Downey Community Health Center: Injury Unreported - CA
The resident, identified in inspection records only as Resident 89, struck both forearms against her bed siderails around 4 a.m. while a certified nursing assistant, CNA 2, was providing personal hygiene care. The impact left skin tears and bleeding on both arms. CNA 2 applied dressings to the wounds and kept working. She did not tell the charge nurse. She did not tell the licensed nurses coming on shift. She did not tell anyone.
In a telephone interview conducted a week later, CNA 2 explained why. She said she was scared. She was afraid she would be suspended.
The physician was not notified until after 2:30 p.m. that same day, when a federal surveyor, identified in the report as RR 1, brought the situation to the attention of licensed nursing staff. More than ten hours had passed since the injuries occurred.
LVN 6, who reviewed Resident 89's electronic medical record during a concurrent interview with inspectors on April 10, confirmed the gaps. The record contained no documentation of how the skin tears, bleeding, and bruises occurred. It contained no documentation of who applied the dressings. There was no record that CNA 2 had reported anything to the licensed nurses on the overnight shift.
LVN 6 was direct about what that meant. She told inspectors that skin tears, bleeding, and bruises constituted a significant change of condition, and that staff should have notified the physician and RR 1 immediately to prevent delayed medical assessment, care, and treatment.
A charge nurse identified as TXN 1 told inspectors she had notified the Director of Nursing about Resident 89's condition, but the inspection record does not indicate when that notification occurred or what, if anything, followed before the surveyor intervened.
The facility's own written policy, last updated in January 2024, states that staff will observe, record, and report changes in a resident's condition to the physician and the resident's representative. None of those three things happened in the hours after Resident 89 hit the siderails.
CNA 2, in her telephone interview, acknowledged the failure plainly. She said she should have notified the charge nurse immediately so the resident could receive timely evaluation and treatment. She knew the right answer. She chose the other one.
What the inspection record does not say is whether anyone at the facility had previously created conditions in which a nursing assistant would weigh a resident's bleeding wounds against her own job security and decide to stay quiet. It does not say whether CNA 2 had reason, from prior experience, to believe that reporting an incident would result in suspension. The record simply captures what she said: she was scared, and so she said nothing.
Resident 89 spent those hours with dressed but unevaluated wounds, no physician aware of her condition, and no documentation that anything had happened to her at all. The injuries were described in the inspection report as causing minimal harm or potential for actual harm, and as affecting few residents. The federal deficiency was cited under standards governing a facility's obligation to notify a resident's physician and representative of a significant change in condition.
The inspection was conducted April 10, 2025. Federal surveyors documented the deficiency as part of a health inspection of the facility at 8425 Iowa Street in Downey.
CNA 2 applied the dressings carefully enough. What she could not bring herself to do was walk down the hall and tell someone what had happened to the woman in her care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Downey Community Health Center from 2025-04-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 29, 2026 · Our methodology
DOWNEY COMMUNITY HEALTH CENTER in DOWNEY, CA was cited for violations during a health inspection on April 10, 2025.
The resident, identified in inspection records only as Resident 89, struck both forearms against her bed siderails around 4 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.