Downey Community Health Center

F-F943.

Findings:

During a review of Resident 44's Admission Record, the Admission Record indicated Resident 44 was originally admitted to the facility on [DATE REDACTED] and was most recently readmitted on [DATE REDACTED]. Resident 44's admitting diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).

During a review of Resident 44's History and Physical (H&P), dated 10/20/2024, the H&P indicated Resident 44 did not have the capacity to understand or make decisions.

During a review of Resident 44's Minimum Data Assessment (MDS, a resident assessment tool), dated 3/3/2025, the MDS indicated Resident 44 did not have cognitive impairments (problems with thinking and memory). The MDS indicated Resident 44 required supervision and/or touch assistance from staff for mobility while in and out of bed.

During a review of Resident 42's Admission Record, the record indicated Resident 42 was originally admitted to the facility on [DATE REDACTED] and was most recently readmitted on [DATE REDACTED]. Resident 42's admitting diagnoses included schizoaffective disorder, paranoid schizophrenia, anxiety disorder (mental health conditions characterized by excessive fear or worry that interferes with daily life), and psychosis.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 2 555128 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555128 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Downey Community Health Center 8425 Iowa Street Downey, CA 90241

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 During a review of Resident 42's MDS, dated [DATE REDACTED], the MDS indicated Resident 42 did not have cognitive impairments. The MDS indicated Resident 42 exhibited verbal behavioral symptoms one to three days out of Level of Harm - Minimal harm or seven days observed. The MDS indicated Resident 44 did not have impairments to her upper extremities potential for actual harm (shoulder, elbow, wrist, hand) or lower extremities (hip, knee, ankle, foot). The MDS indicated Resident 42 was independent to reposition herself while in bed and required set-up or clean-up assistance from staff Residents Affected - Few (staff set up or clean up, but resident completes the activity) to get out of bed and to walk.

During an interview on 4/7/2025 at 9:50 a.m., with Resident 44, Resident 44 stated her previous roommate (Resident 42) threw a chair at her. Resident 44 could not state the date that the altercation occurred. When asked where the alleged incident occurred, Resident 44 stated it occurred in Room A, and stated she was moved to her current room (Room B) after the alleged incident occurred. Resident 44 stated this was her first and only altercation with Resident 42.

During a concurrent interview and record review, on 4/8/2025 at 10:05 a.m., with Social Worker (SW) 1, Resident 44's progress note, dated 3/10/2025 at 10:45 a.m., was reviewed. SW 1 stated the progress note indicated Resident 44 was moved to another room on 3/10/2025 due to incompatibility with her roommate. SW 1 stated that on 3/10/2025, Resident 44 did not report Resident 42 threw a chair at her. The State Agency Surveyor informed SW 1 of Resident 44's allegation that Resident 42 threw a chair at her.

During an interview on 4/8/2025 at 4:04 p.m., with the facility's Program Director (PD), the PD stated she was made aware on 4/8/2024 of the alleged resident-to-resident altercation between Resident 44 and Resident 42, that occurred on an unspecified date. The PD stated she was responsible for reporting the allegation to the State Agency. The PD stated the allegation was not yet reported to the State Agency District Office because they had 24 hours to report.

During a review of the document titled Fax Transmission Details, dated 4/8/2025, the document indicated the SOC-341 (a mandated reporting form used when someone suspects elder or dependent adult abuse or neglect) was sent to the State Agency District Office on 4/8/2025 at 4:52 p.m.

During a review of the document titled Report of Suspected Dependent Adult/Elder Abuse (SOC-341), dated 4/8/2025, the SOC-341 indicated it was completed by the PD, and indicated social services staff were made aware of Resident 44's abuse allegation on 4/8/2025 around 10am.

During an interview on 4/10/2025 at 11:57 a.m., with the Director of Nursing (DON), the DON stated timely reporting of alleged abuse was important for the safety of the facility residents and stated that failing to report timely could negatively impact the safety of the residents.

During an interview, on 4/10/2025 at 12:41 p.m., with the Administrator (ADM), the ADM stated it was the facility's policy and process to report resident-to-resident altercations to the State Agency within two (2) hours.

During a review of the facility P&P titled Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin, reviewed 2018, the P&P indicated all allegations of abuse were to be reported in accordance with state and federal regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 2 555128