Other·January 13, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: 544468 Substantiated Representing the Department of Public Health Evaluator # 36202 RN, HFEN The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were written for the complaint number: CA00544468

F279 SS=E DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 1 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 2 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to develop, review, and revise the care plans in accordance with the comprehensive assessments for one out of three residents (Resident 1). Resident 1 was assessed as a high risk for weight loss and had a history of deep vein thrombosis (DVT- blood thickens and clumps together on to vein mostly occur in the lower leg or thigh) on her right leg. Resident 1's care plan to manage her nutritional needs and weight loss were not revised to include RD recommendations, and reviewed or reevaluated when the interventions to prevent further weight loss were ineffective. Resident 1's care plan to prevent skin breakdown did not include peripheral vascular disease (PVD, also known as DVT), which caused a decrease in tissue perfusion, as a risk factor for skin breakdown. There was no care plan developed to manage the decrease in tissue perfusion in the lower extremities. This deficient practice had the potential to result in unmet needs. Findings: On 7/19/17 at 11 a.m., an unannounced visit was conducted to the facility to investigate an allegation of neglect regarding Resident 1's significant weight loss and development of a wound on Resident 1's right foot. On 7/19/17 at 11:25 a.m., during an observation, Resident 1 was in her bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 3 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sleeping. Resident 1 had a white bandage wrapped around her right foot. Resident 1's right foot was not elevated. A review of Resident 1's Record of Admission indicated the resident was readmitted to the facility on 5/10/17 with diagnoses that included muscles weakness, dementia (long term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning) and diabetes mellitus (a metabolism disorder that affects the body's ability to use blood sugar). A review of Resident 1's Weekly Weight Monitoring form indicated the resident's readmission weight was 99 lbs. A review of Resident 1's History and Physical (H & P) form, dated 5/11/17, indicated Resident 1 did not have the capacity to understand and make decisions. Resident 1's H & P, dated 6/23/16, indicated Resident 1's diagnosis included deep vein thrombosis (DVT- blood thickens and clumps together in the blood vessels that occur in the lower leg or thigh) on the right leg. A review of Resident 1's Care Plan for Nutrition, dated 5/10/17, indicated that Resident 1 was at risk for nutritional needs. Resident 1's care plan goal indicated the resident would not have a weight loss of 5 lbs monthly. The interventions included Resident 1's weight would be monitored and recorded, and the physician would be notified. There was no revisions made on this care plan to include RD recommendations made after 5/10/17 for nutritional supplements. A review of Resident 1's care plan titled, "Risk for Skin Breakdown," dated 5/10/17, indicated Resident 1 was at risk for skin breakdown FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 4 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE related to diabetes mellitus (DM - a metabolism disorder that affects the body's ability to use blood sugar), decrease physical mobility, and poor meal intake. The care plan did not include PVD as a risk factor for skin breakdown. A review of Resident 1's Nutritional Assessment (an evaluation tool to gather information to an individual's food and nutrient intake, lifestyle, and medical history) form, dated 5/12/17 and completed by the RD, indicated Resident 1 was a high risk for excessive weight loss. The form indicated the RD's plan to implement for Resident 1 was to receive fortified (to add extra nutrients) pureed diet, no concentrated sweets, Pro-Stat sugar free (a ready-to-drink medical food for wounds and protein energy malnutrition) three times a day, and health shakes 4 ounces (oz.) daily at 2 p.m. A review of Resident 1's Vital Sign Flow Sheet form indicated the following weight record: - On 6/17/17, the resident's weight was 83 lbs, a decrease of 16 lbs five (5) weeks from readmission. - On 7/7/17, the resident's weight was 77 lbs, a decrease of six (6) lbs four weeks from 6/17/17. Resident 1 lost 22 lbs from readmission. A review of Resident 1's care plan for weight loss, dated 6/17/17, indicated the resident's current weight was 83 lbs. The goal was Resident 1's weight would be stable in 30 days. The interventions included Resident 1's food intake would be monitored and Resident 1 would receive an RD assessment and consult. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 5 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE planning tool), dated 7/5/17, indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 required extensive assistance (resident involved in activity; staff provide weight bearing support) from staff with bed mobility, transfer, toilet use and personal hygiene and limited assistance (resident highly involved with activity; staff provide guidedmaneuvering of limbs or other non-weight bearing assistance) with eating. On 7/19/17 at 3:15 p.m., during an interview and record review with the director of nursing (DON 1), she stated Resident 1's clinical record did not indicate a care plan on risk for decrease tissue perfusion in the lower extremities. On 11/7/17 at 2:10 p.m., during concurrent interview and record review, DON 2 stated Resident 1's care plan that was initiated on 6/17/17 should have been reevaluated and revised due to it not being effective. DON 2 stated Resident 1's care plan should be specific to Resident 1's care needs.

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 6 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to provide necessary treatment, care, and services for one of three sampled residents (Resident 1), who had a history of deep vein thrombosis (DVT - blood thickens and clumps together on to vein mostly occur in the lower leg or thigh) on the right leg by failing to: 1. Assess and monitor Resident 1's right plantar (bottom of the foot) foot skin discoloration, which developed on 7/5/17. 2. Establish and implement interventions to manage the poor circulation on Resident 1's right leg, such as elevating the right leg and checking for pedal (foot) pulses. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 7 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3. Conduct an interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident), to develop a plan of care that addressed the needs and goals of Resident 1. These deficient practices resulted in the progression of Resident 1's right plantar foot skin discoloration to gangrene (death of a body tissue due to lack of blood flow or serious bacterial infection) the next day. These deficient practices had the potential for Resident 1 to lose a body part. Findings: On 7/19/17 at 11 a.m. an unannounced visit was conducted to the facility to investigate an allegation of neglect due to the development of a wound on Resident 1's right foot. On 7/19/17 at 11:25 a.m., during an observation, Resident 1 was in her bed sleeping. Resident 1 had a white bandage wrapped around her right foot. Resident 1's right foot was not elevated. A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility on 4/9/13 and was readmitted on 5/10/17 with diagnoses that included muscles weakness, dementia (long term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning) and diabetes mellitus (a metabolism disorder that affects the body's ability to use blood sugar). A review of Resident 1's History and Physical (H & P) form, dated 5/11/17, indicated Resident 1 did not have the capacity to understand and make decisions. Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 8 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE H & P, dated 6/23/16, indicated Resident 1's diagnosis included deep vein thrombosis (DVT) on the right leg. A review of Resident 1's care plan titled, "Risk for Skin Breakdown," dated 5/10/17, indicated Resident 1 was at risk for skin breakdown related to diabetes mellitus (DM) decrease physical mobility, and poor meal intake. The care plan did not include peripheral vascular disease (PVD, a condition that restricts normal blood flow to and from the heart, which can provoke DVT) as a risk factor for skin breakdown. A review of Resident 1's care plan titled, "Skin Discoloration," dated 7/5/17, indicated Resident 1 would be monitored for skin breakdown daily due to skin discoloration to right plantar foot. A review of Resident 1's revised care plan for the management of skin breakdown related to diabetes mellitus, dated 7/5/17, indicated that Resident 1 was at risk for poor circulation triggered by Resident 1's DM manifested by discoloration to right plantar foot. Resident 1's left pedal pulse (the beat of the heart as felt through the walls of a peripheral artery of the foot) was positive (could be felt) while the right pedal pulse was weak. The care plan indicated Resident 1 would be monitored for skin breakdown to right plantar foot discoloration and pain every shift. There was no specific intervention on how to monitor for poor circulation on Resident 1's record. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 7/5/17, indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 required extensive assistance (resident involved in activity; staff provide weight bearing support) from staff with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 9 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bed mobility, transfer, toilet use and personal hygiene and limited assistance (resident highly involved with activity; staff provide guidedmaneuvering of limbs or other non-weight bearing assistance) with eating. A review of Resident 1's Physician Progress Notes form, dated 7/6/17, indicated Resident 1's right foot was cold on palpation (an examination by touch), had a dark gangrenous color on the right big and second toe (next to the big toe), and it was tender to touch. Resident 1's pulses on post tibial (area near the ankle) and dorsalis pedis (upper surface of the foot) was not palpable (could not be felt). On 7/19/17 at 1:40 p.m., during an interview with the licensed vocational nurse (LVN 1) stated she was not monitoring Resident 1's right foot LVN 1 stated the outgoing licensed nurse endorsed to her last night that Resident 1's right foot was red, not put a sock on the right foot and to elevate the right foot. LVN 1 stated Resident 1's right foot should be slightly elevated on a pillow to protect from further breakdown (by improving blood circulation). On 7/19/17 at 3:15 p.m., during a concurrent interview and review of Resident 1's medical record with the director of nursing (DON 1), she stated Resident 1's record did not indicate a care plan on risk of decrease tissue perfusion in the lower extremities. DON 1 stated Resident 1 was not assessed and monitored for the progression of right plantar foot skin discoloration to gangrene of the right foot. DON 1 stated Resident 1 was not assessed and monitored for right foot pulses. The DON stated there was no interdisciplinary meeting concerning Resident 1's right plantar foot gangrenous discolorations. DON 1 stated the facility did not have policy and procedure for the management of DVT. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 10 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F325 MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE CFR(s): 483.25(g)(1)(3)

F325 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to provide care and services to prevent weight loss in accordance with the plan of care and the facility's policy and procedure for one out of three sampled Resident (Resident 1) by failing to: 1. Assess, monitor, and record Resident 1's weekly weight for four weeks upon readmission to the facility from a General Acute Care Hospital (GACH). 2. Notify the primary physician of the Registered Dietician (RD - are the food and nutrition experts who can translate the science of nutrition into practical solutions for healthy living) recommendations for nutritional FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 11 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE supplement on 5/12/17. 3. Implement the RD's recommendation within five days. 4. Ensure that Resident 1 received the recommended nutritional supplement and monitor Resident 1's intake of the nutritional supplement. 5. Conduct a complete Interdisciplinary (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) weight management care plan. Resident 1, who was assessed as a high risk for weight loss, had a readmission weight of 99 pounds (lbs). The RD made dietary recommendations on 5/12/17 but the physician made an order to implement the RD recommendation on 5/22/17 because the licensed nurses failed to notify the physician. The facility did not monitor the resident's weight weekly in accordance with the facility's policy and procedure. On 6/17/17, Resident 1 lost 16 lbs from readmission. The physician ordered a dietary (RD) consult but the RD evaluated the resident on 7/7/17, 20 days after the physician order was made due to lack of communication from the licensed nurses. The IDT conducted a weight management care planning on 6/17/17 and 7/7/17 but the IDT did not develop interventions to prevent further weight loss and documentation of an effort to determine the cause of the weight loss. On 7/7/17, Resident 1 lost six more pounds. This deficient practice resulted in Resident 1's weight loss of 22 lbs. in 8 weeks from readmission. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 12 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 7/19/17 at 11 a.m., an unannounced visit was conducted to the facility to investigate an allegation of neglect regarding Resident 1's significant weight loss. On 7/19/17 at 11:25 a.m., during an observation, Resident 1 was in her bed sleeping. Resident 1 had a white bandage wrapped around her right foot. A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility on 4/9/13 and was transferred to GACH on 5/4/17 due to tachypnea (rapid breathing) and tachycardia (rapid heart beat). During the hospitalization, Resident 1's family wanted a do not resuscitate status (DNR) status and refused tube feeding for the resident, and was aware that the resident was at a high risk for recurrent dehydration with aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach). A review of Resident 1's Record of Admission indicated the resident was readmitted to the facility on 5/10/17 with diagnoses that included muscle weakness, dementia (long term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning) and diabetes mellitus (a metabolism disorder that affects the body's ability to use blood sugar). Resident 1 was transferred to GACH on 7/9/17 for failure to thrive (declining weight). The physician's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 13 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE progress note, dated 7/18/17, indicated the resident returned from GACH after hydration and antibiotic (a medication for infection) therapy for urinary tract infection and dehydration. A review of Resident 1's Vital Sign Flow Sheet form indicated Resident 1's weight record as follows: - 97 lbs on 1/6/17 - 96 lbs on 2/25/17 and 3/11/17 - 93 lbs on 4/1/17 - 90 lbs on 5/2/17 A review of Resident 1's Admission Care Plan, dated 5/10/17, indicated to monitor the resident's weight weekly for four weeks. A review of Resident 1's Care Plan for Nutrition, dated 5/10/17, indicated that Resident 1 was at risk for nutritional needs. Resident 1's care plan goal indicated the resident would not have a weight loss of 5 lbs monthly. The interventions included Resident 1's weight would be monitored and recorded, and the physician would be notified. There was no revisions made on this care plan to include RD recommendations made after 5/10/17 for nutritional supplements. A review of Resident 1's Weekly Weight Monitoring form, initiated on 5/10/17, indicated the resident's readmission (on 5/10/17) weight was 99 lbs and the reason for the weekly weights was the readmission. The monitoring form indicated to obtain the resident's weight on 5/17/17 (the first week), 5/24/17 (the second week), 5/31/17 (the third week), and on 6/7/17 (the fourth week). A review of Resident 1's Vital Sign Flow Sheet form indicated the following weight record: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 14 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE - On 6/17/17, the resident's weight was 83 lbs, a decrease of 16 lbs five (5) weeks from readmission. - On 7/7/17, the resident's weight was 77 lbs, a decrease of six (6) lbs four weeks from 6/17/17. Resident 1 lost 22 lbs from readmission. A review of Resident 1's History and Physical form, dated 5/11/17, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Physician's Progress Notes form, dated 5/11/17, indicated Resident 1's insulin therapy (a medication to treat high blood sugar) would be adjusted due to Resident 1's oral intake was poor. A review of Resident 1's Nutritional Assessment (an evaluation tool to gather information to an individual's food and nutrient intake, lifestyle, and medical history) form, dated 5/12/17 and completed by the RD, indicated Resident 1 was a high risk for excessive weight loss. The form indicated the RD's plan to implement for Resident 1 was to receive fortified (to add extra nutrients) pureed diet, no concentrated sweets, Pro-Stat sugar free (a ready-to-drink medical food for wounds and protein energy malnutrition) three times a day, and health shakes 4 ounces (oz.) daily at 2 p.m. A review of Resident 1's Physician Order form, dated 5/22/17, indicated to provide the resident with Pro-Stat sugar free three times a day and health shakes 4 oz. no sugar added daily at 2 p.m. The RD's dietary recommendation was relayed to primary physician 10 days after RD's evaluation of Resident 1's nutritional status. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 15 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Physician Order form, dated 6/17/17, indicated to weigh Resident 1 weekly times four weeks, monitor Resident 1's meal intake, and dietary (RD) consult due to 16 lbs. weight loss (from readmission). A review of Resident 1's care plan for weight loss, dated 6/17/17, indicated the resident's current weight was 83 lbs. The goal was Resident 1's weight would be stable in 30 days. The interventions included Resident 1's food intake would be monitored and Resident 1 would receive an RD assessment and consult. A review of Resident 1's Interdisciplinary Weight Management Care Plan, dated 6/17/17, indicated Resident 1 had a weight loss of 16 lbs. in a month. The form included sections for IDT recommendations and determination if the weight loss was expected, planned, or unavoidable but these sections were blank. The IDT weight management care plan did not contain signatures of the facility staff who attended the meeting and if the family was notified of the scheduled IDT weight management care plan. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 7/5/17, indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 required extensive assistance (resident involved in activity; staff provide weight bearing support) from staff with bed mobility, transfer, toilet use and personal hygiene and limited assistance (resident highly involved with activity; staff provide guidedmaneuvering of limbs or other non-weight bearing assistance) with eating. A review of Resident 1's Nutritional progress notes by Registered Dietician form, dated 7/7/17, indicated Resident 1 had a significant FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 16 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE weight loss in the last 30 days of 7.23 percent. The RD's recommendations included a speech therapist (ST) evaluation (to evaluate the resident for difficulty in swallowing) and treatment as needed. The form indicated that Resident 1 was evaluated by the RD 20 days after the resident's primary physician ordered the dietary (RD) consult due to weight loss on 6/17/17. A review of Resident 1's IDT's weight management care plan form, dated 7/7/17, included sections for IDT recommendations and determination if the weight loss was expected, planned, or unavoidable but these sections were blank. The IDT weight management care plan did not contain signatures of the facility staff who attended the meeting and if the family was notified of the weight management care plan. There was no documentation indicating Resident 1's family declined the treatment plan for the weight loss, and there was no evidence indicating Resident 1's family was invited to IDT meeting. On 9/14/17 at 3:40 p.m., during an interview, Registered Nurse 1 (RN 1) stated Resident 1 was not assessed for one on one feeding assistance. RN 1 stated he does not know the reason Resident 1's weekly weight was not recorded. RN 1 stated he did not know about the RD recommendations. RN 1 stated he did not know why the IDT Weight Management Care was not complete. On 10/13/17 at 10:35 a.m., during an interview, the RD stated she could remember the date the facility notified her on Resident 1 weight loss of 16 lbs in 5 weeks and the physician order on 6/17/17 for dietary consult. The RD stated she evaluated Resident 1 on readmission on 5/12/17. The RD stated Resident 1 was a high risk for weight loss and the recommendations FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 17 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE should be relayed to the resident's primary physician and carried out within 5 days. The RD stated the dietary recommendations were started on 5/22/17. The RD stated 10 days (5/12/17 to 5/22/17) was a long period of wait to start the dietary recommendations of additional supplement for Resident 1 to benefit from. On 10/13/17 at 12:20 p.m., during an interview, the Dietary Services Supervisor (DSS) stated Resident 1 did not have a record of weekly weights from readmission to the facility. The DSS stated Resident 1 should be on weekly weights. The DSS stated Resident 1 was not on feeding assistance. The DSS stated Resident 1 weight was not monitored. The DSS stated the RD's recommendations on 5/12/17 were not followed until 5/22/17. The DSS stated there was lack of communication to follow up on the RD recommendations for nutritional supplements for Resident 1. On 10/13/17 at 3:40 p.m., during an interview, the director of nursing (DON) stated Resident 1's weekly weight should be monitored upon readmission to facility on 5/10/17. On 11/7/17 at 2:10 p.m., during a concurrent interview and record review with the DON, she stated it was important to monitor Resident 1's weight upon readmission to the facility on 5/10/17 to establish a baseline and then monitor the resident's weight weekly to ensure Resident 1's did not have weight loss. The DON stated Resident 1's weekly weight should be monitored to determine underlying cause of weight loss. The DON stated the facility should call and notify the primary physician timely of the RD's recommendations. The DON stated Resident 1's RD recommendations on 5/12/ 17 were relayed to primary physician on 5/22/17 and that there was a 10-day delay. The DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 18 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated RD recommendations should be initiated within 5 days. During the interview, the DON stated the RD recommendations for health shakes and ProStat could be beneficial to Resident 1 to prevent further progression of weight loss and development of pressure sore. The DON stated Resident 1's care plan was not revised and was not specific to Resident 1's needs. The DON stated Resident 1's care plan that was initiated on 6/17/17 should have been re-evaluated and revised as it was not effective. The DON stated Resident 1's care plan should be specific to Resident 1's care needs. During the interview on 6/17/17, the DON stated Resident 1's primary physician ordered dietary consult due to the resident's 16 lbs weight loss and the RD reevaluated Resident 1 on 7/7/17. The DON stated 3 weeks to be evaluated by the RD was too long. The DON stated she did not know if the RD was notified when Resident 1 had a 16 lbs. weight loss in 5 weeks (recorded on 6/17/17). A review of facility's undated policy and procedure titled, "Policy and Procedure on Weights," indicated the facility must ensure that based on a resident's comprehensive assessment, acceptable parameters of a resident's nutritional status, such as body weight and protein level shall be maintained. Weight shall be monitored for four (4) weeks after resident's admission or readmission. The Dietician and/or Food Services Supervisor shall record outcome of assessment and recommendation for changes to plan of care. Licensed Nurse shall notify primary physician for orders or recommendations. A review of facility undated policy and procedure titled, "Weight Management," FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 19 of 20 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555865 (X3) DATE SURVEY COMPLETED 12/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HUNTINGTON HEALTHCARE CENTER 4515 Huntington Dr S Los Angeles, CA 90032 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated: All residents are monitored for weight changes on a regular basis, or at least monthly. Residents with known nutritional risk factors and problematic weight gain/loss potential are placed on a weight management system. Resident at high risk of weight loss should be monitored weekly. Weekly meetings with the Food Service Director/Consultant Dietician and nursing management personnel are scheduled to review interventions and progress towards measurable resident care goals. Care plan are revised as necessary to reflect the current resident status. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SNC211 Facility ID: CA970115 If continuation sheet 20 of 20