Downey Community Health Center

During a concurrent interview and record review on 4/10/2025 at 1:10 p.m., with LVN 6, Resident 89's

89's EMR indicated there was no documented evidence how Resident 89 sustained the skin tears, bleeding, and bruises, and who applied the dressings. LVN 6 stated there was no documentation Resident 89's assigned 11 p.m. to 7 a.m.

Certified Nursing Assistant (CNA 2) reported to the licensed nurses regarding the change of condition. LVN 6 stated the physician was not notified until after the concern was brought to the licensed nurses' attention by RR 1 on 4/7/2025 around 2:30 p.m. LVN 6 stated Resident 89's skin tears, bleeding, and bruises was a significant change of condition and staff should have notified the physician and RR 1 immediately to prevent delayed medical assessment, care, and treatment.

During a telephone interview on 4/14/2025 at 9:32 a.m., with CNA 2, CNA 2 stated on the morning of 4/7/2025 around 4:00 a.m., while she was providing personal hygiene care to Resident 89, Resident 89 was moving her arms and struck the bed siderails. CNA 2 stated this resulted in skin tears and bleeding to both forearms. CNA 2 stated she applied the dressings to Resident 89's forearms but did not report the incident to the licensed nurse because she was scared and afraid that she would be suspended. CNA 2 stated she should have notified the charge nurse immediately so the resident could receive timely evaluation and treatment.

During a review of the facility's policy and procedure (P&P) titled Condition Change of Resident, dated 1/2024, the P&P indicated the facility would observe, record, and report changes in condition to the physician and resident's representative.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

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.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

Each resident assessment must be conducted and coordinated with the appropriate participation of

555128 04/10/2025

Downey Community Health Center 8425 Iowa Street Downey, CA 90241

During a review of Resident 479's admission Record [(Face Sheet) front page of the chart that contains a summary of basic information about the resident], the admission Record indicated the facility admitted Resident 479 on 3/25/2025, with diagnoses including arthritis (a condition that causes inflammation and pain in the joints), muscle weakness (a reduced ability to contract or exert force with muscle), polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) and acute pulmonary edema (a medical emergency characterized by a rapid buildup of fluid in the lungs, making it difficult to breath).

During a review of Resident 479's Minimum Data Set (MDS - a resident assessment tool), dated 3/28/2025, the MDS indicated Resident 479's cognition (ability to think, remember, and reason) was intact.

The MDS indicated Resident 479 required maximal (helper does more than half the effort) assistance from staff for Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily).

During a review of Resident 479's History and Physical (H&P), dated 3/27/2025, the H&P indicated Resident 479 had the capacity to understand and make decisions.

During a review of Resident 479's physician order dated 3/26/2025, the physician order indicated an order for Pregabalin oral capsule 75 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount) by mouth two times a day for neuropathic pain (pain that caused by nerve damage).

During a concurrent interview and record review on 4/9/2025 at 12:04 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 479's care plans were reviewed. LVN 1 stated a care plan for Resident 479's pregabalin medication could not be found. LVN 1 stated having a care plan for pregabalin was important to monitor parameters, potential side effects and have the appropriate interventions in place.

During an interview on 4/10/2025 at 11:00 a.m. with the Director of Nursing (DON), the DON stated care plans were the nurse's bible and are initiated upon admission, during any change of condition and be revised as needed.

The DON stated care plans were in place for proper delivery of resident care and needs.

During a review of the facility's policy and procedure (P&P) titled Care Plans, dated 1/2024, the P&P indicated It is the policy of this facility to develop a plan of care for residents to manage risks and promote improvement in general condition.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

During a review of the facility's policy and procedure (P&P) titled, Care Plans, undated, the P&P indicated the facility was to develop of a plan of care for residents to manage and promote improvement.

The P&P indicated care plans could be updated of new risk factors, new goals, or new interventions, as necessary.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

During a concurrent observation and interview on 4/7/2025 at 11:00 a.m., with CNA 3, in Resident 75's room, Resident 75 was observed with long fingernails with a brown substance underneath. CNA 3 stated Resident 75's fingernails were long and dirty. CNA 3 stated it was important to keep Resident 75's fingernails clean and trimmed to prevent the growth of bacteria (infection). CNA 3 stated long, dirty fingernails had the potential for the resident to scratch his skin and if Resident 75 scratched himself hard enough, it could create an open wound and increased risk of infection. CNA 3 stated having dirty fingernails was not sanitary because the resident will use her hands to hold utensils when eating and any bacteria could transfer into the body.

During an interview on 4/10/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated residents should be provided with care and services necessary to maintain good personal hygiene.

During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADLs), dated 1/2024, the P&P indicated the facility would provide assistance to residents in meeting their ADLs needs and nail care.

During a review of the facility's P&P titled Job Description Certified Nursing Assistant (CNA), undated, the P&P indicated the CNAs would assist residents with personal grooming, e.g., trimming fingernails.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

During a review of Resident 155's H&P, dated 2/28/2025, the H&P indicated Resident 155 had the capacity to understand and make decisions.

During a review of Resident 155's Orders, order date 2/26/2025, the Orders indicated to give tapentadol (medication used to treat pain) 100mg, by mouth, two times a day for pain management.

During a review of Resident 155's eMAR, dated 4/10/2025, the eMAR indicated tapentadol 100mg was administered to Resident 155 on 4/10/2025 at 7:29 a.m.

During an observation on 4/10/2025 at 9:45 a.m., at Station 3 Cart 1, with LVN 2 present, Resident 155's bubbe pack for tapentadol was observed with four tablets left in the bubble pack.

During a concurrent interview and record review on 4/10/2025 at 9:47 a.m., with LVN 2, Resident 155's Controlled Drug Record, undated, was reviewed. LVN 2 stated the last documentation on the record was 4/9/2025 at 7:25 a.m. and the Record indicated there should be five doses of tapentadol left in the bubble pack. LVN 2 stated she administered Resident 155 tapentadol earlier in the morning and she thought she documented on the Controlled Drug Record but did not. LVN 2 stated after removing the tablet from the bubble pack, she was responsible for documenting on the Controlled Drug Record to indicate the number of remaining doses. LVN 2 stated having an inaccurate count of remaining doses of Resident 155's tapentadol could cause confusion whether Resident 155 received the medication.

During a review of the facility's policy and procedure (P&P) titled, Controlled Drug Handling, undated, the P&P indicated, Licensed nurses must record the controlled medication administered on the resident on the MAR and narcotic count sheet.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

During a review of the facility's policy and procedure (P&P) titled, Medication Side Effects, dated

side effects and adverse drug reactions (ADRs), with documentation, communication, and response to safeguard resident health.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

the P&P indicated a licensed nurse would determine why the resident refused medication in order to

medications are prepared and administered by a licensed nurse in accordance with written orders of the attending physician.

The P&P indicated medications are administered within 60 minutes of scheduled time, except before and after meal order, which are administered based on mealtimes.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

During a concurrent observation and interview on 4/7/2025 at 8:35 a.m., in the kitchen, with Dishwasher 1, observed Dishwasher 1 without the required hair covering while working in the dishwashing area, near the food preparation station.

Dishwasher 1 stated he did not realize that his hair netting had fallen, and he believed his hair was still covered.

During an interview on 4/7/2025 at 8:45 a.m., in the kitchen, with Dietary Supervisor (DS 1), DS 1 stated a hair covering not properly secured could result in hair falling into the food, clean dishes, or food preparation area, and increased risk of food contamination.

• During a concurrent observation and interview on 4/7/2025 at 9:00 a.m., in the dry food storage

room, with DS 1, observed one large plastic container filled with a powdered substance unlabeled and undated. DS 1 stated the container held powdered nutritional supplement and should have been labeled and dated according to facility protocol. DS 1 stated all items in the storage room should be labeled with both the delivery and expiration dates to ensure safe usage.

During a review of the facility's policy and procedure (P&P) titled Infection Control- Dietary, dated 1/2024, the P&P indicated personnel would wear a hair covering in food preparation, food service, and food storage areas.

During a review of the facility's P&P titled Labeling and Dating of Foods, undated, the P&P indicated all food items in the storeroom would be labeled and dated.

The P&P indicated food delivered to the facility would be marked with a received date.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

During a review of the facility's P&P titled, Foods brought by family or visitors, undated, the P&P indicated Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

During a review of Resident 132's admission Record, the admission Record indicated Resident 132 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and anemia (a condition where the body does not have enough healthy red blood cells).

During a review of Resident 132's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/29/2025, the MDS indicated Resident 132's cognitive (the ability to think and process information) skills for daily living was intact.

The MDS indicated Resident 132 was dependent (helper does all the effort) from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

During a concurrent interview and record review on 4/9/2025 at 8:15 a.m., with the admission Coordinator, Resident 132's ADA form was reviewed.

The admission Coordinator stated she was responsible for completing the ADA form for residents upon admission to the facility.

The admission Coordinator stated Resident 132's ADA form was incomplete and was missing Resident 132's initials.

The admission Coordinator stated the ADA form was a legal document included in the resident's medical record which reflected the resident's medical needs and wishes.

The admission Coordinator stated the form should have been completed accurately per the facility's policy to ensure the resident would receive treatment, and services needed.

The admission Coordinator stated inaccuracies could lead to actions that could harm the resident.

During a review of the facility's policy and procedure (P&P) tilted Documentation, dated 1/2024, the P&P indicated the medical record will be complete and accurate.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

the P&P indicated the facility must ensure the agreement is explained to the resident and his or her

555128 04/10/2025

Downey Community Health Center 8425 Iowa Street Downey, CA 90241

During a concurrent interview and record review on 4/8/2025 at 10:18 a.m., with the IPN, the IPN's Nursing Home Infection Preventionist Training Court Certification, dated 11/14/2023, was reviewed.

The IPN stated he completed his certification to become the facility's IPN on 11/14/2023 but did not complete any documented continuing education in the filed of Infection Prevention and Control since then.

The IPN stated he was responsible for completing at least ten hours of continuing education in Infection Control on an annual basis to keep up to date with all guidelines and protocols.

The IIPN stated without the completion of continuing education, he may not be educating the facility's staff on the best way to treat infections in the facility.

During a review of the California Department of Public Health (CDPH) All Facilities Letter (AFL, official letter from the CDPH to facilities to keep them informed about changes in regulations, enforcement actions, new technologies, and other important updates), dated 11/4/2020, the AFL indicated, The IP should complete 10 hours of continuing education in the field of [Infection Prevention and Control] on an annual basis.

Facilities should provide encouragement and support for IP staff to stay abreast of current news and training sources through a nationally recognized infection prevention and control association.

During a review of the facility's Infection Control Coordinator Job Description, undated, the Job Description indicated the Infection Control Coordinator was responsible for promoting professional growth and development by educational activities and participating in educational trainings.

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

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

During a review of the facility's Policy and Procedure (P&P) titled Call Light, dated 1/2024, the P&P indicated staff would assess residents' ability to use the facility call system, and alternative ways of calling for assistance would be accommodated as needed.

The P&P indicated if the call light is not functional for the resident, the facility must provide an alternative way to call for help.

Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of

remind facilities of the federally mandated reporting requirements of potential abuse, neglect, exploitation, or mistreatment of elders or dependent adults. AFL 21-26 indicated incidents involving abuse were to be reported to the State Agency, in writing or by electronic report, within two (2) hours.

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Downey Community Health Center 8425 Iowa Street Downey, CA 90241

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] and was most recently readmitted on [DATE]. 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.

During a review of Resident 42's MDS, dated [DATE], 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 seven days observed.

The MDS indicated Resident 44 did not have impairments to her upper extremities (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 (staff set up or clean up, but resident completes the activity) to get out of bed and to walk.

555128

Form Approved OMB

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