Downey Community Health Center

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Based on interview and record review, the facility failed to ensure the nursing staff was aware of what the facility used visual identifiers (icons placed by resident to identify special needs or accommodations) meant that were posted in resident rooms.This deficient practice had the potential to result in staff not providing

the appropriate care for the residents.Findings:During a review of the facility's Lesson Plan titled Visual Identifier, undated, the Lesson Plan indicated the course content covered what visual identifiers were used

in the facility. The visual identifier of a 5- fingers sign meant more than 2-persons assistance during transfer.

The evaluation for the Lesson Plan included a question that asked the participants what the 5- fingers visual identifier meant in the facility.During an interview on 8/27/2025 at 10:10am with Certified Nurse Assistant (CNA) 2, CNA 2 was asked if she knew what the visual identifier with 5-fingers on a red hand posted up at the head of a resident's bed meant. CNA 2 stated she was not sure if she had ever seen that sign before and did not know what that visual identifier was meant to signify if it was posted up. During a

review of the facility's In-service Training for Certified Nurse Assistants titled, Visual Identifiers, dated 3/10/2025, the In-Service Training for Certified Nurse Assistants indicated CNA 2 attended the Visual Identifiers training on 3/10/2025.During an interview on 8/28/2025 at 2:38 p.m. with the Director of Staff Development, the DSD stated the expectations from staff after receiving an in-service training are that the staff would apply what they have learned in class into practice. The DSD further stated the facility expected

the staff to remember what they were taught and apply it during the care for the residents, and it was important to do so because it ensured resident and staff safety.During a review of the facility's policy and procedures (P&P) titled Visual Identifiers, dated 1/2024, the P&P indicated the 5-fingers visual identifier meant a resident required more than 2 persons during transfers and staff should check for visual identifiers

before providing care or services, follow any precautions associated with the identifier.

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure accurate documentation in accordance with professional standards of practice for one of two sampled residents (Resident 1) by documenting Resident 1 received Restorative Nurse Aide (RNA- a Certified Nursing Assistant with specialized training in restorative care to help residents regain physical and cognitive functions and maintain independence) services when they did not. This deficient practice had the potential to affect future care provided to the resident due to inaccurate documentation practices.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted on [DATE REDACTED], and readmitted on [DATE REDACTED] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 1's History and Physical (H&P), dated 3/11/2025, the H&P indicated Resident 1 did not have the capacity to make and understand decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/18/2025, the MDS indicated Resident 1 did not have the ability to understand others or make themselves understood. The MDS further stated Resident 1 was severely cognitively impaired (ability to reason, understand, remember, judge, and learn) and did had limitations in range of motion to the upper and lower extremities (related to the arms and legs). During a review of Resident 1's Order Summary Report, dated 7/27/2025, the Order Summary Report indicated Resident 1 had an order for the right and left lower extremity (related to the legs) passive range of motion (PROM- exercises by a therapist to improve mobility, increase circulation, and prevent stiffness, especially for those who cannot move their own limbs) 5 times per week, and a Pressure Relief Ankle Foot Orthosis (PRAFO- a boot used to prevent and treat heel ulcers and muscle tightness in those who spend extended periods in bed) to be applied to the right and left extremities for 3-4 hours per day, 5 days each week. During a review of Resident 1's RNA Program Administration Report, dated 8/2025, the RNA Program Administration Report indicated the ordered tasks assigned to the RNA Program were signed off as performed on 8/18/2025 by RNA 1. During a review of the facility's Interview Record as part of

the facility's investigation, dated 8/20/2025, the Interview Record indicated Restorative Nursing Aid (RNA) 1 was not able to see Resident 1 on 8/18/2025. During a concurrent interview and record review on 8/27/2025 at 11:50 a.m. with RNA 1, RNA 1 stated he did not observe Resident 1's lower extremities on 8/18/2025 because he was not able to perform the RNA orders for Resident 1 because there was not enough RNA for the whole building that day. RNA 1 reviewed the RNA Program Administration Report and stated the initial under the date of the RNA task indicated it was performed. RNA 1 stated he just signed off

on it, but it should have been noted with a reason why the task was not performed because it looked like

the tasks were performed on that day. During an interview on 8/28/2025 at 2:38 p.m. with the Director of Staff Development (DSD), the DSD stated nursing documentation should be accurate. The DSD further stated the nurse should never document a task was performed when it was not, because this could affect future treatment that would be given to the resident later due to inaccurate documentation. During a review of the facility's policy and procedures (P&P) titled Documentation, dated 1/2024, the P&P indicated documentation in the medical record would be objective, complete, and accurate.

Event ID:

Facility ID:

If continuation sheet