Other·October 23, 2020

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 Department of Public Health during a Facility Reported Incident (FRI) investigation during an Abbreviated Standard Survey. FRI number: CA00654894 FRI number: CA00654783 FRI number: CA00654306 FRI number: CA00654898 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 36526 The inspection was limited to the specific complaint investigation and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for FRIs CA00654894, CA00654783, CA00654898, CA00654306

F600 SS=E Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 10/24/2020 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, 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: KYF111 Facility ID: CA970115 If continuation sheet 1 of 21 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 09/23/2020 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 or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure residents were free from abuse by implementing resident's care plans and its policy for two of four sampled residents (Residents 2 and 6). Resident 2 sustained a scratch to the right lower eye after being struck on the face by Resident 3. Resident 7 hit Resident 6 two times in the back of the head while in the dining room unsupervised waiting for breakfast. These deficient practices resulted in Residents 2 and 6 being physically abused and had the potential for other residents who were left unsupervised to be abused. Findings: a1. A review of Resident 2's Face Sheet (Admission Record) indicated Resident 2 was admitted to the facility on 7/31/19. Resident 2's diagnoses included cerebrovascular disease (disease of the blood vessels in the brain), unspecified dementia (loss of brain functioning) with behavioral disturbance (persistent negative outbursts), and muscle weakness (lack of strength). A review of Resident 2's History and Physical (H/P), dated 8/5/19 indicated Resident 2 had periods of confusion and did not have the capacity to understand and be understood. A review of Resident 2's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 2 of 21 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 09/23/2020 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 (MDS), a standardized assessment and care screening tool, dated 8/11/19 indicated Resident 2 was unsteady on her feet and required an extensive assistance of a oneperson physical assist for weight-bearing (amount of weight placed on an individual's leg) support. A review of a Situation/Background/Assessment/Recommen dations ([SBAR], an internal documentation technique to facilitate prompt and appropriate communication), dated 9/10/19 indicated Resident 2 had a scratch to her right lower eye. A review of Resident 2's 72-Hour Neuro Check List, from 9/16/19 through 9/18/19 indicated there was no neurological checks (sensory neuron and motor responses, especially reflexes, to determine impairment) done after Resident 3 struck Resident 2 (on 9/10/19). A review of Resident 2's Physician Orders, dated 9/10/19 indicated a right lower eye linear (straight line) scratch to Resident 2's eye and the order indicated to cleanse the scratch with normal saline (salt water), pat dry, apply triple antibiotic (drug used to treat bacterial infections) ointment every day for 30 days until 10/10/19. A review of Resident 2's Physician Orders, dated 9/14/19 indicated an order for a psychology (specialist in behavior study) consultation for Resident 2. a2. A review of Resident 3's Face Sheet indicated Resident 3 was admitted to the facility on 6/3/2019. Resident 3's diagnoses included encephalopathy (malfunction of the brain), altered mental status (unusual behavior), Alzheimer disease (progressive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 3 of 21 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 09/23/2020 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 brain disorder destroying memory and thinking), and dementia with behavioral issues. A review of Resident 3's H/P, dated 6/4/19 indicated Resident 3 did not have the capacity (ability) to understand and make decisions. A review of Resident 3's care plan dated 6/18/19 and titled, "Potential for Emotional Distress Related to Resident to Resident Altercation," indicated Resident 3 would not have episodes of distress. A review of Resident 3's Physician Orders, dated 9/10/19 indicated to transfer Resident 3 to a general acute care hospital (GACH) for further evaluation for aggressive behaviors. A review of Resident 3's Physician's Order dated 9/11/19 indicated Resident 3 was readmitted to the facility and later that day transferred to another GACH for reevaluation of aggressive (impulsive) behaviors. On 9/16/19 at 8 a.m., during an interview, Resident 4 stated her roommate, Resident 3, was transferred to a general acute care hospital (GACH) two days prior because of her aggressive behaviors. Resident 4 stated, "Resident 2 would sneak into Resident 3's room as they were friends and lay on Resident 3's bed." Resident 4 stated Resident 3 was very aggressive towards everyone in the facility and all staff were aware of Resident 3's behavior. Resident 4 stated she informed the Administrator (ADM) Resident 3 would, "steal our personal belongings and would try to hit us all the time." Resident 4 stated she was old and should not be hit by other residents. Resident 4 stated Residents 2 and 3 were fighting in the room (on 9/10/19) over Resident 2 talking to a female staff. Resident 4 stated Residents 2 and 3 began to punch each other leaving Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 4 of 21 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 09/23/2020 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 2 with a scratch to the left side of her face. Resident 4 stated, "It's scary to have both of the residents here because we don't know if they would come and attack us." Resident 4 stated Resident 3 was always trying to hit people, steal their belongings, slamming doors and hitting the walls. On 9/16/19 at 8:35 a.m., during an interview, Resident 5 stated being roommates with Resident 3. Resident 5 stated Resident 3 was always bringing Resident 2 into the room and have her lay on the bed and it made her feel uncomfortable. On 9/16/19 at 12:20 p.m., during an observation and interview, Resident 2 was in the dining room having lunch with no injuries observed. Resident 2 stated Resident 3 approached her (on 9/11/19) and hit her on the face for no reason. On 11/25/19 at 4:17 p.m., during an interview, Certified Nurse Assistant 6 (CNA 6) stated hearing Resident 3 yelling from the hallway (on 9/10/19). CNA 6 stated upon entering Resident 2's room, Residents 2 and 3 were observed arguing about clothing. CNA 6 stated, "I told them to move apart and asked Resident 3 to leave the room, before Resident 3 left the room, she reached out to Resident 2 and scratched her on the face. CNA 6 stated Residents 2 and 3 had altercations in the past. b1. A review of Resident 6's Face Sheet indicated Resident 6 was admitted to the facility on 7/2/18. Resident 6's diagnoses included diabetes mellitus (inability of the body to use glucose (sugar), impulse disorder (failure to resist an urge), and unspecified dementia. A review of Resident 6's H/P, dated 7/3/18 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 5 of 21 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 09/23/2020 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 Resident 6 did not have the capacity to understand and make decisions. A review of Resident 6's MDS, dated 7/11/19 indicated Resident 6 was able to make herself understood and understand others. The MDS indicated Resident 6 required supervision of a one-person physical assist with ambulation in the facility and had no behavioral issues. A review of Resident 6's care plan titled, "Impulse Control," evaluated on 7/2019 indicated the goal was for Resident 6's behaviors to decrease for nine months. The staffs' interventions included to monitor Resident 6's mood state, monitor behavior in private/public and report to physician. b2. A review of Resident 7's Face Sheet indicated Resident 7 was admitted to the facility on 1/15/18. Resident 7's diagnoses included schizophrenia, epilepsy (neurological disorder characterized by episodic loss of attention or sleepiness [petit mal] or severe convulsion), and muscle weakness. A review of Resident 7's MDS, dated 7/14/19 indicated Resident 7 was able to make himself understood and understand others. The MDS indicated Resident 7 had behavioral symptoms of hitting, pushing, scratching, screaming, threatening, and cursing towards others and required limited assistance of one-person physical assist for locomotion (how resident moves between location) on/off unit. A review of Resident 7's care plan titled, "Behavioral Patterns," dated 8/3/19 indicated the goal was for Resident 7 to not have more than three (3) episodes. The staffs' interventions included to monitor Resident 7's whereabouts frequently, keep away from other residents, monitor and document number of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 6 of 21 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 09/23/2020 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 episodes, evaluate effectiveness and notify physician. A review of Resident 7's Physician Order, dated 8/19/19 indicated Resident 7 was receiving Seroquel (antipsychotic medication) 50 milligrams ([mg], unit of measure) by mouth (PO) twice a day (BID) for schizophrenia manifested by ([m/b], symptoms of) delusion (belief that is not true) and verbalizing people are against him. On 9/16/19 at 9:40 a.m., during an interview, Resident 7 was observed confused stating he was going home to twenty-nine palms (military base) with his stepfather. Resident 7 stated he hit Resident 6 on her head twice (on 9/16/19) because she hit him twice in the back of the head on 9/16/19 on the same day early morning. Resident 7 stated he did not tolerate others hitting him. On 9/16/19 at 9:45 a.m., during an interview, the facility's Housekeeper (HK) stated on 9/16/19 at approximately 6:40 a.m., Residents 6 and 7 were in the dining room unsupervised getting ready for breakfast. The HK stated Resident 7 was sitting behind Resident 6 when suddenly Resident 7 hit Resident 6 twice in the head. The HK stated Resident 6 started crying, turned around and punched Resident 7 twice in the face. The HK stated she informed LVN 4 immediately but was not able to separate the residents. The HK stated 15 minutes after the first fighting incident with Residents 6 and 7, she went to call LVN 4 again because Resident 7 threw a cup of water at Resident 6 and attempted to hit her again. The HK stated LVN 4 did not show up the first time she reported the fighting incident. The HK stated she then called LVN 3 and both Residents 6 and 7 were separated immediately. The HK stated Resident 7 also attempted to hit LVN 3. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 7 of 21 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 09/23/2020 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 HK stated Resident 7 was aggressive towards others. The HK stated several residents were left in the dining room with no staff members present to supervised them. On 9/16/19 at 10:18 a.m., during an interview, LVN 2 stated LVN 4 informed him of the altercation between Residents 6 and 7. LVN 2 stated he was unaware there had been two separate incidents between the two residents that morning. On 9/16/19 at 10:22 a.m., during an interview, CNA 5 stated Resident 7 was very aggressive and yelled at the nurses and residents all the time. CNA 5 stated Resident 7 discriminated (treated someone unfairly) against certain ethnic groups. CNA 5 stated Resident 7 had to be monitored all day, but the nurses were afraid to monitor Resident 7 because of his aggressive behaviors. On 11/25/19 at 4:27 a.m., during an interview, LVN 3 stated on 9/16/19 at approximately 6:30 a.m., she was informed Resident 6 was crying in the dining room unsupervised. LVN 3 stated no CNA was present in the dining room monitoring the residents. LVN 3 stated a staff member should be in the dining room at-alltimes monitoring the residents. LVN 3 stated Resident 7 was very aggressive and had episodes of hitting other residents and should not be left alone and unsupervised. A review of the facility's undated policy and procedures titled, "Resident to Resident Abuse," indicated the facility staff would monitor residents for aggressive/inappropriate behavior towards other residents or staff. The policy indicated the staff would remove the aggressor from the situation and temporarily separate the resident form the others to help lower agitation. The staff would evaluate the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 8 of 21 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 09/23/2020 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 circumstances that lead to the incident and report to the physician.

F689 SS=H Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 10/24/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility's staff failed to follow its policy and procedures (p/p) titled, "Safety and Supervision of Residents," to supervise residents with escalating aggressive behavior, identify residents who had suicidal thoughts (to kill oneself) tendencies and illicit (forbidden by law) drug use to prevent accidents and injuries for five of seven sampled residents (Residents 1, 2, 3, 6 and 7) crossed referenced to F600. a. Resident 1, who had a history of suicidal ideation with a plan to commit suicide by verbalizing a desire to overdose (to consume excessive and dangerous dose of a drug) on drugs was not supervised in the facility to prevent self-harm. Resident 1 was found on 8/20/19 sedated (sleepy) and diaphoretic (sweating heavily) in a wheelchair inside the resident's bathroom complaining of drug overdose and on 9/7/19 at 8:10 a.m., Resident 1 was found unresponsive (lack of the ability to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 9 of 21 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 09/23/2020 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 notice or respond to stimuli in the environment) in a wheelchair inside the restroom with a metal spoon containing an unknown substance on top of the bathroom sink. b. Resident 2 sustained a scratch to the right lower eye after being struck on the face by Resident 3, while unsupervised. c. Resident 7 hit Resident 6 two times in the back of the head while in the dining room unsupervised waiting for breakfast. These deficient practices resulted in Resident 1 requiring Narcan medication (given to reverse narcotic overdose in an emergency) and a transferred to the general acute care hospital (GACH) after overdosing on two separate occasions while on the facility. Residents 2 and 6 being physically injured. Findings: a. A review of Resident 1's GACH history and physical (H/P) record dated 8/11/19 indicated Resident 1 had attempted to commit suicide prior to admission to the GACH. The report indicated Resident 1 admitted to using heroin (highly addictive analgesic drug derived from morphine) and methamphetamines (synthetic, addictive, mood-altering drug, used illegally as a stimulant). A review of Resident 1's GACH discharge note, dated 8/14/19 indicated for Resident 1 to follow-up with a psychiatrist (medical practitioner specializing in the diagnosis and treatment of mental illness) and primary physician at the facility. A review of Resident 1's Ambulance Service transportation sheet, dated 8/14/19, indicated Resident was transfer from GACH 1 to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 10 of 21 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 09/23/2020 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 after being discharged with diagnosis of suicidal ideation by drug overdose. The report indicated the facility was made aware of Resident 1's required care to supervise to prevent overdose. A review of Resident 1's skill nursing facility (SNF) Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on 8/14/19. Resident 1's diagnoses included depression (feelings of severe sadness) and anxiety (mental disorder causing worry or fear). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/21/19 indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required an extensive assistance of a one-person physical assistance for ambulating in/off unit and was dependent on a wheelchair for mobility. The MDS indicated Resident 1 had no behaviors. A review of all Resident 1's care plans indicated there was no baseline Person-center care plan to indicate the facility staffs' interventions and supervision to prevent Resident 1 to commit suicide and drug use. A review of Resident 1's care plan titled, "Antidepressant," dated 8/14/19 indicated the staffs to monitor and document the number of depression behaviors every shift and monitor Resident 1's whereabouts frequently. A review of Resident 1's GACH's Prehospital Care Report Summary, dated 8/20/19 indicated Resident 1 was seen for altered level of consciousness ([ALOC] abnormal measurement of a resident's awakening and responsiveness to stimuli) and drug overdose. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 11 of 21 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 09/23/2020 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 The Prehospital Care Report indicated the facility's staff reported Resident 1 obtained illegal drugs an hour prior to the paramedic's arrival. A review of Resident 1's physician telephone order, dated 8/20/19, and timed at 12:20 p.m., indicated to transfer Resident 1 to the GACH via 911 (emergency services) for evaluation. A review of Resident 1's Nurses Progress Note, dated 8/20/19 and timed at 12:20 p.m., indicated Resident 1 was transferred to GACH 2 for altered mental status ([AMS] abnormal measurement of a resident's mental status). A review of Resident 1's GACH's laboratory results, dated 8/20/19 and timed at 12:42 p.m., indicated the resident's urine tested positive for amphetamines, benzodiazepines (a class of psychoactive drugs, used to treat anxiety and other conditions) and opioids (highly addictive pain relief drugs). A review of Resident 1's Nurse's Progress Note, dated 9/3/19 and timed at 1:20 a.m., indicated Resident 1 was readmitted to the facility 14 days from GACH in stable condition. A review of Resident 1's Licensed Nurse Progress note, dated 9/7/19 and timed at 8:40 a.m., indicating Resident 1 was found unresponsive in the bathroom, skin noted flushed (red and hot) and perspired (sweat). The Nurses' note indicated a spoon with an unknown substance was found on the bathroom's sink and a syringe found on the floor. The note indicated Resident 1 was placed on a non-rebreather mask (nose/mouth mask that allows delivery of high oxygen concentrations delivery) with 15 liters of oxygen via the mask given. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 12 of 21 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 09/23/2020 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 telephone order, dated 9/7/19 and timed at 8:40 a.m., indicated to transfer Resident 1 to GACH 3 via 911 for evaluation related to drug use. A review of Resident 1's Situation, Background, Assessment, and Re-evaluation ([SBAR] internal communication document) dated 9/7/19 and timed at 8:44 a.m., indicated Resident 1 was found unresponsive sitting in his wheelchair inside the bathroom. The SBAR indicated an unknown substance was found on a spoon and a syringe was on the floor near Resident 1. The SBAR indicated Resident 1 was placed on a non-rebreather and 911 was called. A review of Resident 1's Prehospital Care Report Summary, dated 9/7/19 indicated Resident 1 was noted somnolent (drowsy/sleepy), with decreased respirations of 8 breath per minute ([bpm] normal reference range [NRR] 16-20 bpm) low oxygen saturation of 86 percent (%) (NRR 94-100% on room air) and an overdose of heroin. The report indicated a dose of Narcan nasal spray was administered on 9/7/19 at 8:36 a.m., with positive effect. A review of Resident 1's GACH H/P, dated 9/7/19 indicated Resident 1 arrived to the GACH for shortness of breath (SOB) and a heroin overdose Resident 1 was admitted for monitoring of heroin overdose and rapid heart rate. A review of the facility's investigation report, dated 9/7/19 and timed at 8:10 a.m., indicated a certified nurse assistant1 (CNA 1) found Resident 1 in the bathroom unresponsive with an unknown substance on a metal spoon on top of the sink. The facility's investigation indicated Resident 1 received drugs from a friend in the facility's smoking patio. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 13 of 21 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 09/23/2020 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 9/16/19 at 10:50 a.m., during an interview, Resident 1 stated he did overdose twice while in the facility. Resident 1 stated he injected heroin while in the facility's restroom on 8/20/19 and then again on 9/7/19. Resident 1 stated a friend brought him the heroin to the facility's parking lot. Resident 1 stated on 8/20/19 he was "out of it" after consuming the heroin, but the second time he was found unconscious. Resident 1 stated he was supposed to be monitored by facility's staff because of his drug abuse, but he was always left by himself. Resident 1 stated he was trying to commit suicide by overdosing and needed help. Resident 1 stated the facility's staff was aware of his drug addiction and of the two times he overdosed. On 9/16/19 at 11:10 a.m., during an interview, Registered Nurse 1 (RN 1) stated on 9/7/19 at approximately 8-8:30 a.m., she was called by CNAs 1 and 2 to come to Resident 1's room. RN 1 stated she walked into the bathroom and Resident 1 was in his wheelchair facing the sink, his face was red in color and was down between his legs. RN 1 stated it was the second incident of Resident 1 overdosing. On 9/16/19 at 11:45 a.m., during an interview and a concurrent review of Resident 1's care plans, admission chart, and GACH's laboratory results, the Director of Nursing (DON) stated she was not aware of Resident 1's drug overdose incident that occurred on 8/20/19. The DON stated and confirmed Resident 1 was admitted to the facility on 8/14/19 with a history of suicidal attempt by drug overdose and there was no care plan created. The DON stated there was no close monitoring or supervision of Resident 1 implemented. The DON stated the staff should had evaluated Resident 1's chart prior to readmission and created a care plan to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 14 of 21 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 09/23/2020 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 closely monitor Resident 1 to prevent any suicide of use of illicit drugs while in the facility. On 11/25/19 at 4:39 p.m., during an interview with CNAs 1 and 2, CNA 1 stated Resident 1 had been found unresponsive from drug overdose twice in the bathroom but could not recall the date or time. CNA 1 stated RN 1 found Resident 1 in the bathroom unresponsive and immediately called him (CNA 1) and CNA 2 to bring the crash cart and oxygen. CNA 2 stated Resident 1 had overdosed twice while in the facility and all the staff was aware Resident 1 needed to be monitored at all times. CNA 2 stated the DON and the ADM were aware Resident 1 used drugs. b1. A review of Resident 2's Face Sheet (Admission Record) indicated Resident 2 was admitted to the facility on 7/31/19. Resident 2's diagnoses included unspecified dementia (loss of brain functioning) with behavioral disturbance (persistent negative outbursts), A review of Resident 2's History and Physical (H/P) dated 8/5/19 indicated Resident 2 had periods of confusion and did not have the capacity to understand or make herself understood. A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 8/11/19 indicated Resident 2 was unsteady on her feet and required an extensive assistance of a oneperson physical assist for weight-bearing (amount of weight placed on an individual's leg) support. A review of a SBAR, dated 9/10/19 indicated Resident 2 had a scratch to her right lower eye. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 15 of 21 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 09/23/2020 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 2's Physician Orders, dated 9/10/19 indicated there was a right lower eye linear (straight line) scratch to Resident 2's eye and the order indicated to cleanse with normal saline (salt water), pat dry, apply triple antibiotic ointment every day for 30 days until 10/10/19. b2. A review of Resident 3's Face Sheet indicated Resident 3 was admitted to the facility on 6/3/2019. Resident 3's diagnoses included encephalopathy (malfunction of the brain), altered mental status (unusual behavior), Alzheimer disease (progressive brain disorder destroying memory and thinking), and dementia with behavioral issues. A review of Resident 3's H/P, dated 6/4/19 indicated Resident 3 did not have the capacity (ability) to understand and make decisions. A review of Resident 3's care plan titled, "Potential for Emotional Distress Related to Resident to Resident Altercation," dated 6/8/19 indicated Resident 3 would not have episodes of distress. A review of Resident 3's Physician Orders, dated 9/10/19 indicated to transfer Resident 3 to a general acute care hospital (GACH) for further evaluation for aggressive behaviors. A review of Resident 3's Physician's Order dated 9/11/19 indicated Resident 3 was readmitted to the facility and later that day transfer to another GACH for reevaluation of aggressive (impulsive) behaviors. On 9/16/19 at 8 a.m., during an interview, Resident 4 stated her roommate Residents 3 was transferred to the GACH two days prior because of her aggressive behaviors. Resident 4 stated, "Resident 2 would sneak into FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 16 of 21 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 09/23/2020 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 Resident 3's room as they were friends and lay on Resident 3's bed." Resident 4 stated Resident 3 was very aggressive towards everyone in the facility and all staff were aware of Resident 3's behavior. Resident 4 stated she informed the Administrator (ADM) Resident 3 would, "steal our personal belongings and would try to hit us all the time." Resident 4 stated she was old and should not be hit by other residents. Resident 4 stated Residents 2 and 3 were fighting in the room over Resident 2 talking to a female staff. Resident 4 stated Residents 2 and 3 began to punch each other leaving Resident 2 with a scratch to the left side of her face. Resident 4 stated, "It's scary to have both of the residents here because we don't know if they would come and attack us." On 11/25/19 at 4:17 p.m., during an interview, Certified Nurse Assistant 6 (CNA 6) stated hearing Resident 3 yelling from the hallway. CNA 6 stated upon entering Resident 2's room, Residents 2 and 3 were observed arguing about clothing. CNA 6 stated, "I told them to move apart and asked Resident 3 to leave the room, before Resident 3 left the room, she reached out to Resident 2 and scratched her on the face. CNA 6 stated Residents 2 and 3 had altercations in the past. c1. A review of Resident 6's Face Sheet indicated Resident 6 was admitted to the facility on 7/2/18. Resident 6's diagnoses included impulse disorder (failure to resist an urge), and unspecified dementia. A review of Resident 6's H/P, dated 7/3/18 indicated Resident 6 did not have the capacity to understand and make decisions. A review of Resident 6's MDS, dated 7/11/19 indicated Resident 6 was able to make herself understood and understand others. The MDS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 17 of 21 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 09/23/2020 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 Resident 6 required supervision of a one-person physical assist ambulation in the facility and had no behavioral issues. A review of Resident 6's care plan titled, "Impulse Control," evaluated 7/2019 indicated the goal was for Resident 6's behaviors to decrease within nine months. The staffs' interventions included to monitor Resident 6's mood state, behavior in private/public and report to physician. On 11/25/19 at 4:27 a.m., during an interview, LVN 3 stated on 9/16/19 at approximately 6:30 a.m., she was informed Resident 6 was in the dining room unsupervised and crying. LVN 3 stated there was no CNA present in the dining room monitoring the residents. LVN 3 stated a staff member should be in the dining room atall-times monitoring the residents. LVN 3 stated Resident 6 was very aggressive and had episodes of hitting other residents and should not be left unsupervised c2. A review of Resident 7's Face Sheet indicated Resident 7 was admitted to the facility on 1/15/18. Resident 7's diagnoses included schizophrenia, epilepsy (neurological disorder characterized by episodic loss of attention or sleepiness (petit mal) or severe convulsion), and muscle weakness. A review of Resident 7's MDS, dated 7/14/19 indicated Resident 7 was able to make himself understood and understand others. The MDS indicated Resident 7 had behavioral symptoms of hitting, pushing, scratching, screaming, threatening, and cursing towards others and required limited assistance of one-person physical assist for locomotion (how resident moves between location) on/off unit. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 18 of 21 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 09/23/2020 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 7's care plan titled, "Behavioral Patterns," dated 8/3/19 indicated the goal was for Resident 7 to not have more than three (3) episodes. The staffs' interventions included to monitor Resident 7's whereabouts frequently, keep away from other residents, monitor and document number of episodes, evaluate effectiveness and notify physician. A review of Resident 7's Physician Order, dated 8/19/19 indicated Resident 7 was receiving Seroquel (antipsychotic medication) 50 milligrams ([mg], unit of measure) by mouth (PO) twice a day (BID) for schizophrenia manifested by ([m/b], symptoms of) delusion (belief that is not true) and verbalizing people are against him. On 9/16/19 at 9:40 a.m., during an interview, Resident 7 was noted confused stating he was going home to twenty-nine palms (military base) with his stepfather. Resident 7 stated hitting Resident 6 on her head twice because she hit him twice in the back of the head on 9/16/19 early morning. Resident 7 stated he did not tolerate others hitting him. On 9/16/19 at 9:45 a.m., during an interview, the facility's Housekeeper (HK) stated on 9/16/19 at approximately 6:40 a.m., Residents 6 and 7 were in the dining room getting ready for breakfast. The HK stated Resident 7 was sitting behind Resident 6 when studently Resident 7 hit Resident 6 twice in the head. The HK stated Resident 6 started crying and turned around and punched Resident 7 twice in the face. The HK stated she informed Licensed Vocational Nurse 4 (LVN 4) immediately but LVN 4 was not able to separate the residents. The HK stated 15 minutes after the first incident with Residents 6 and 7, she went to call LVN 4 again because Resident 7 threw a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 19 of 21 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 09/23/2020 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 cup of water at Resident 6 and attempted to hit her again. The HK stated LVN 4 did not show up the first time she reported the incident. The HK stated then LVN 3 and both Residents 6 and 7 were separated immediately. The HK stated Resident 7 also attempted to hit LVN 3. The HK stated Resident 7 was aggressive towards others. The HK stated several residents were left in the dining room with no staff members present to supervised them. On 9/16/19 at 10:18 a.m., during an interview, LVN 2 stated LVN 4 informed him of the altercation between Residents 6 and 7. LVN 2 stated he was unaware there had been two separate incidents between the two residents that day. On 9/16/19 at 10:22 a.m., during an interview, CNA 5 stated Resident 7 was very aggressive and would yelled at the nurses and residents all the time. CNA 5 stated Resident 7 discriminated (treated someone unfairly) against certain ethnic groups and needed to be monitored all day, but the nurses were afraid to monitor Resident 7 because of his aggressive behaviors. A review of the facility's policy and procedures titled, "Safety and Supervision of Residents," revised 7/2017 indicated resident supervision was a core component of the system approach to safety. The type and frequency of resident supervision was determined by the individual resident's assessment and identified hazards in the environment. The policy indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. A review of the facility's undated policy and procedures titled, "Resident to Resident Abuse," indicated the facility staff would FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 20 of 21 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 09/23/2020 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 monitor residents for aggressive/inappropriate behavior towards other residents or staff. The policy indicated the staff would remove the aggressor from the situation and temporarily separate the resident form the others to help lower agitation. The staff would evaluate the circumstances that lead to the incident and report to the physician. A review of the facility's undated policy and procedures titled, "Care Plan," indicated the residents care plan should reflect the needs, strengths, and preferences of the residents and oriented to prevent of avoidable declines in functioning levels. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KYF111 Facility ID: CA970115 If continuation sheet 21 of 21