Meadow Creek Post-acute

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

blade]). During a review of Resident 1's the Physician Discharge Note dated 9/5/2025 and timed at 5:14 a.m., the Physician Discharge Note indicated Resident 1 was transferred to a GACH due to a left shoulder dislocation at the glenohumeral joint. During an interview on 9/12/2025 at 10:53 a.m., and a subsequent

interview on 9/15/2025 at 9 a.m., the Director of Nursing (DON) stated she did not report this to CDPH because when they searched Resident 1's records from previous hospitalizations they found that Resident 1 had a shoulder issue from a long time ago. The DON stated they considered Resident 1's shoulder dislocation a chronic (persist for a long time, typically, for more than 12 months) issue not an acute (develops suddenly) issue. During an interview on 9/17/2025 at 1:13 p.m., the Administrator (ADM) stated Resident 1's left shoulder dislocation was not reported to CDPH because it was considered a chronic issue.

The ADM stated the facility had a 24-hour window to report injuries from an unknown origin, and the facility found out why Resident 1's left shoulder was dislocated during their investigation and before 24 hours had surpassed. During a review of the facility's Policy and Procedure (P/P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 9/2022, the P/P indicated the facility will report all resident abuse (including injuries of unknown origin) to local, State and Federal agencies (as required by current regulations) and thoroughly investigate by facility management. Findings of all investigations are documented and reported. 1. If an injury of an unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The investigator notifies the ombudsman that an investigation is being conducted. The ombudsman is invited to participate

in the review process. 3. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report.

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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

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow Creek Post-Acute

7039 Alondra Blvd Paramount, CA 90723

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 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

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

Resident 2 sustained a cut on her face. FM 1 stated she asked LVN 1 how Resident 2 got the cut on her face because Resident 2 was unable to move her hands, LVN 1 could not tell her what happened. FM 1 stated later that day she received a phone call from the facility's Administrator (ADM) informing her that upon investigation he determined that CNA 2, when repositioning Resident 2, placed Resident 2 on top of her ventilator circuit on her left side, which caused Resident 2 to sustain an injury to her face. During an

interview on 9/9/2025 at 12:11 p.m., the Treatment Nurse (LVN 1) stated on 9/5/2025, she entered Resident 2's room to perform a wound treatment to Resident 2 and observed her lying on her left side. LVN 1 stated following the wound treatment, she and CNA 2 turned Resident 2 on her back, that's when they both noticed blood on Resident 2's face and on her ventilator circuit. LVN 1 stated Resident 2 required a two-person assist for care and CNA 2 should have gotten another person to assist her when turning Resident 2 in bed. During an interview and on 9/10/2025 at 9:52 a.m., the Director of Staff Development (DSD) stated nurses who work on the Sub-Acute Unit, upon hire, they were instructed not to turn or reposition any of the residents by themselves. During an interview on 9/10/2025 at 11:52 a.m., the Respiratory Therapy Manager (RTM) stated nurses who work on the Sub-acute Unit should turn and reposition residents using two people and make sure the ventilator circuit tubing is not on the resident's face or head. During an interview and on 9/10/2025 at 3:48 p.m., the Director of Nursing (DON) stated the nursing staff were trained on how to prevent accidents or injuries by using a two-person assist while turning or repositioning residents. During a review of the facility's Policy and Procedure (P/P) titled, Repositioning revised on 5/2013, the P/P indicated repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. The P/P indicated to. use two people while tuning or moving the resident in bed.

During a review of the facility's P/P titled, Safety and Supervision of Residents, revised 7/2017, the P/P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety supervision and assistance to prevent accidents are facility wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision.

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