resident 1 had intact cognitive skills (thought process). The MDS indicated Resident 1 was dependent with staff with activities of daily living (ADLs) such as dressing, toilet use, shower, lower body dressing, outing on/taking off footwear. Resident 1 required substantial/ maximum assistance with personal hygiene, upper body dressing. Resident 1 was dependent with staff with transfer (moving between surfaces to and from bed, chair, and wheelchair) and substantial /maximal assistance with bed mobility (how resident moves from lying to turning side to side). A review of Resident 1's care plan, titled, Resident had osteoporosis, at risk for spontaneous fractures due to brittle bones , dated 4/17/2023, the goal indicated, Resident 1 will remain free of injuries or complications related to osteoporosis. One of the interventions indicated to monitor/ document/ report as needed, signs and symptoms related to osteoporosis and provide pillows to help maintain comfortable position. The care plan did not indicate interventions to provide resident safety and to prevent injuries. During an interview on 4/5/2024 at 11:27 a.m., with Resident 1 in Resident 1's room, Resident 1 stated, approximated one year ago, the Certified Nursing Assistance (CNA) helped me to the wheelchair. The CNA moved my knee harder, and I think it broke. Resident 1 stated, at that time, I had a pain and I needed to wear a blue splint. During an interview on 4/18/2024 at 11:46 a.m., with Registered Nurses (RN) 2, RN2 stated, care plans are done, so nurses are aware of the care, residents need. RN2 stated, Resident 1's care plan for osteoporosis diagnosis, should have included safety interventions, such as handling Resident 1 with care while providing ADL care. RN2 stated, with Residents 1's care plan for pain management, the care plan should have included interventions for safety and to avoid pain when repositioning the resident. RN2 stated, interventions are important because it described the plan of care for Resident 1. During a concurrent interview and record review on 4/18/2024 at 12:38 p.m., with Assistance 056144 Page 3 of 4 056144 04/18/2024 Huntington Park Nursing Center 6425 Miles Avenue Huntington Park, CA 90255

F 0657 Level of Harm - Minimal harm or potential for actual harm Director of Nursing (ADON), Resident 1's osteoporosis care plans were reviewed. The ADON stated, individualized care plans are formulated to identify the residents' problems or risk factor and implement the interventions to meet the goal. The ADON stated, Resident 1 with osteoporosis should have safety measures such as gentle handling upon transfer and the care plan interventions should have been updated. Residents Affected - Few A review of the facility's policies and procedures (P&P) titled Comprehensive Care Plans , dated 10/22/2022, indicated, it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P indicated, the care planning process will include an assessment of the resident's strengths and needs, and will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 056144 Page 4 of 4