Downey Community Health Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following food safety and food preparation practices was observed by failing to ensure:1. Foods were stored and/or prepared under sanitary conditions.2. Proper sanitation and food handling practices were maintained to prevent outbreak or foodborne illness.3. Frozen vegetables were dated and labeled to prevent the potential for foodborne illness.4. One bag of hot dog buns, a container of black pepper, tarragon leaves, curry powder, and basil were labeled with an open date.5. Dietary Aide 1 (DA 1) properly explained thermometer calibration and did not reuse the same alcohol pad for multiple probe sanitizations during tray line observation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures for four of four sampled residents (Resident 117, Resident 58, Resident 80, and Resident 184) by failing to ensure:1. Hand hygiene was performed between the medication pass of Residents 117 and 58.2. Hand hygiene was performed prior to administering Resident 80's medicated eye drops.3. Hand hygiene was performed prior to Licensed Vocational Nurse (LVN) 2 dispensing the contents of Resident 184's medication capsules into a medication cup.4. Registered Nurse (RN) 3 did not wear gloves while walking in the hallway. These failures had the potential to result in the avoidable spread of bacteria and disease throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent for psychotropic medication (any prescription drug that alters chemicals in the brain to affect a person's mind, emotions, thoughts, or behavior) was obtained from someone with medical decision-making capacity for one of five sampled residents (Resident 91) reviewed for unnecessary medications. This failure created the potential for Resident 91 to sustain adverse effects related to the administration of risperidone (an antipsychotic medication), including movement disorders, discomfort, hypotension (low blood pressure), gait (manner of walking) disturbance, constipation/impaction, or cognitive/behavioral impairment (trouble with thinking, learning, remembering, and making decisions).

Inspectors wroteBased on interview and record review, the facility failed to ensure the fall risk was accurately assessed for one of three sampled residents (Resident 17). This failure created the potential for Resident 17's fall risk assessment to be higher than staff were aware of, and increased her risk of falling and sustaining subsequent injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following for three of three sampled residents (Residents 23, 117, and 182): 1. Licensed Vocational Nurse (LVN) 1 accurately documented Residents 23 and 117's medication refusals.2. Resident 182 received his antibiotics (medication to treat a bacterial infection) at the scheduled time. These failures resulted in incorrect medication administration documentation given to the general acute care hospital (GACH) when Resident 23 was transferred out for evaluation and had the potential for Resident 23 to not receive his required medication. This failure also had the potential to result in the mismanagement of Resident 117's pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Hydrocodone-Acetaminophen (a medication used to treat pain) was administered within the physician ordered parameters (specific, measurable, and objective clinical criteria set by a healthcare provider that dictate when a medication should be given, withheld, or adjusted) for one of two sampled residents (Resident 7). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure blood pressure medications were administered as ordered by the physician for two of six sampled residents (Resident 10 and Resident 154). This failure created the potential for Resident 10 and Resident 154 to experience complications related to hypotension (low blood pressure), including dizziness, falls, and increased heart rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment when the water from a plumbing pipe ( a tube that carries water) under the sink was observed draining into the floor drain. The floor drain was uncovered creating steam (is water in the form of a hot gas) and slippery conditions (a surface that us easily to slip on because it is wet). This failure created safety hazards and the potential for burns from the steam.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure a two-person assist was used when using the Hoyer Lift (a mechanical device used to lift and/or transfer a person) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 falling from the Hoyer Lift.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IPN) completed ten hours of continuing education in the field of Infection Prevention and Control on an annual basis. This deficient practice had the potential to result in the IPN being unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control.

Inspectors wroteBased on interview and record review, the facility failed to ensure the training provided to all facility staff, specifically related to abuse reporting, was consistent with federal reporting guidelines. This failure had the potential to affect all facility residents due to late reporting of abuse, and delayed investigations by the State Agency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Kitchen staff wore a hair covering in the food service or preparation areas of the kitchen. 2. All food items in the storeroom were labeled and dated. These deficient practices had the potential to result in improper food safety practice and could lead to food contamination, and possible food borne illness in residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 142) fully understood the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) in a language Resident 142 understood. This deficient practice resulted in Resident 142 not fully understanding what entering a binding Arbitration Agreement meant.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of seven sampled residents (Resident 100). This deficient practice had the potential to result in a delay in meeting the residents' needs for assistance and could lead to falls and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly notify the physician and the resident's representative (RR 1) of a change in condition (COC) of skin tears (separation of the skin) and bleeding on both forearms for one of four sampled residents (Resident 89). This deficient practice resulted in a delay in medical assessment and treatment for Resident 89 and placed the resident at risk of harm.

Inspectors wroteBased on interview and record review, facility staff failed to report an allegation of resident-to-resident physical abuse to the State Agency within two (2) hours, for two of four sampled residents (Resident 44 and Resident 42). This failure resulted in delayed notification to the State Agency and increased the potential for additional resident-to-resident abuse incidents to occur. Cross reference F-tag F943.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents' (Resident 129) assessment entry on the Minimum Data Set ([MDS], a resident assessment tool) was accurate and included the depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) diagnosis. This deficient practice had the potential to negatively affect Resident 129's plan of care and delivery of necessary care and services related to depression.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a care plan (a document that outlines a resident's care needs, diagnosis, and treatment goals) for Pregabalin (medication to treat nerve pain by calming overactive nerves in the body was developed and implemented for one of four sampled residents (Resident 479). This deficient practice placed Resident 479 at risk for delayed monitoring and implementing interventions.

Inspectors wroteBased on interview and record review, the facility failed to revise the person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of seven sampled residents (Resident 328) who was on dual (two) antiplatelet medication (medication to prevent blood clots from forming). This deficient practice had the potential to result in confusion between licensed nurses regarding Resident 328's appropriate use of dual antiplatelet medication and navigation of Resident 328's plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for two of four sampled residents (Residents 112, and 75) by failing to keep the residents' fingernails clean and neat. This failure had the potential to result in negative impact on Residents 112 and 75's quality of life and self-esteem, and had the potential for development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate and complete documentation on the Controlled Record for two of two sampled residents (Residents 155 and 178). This deficient practice resulted in the inaccurate count of medications left in the medications bubble packs (a card used to store medications for the resident) and had the potential to result in an additional dose administered, for drug diversion (the act of health care providers stealing prescription medicine for their own use), and/or the potential for medication error to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor Resident 479 for signs of being over medicated while on Pregabalin (medication to treat nerve pain by calming overactive nerves in the body) for one of four sampled residents (Resident 479). This deficient practice placed Resident 479 at risk for adverse medication side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled resident (Resident 230) was free from significant medication error (one which causes the resident discomfort or jeopardizes his or her health and safety) by failing to: 1. Ensure Resident 230 received glipizide (lowers blood sugar) 30 minutes before breakfast. 2. Ensure licensed nurses followed the physician's orders. These deficient practices placed Resident 230 at a higher risk to experience extremely lower blood sugar levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove outside food from the bedside after two hours for one out of seven residents (Resident 79) in accordance with the facility's Policy and Procedure (P&P) titled, Foods brought by family or visitors. This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 79, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever. It could lead to other serious medical complications (a medical problem that occurred during a disease) and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and accurately complete the Advance Directives Acknowledgement ([ADA]- a form gives you the right to give instructions about your own health care) for one of four sampled residents (Resident 132). This deficient practice resulted in inaccurate and incomplete medical records and had the potential to result in confusion in the resident's care and services. This also placed Resident 132 at risk of not receiving necessary care or not receiving care based on the resident's wishes due to inaccurate and incomplete information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a touch pad (button activated by light touch) call light for one out of eight residents (Resident 86). This deficient practice had the potential to cause a delay or an inability in Resident 86 obtaining necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA 1) did not continue to have access to one of two sampled residents (Resident 1) after an allegation of physical abuse. This deficient practice resulted in CNA 1 still being assigned to the care of Resident 1 ' s roommates after Resident 1 ' s allegation of abuse.

Inspectors wroteBased on interview, and record review, the facility failed to document records completely for one of two sampled residents (Resident 1) when: 1. Resident 1 had concerns with Certified Nurse Assistant (CNA) 1 during care on 3/15/2025. 2. The facility failed to document a change of condition when Resident 1 had an allegation of abuse on 3/17/2025. These deficient practices had the potential to result in a lack of or a delay in communication between the staff and could interrupt provision of care/intervention to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for one of the 3 sampled residents (Resident 1) by failing to ensure the physician order to check Resident 1 ' s blood sugar (BS) levels were implemented on 2/28/2025, 3/1/2025 and 3/2/2025. This failure placed Resident 1 at risk for hypoglycemia (low blood sugar) and/or hyperglycemia (high blood sugar) episodes, and potential for complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was readmitted to the facility after Resident 1 was transferred and treated at the General Acute Care Hospital (GACH). This deficient practice resulted in Resident 1 remaining at the GACH for two additional days after Resident 1 was deemed appropriate for discharge back to the facility but was denied readmission by the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection prevention and control measures by failing to ensure clear signage was posted for two of five sampled residents (Resident 4 and Resident 5) who were on Enhanced Barrier Precautions ([EBP] use of gown and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms ([MDROs] bacteria or other microorganism resistant to multiple classes of antibiotics)). This deficient practice had the potential to result in staff and visitors entering the room without the proper personal protective equipment ([PPE] specialized clothing or equipment such as gloves and gown, worn to minimize exposure to serious illness) and increasing the risk of transmitting disease-causing organisms leading to illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan intervention of bilateral floor mats. This failure had the potential to result in Resident 3 being injured if she fell.

Inspectors wroteBased on observation, interview, and record review, the facility did not implement infection practices as outlined in the facility's infection control program when the facility did not perform the following: 1. Implement Enhanced Barrier Precautions ([EBP]-the use of gown and gloves for specific care activities that involve a high chance of the spread of infection), as mandated, to limit the spread of infections. 2. Ensure the Treatment Nurse wore proper personal protective equipment ([PPE] -a barrier precaution which includes use of gloves, gown, mask, face shield, shoe covers, head covers, respirators, etc. when you anticipate contact with blood or body fluids or other communicable toxins or agents) during Resident 88's wound treatment. 3. Ensure certified staff used PPE when providing wound treatment for Resident 129. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure medications brought from home (Home Medications) were reviewed by the pharmacist for two of two residents (Resident 65 and Resident 113) prior to administering Home Medications stored inside of two of four medication carts inspected (Medication Cart 2 located on Station 3 and Medication Cart 3 on Station 1) respectively. 2. Accurately account for and document the administration of eight out of 12 doses of Lorazepam, a controlled medication (has a high potential for abuse) affecting Resident 36 on Station 2, Medication Cart 2. These deficient practices increased the risk for unsafe medication administration, potential for diversion, medication errors due to lack of documentation, possibly resulting in serious health complications that could lead to hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure lorazepam (a medication used to treat mental illness) was used for a medical condition as diagnosed and documented in the resident's clinical record between 3/25/2024 and 4/2/2024, for one of five residents sampled for unnecessary medications (Resident 36). 2. Define resident-specific target behaviors regarding the use of lorazepam for one of five residents sampled for unnecessary medications (Resident 36). 3. Monitor lorazepam for adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and effectiveness between 3/35/2025 and 4/2/2024, for one of five residents sampled for unnecessary medications (Resident 36). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for four of five sampled residents (Residents 10, Resident 16, Resident 53, and Resident 621) observed during medication administration by failing to: 1. Ensure Resident 621's physician orders for hydroxychloroquine and potassium chloride extended release (ER) were administered in accordance with manufacturer's specification, the facility's policy and procedure (P&P) titled Medication Administration-General Guidelines, dated 5/2016, and/or the form titled, Medications Not To Be Crushed, list dated 7/2015 (Cross Ref F-tag F760). 2. Ensure Resident 621's physician order for aspirin was administered as prescribed on 4/2/2024. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved texture and appearance for 23 of 23 residents receiving a pureed diet (a regular diet that has been designed for residents who have difficulty chewing and or swallowing). The texture of the pureed diet was lumpy and not smooth with large pieces of pasta present requiring chewing before swallowing. This deficient practice had the potential to result in meal dissatisfaction, decreased food intake, risk for unplanned weight loss, and placed al 23 residents receiving a pureed diet at risk for choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1. Six plastic bags of packed lunch with meat sandwiches for residents were stored in the refrigerator with use by dates of 3/27/2024, 3/30/2024, and 3/31/2024, exceeding the storage period for previously prepared sandwiches. There was one medium size container of tomato sauce with a use by date of 3/26/2024, and one medium size container of cooked green beans with a use by date of 3/28/2024, stored in the walk-in refrigerator exceeding use by date mark. There were four ham and cheese sandwiches stored in walk in refrigerator with no date. One container of a liquid egg carton with an open date of 3/27/2024 and manufactures instruction to use within 3 days stored in the walk-in refrigerator exceeding manufactures use by date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep a resident informed and did not ensure a resident exercised his right to choose for one out of eight sampled residents (Resident 74) by failing to: 1. Ensure licensed nursing staff informed Resident 74 of the medications being administered prior to administration. 2. Ensure Resident 74 was given an opportunity to participate during medication administration. These deficient practices violated Resident 74's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was provided for one of eight sampled residents (Resident 134) by not ensuring Resident 134 was served meals with disposable plastic utensils and not informing Resident 134 of the reason she received the disposable plastic utensils. This deficient practice violated Resident 134's right to be treated with respect and dignity and had the potential to negatively impact Resident 134's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to respect a residents' right to personal privacy for one out of eight sampled residents (Resident 90) by failing to ensure the facility's case manager did not open Resident 90's mail. This deficient practice violated Resident 90's right to privacy and had the potential to cause psychosocial harm to Resident 90.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement an individualized person-centered care plan (document helps nurses and other team care members organize aspect of resident care) with measurable objectives, timeframes, and interventions to meet the residents' needs addressing one out of eight sampled residents (Resident 134) suicidal ideations (Intrusive thoughts and a preoccupation with death and dying). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 134.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain appropriate grooming and personal hygiene for two of 12 sampled residents (Residents 88 and 222) by failing to keep the residents' nails clean and neat. This failure had the potential to result in negative impact on the residents' quality of life and self-esteem and had the potential for development of infection.

Inspectors wroteBased on interview and record review, the facility failed to assess and identify the potential hazard and resident's risk factors for falls for one of three sampled residents (Resident 36), by failing to complete a Post-Fall Assessment and conduct an Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) meeting after Resident 36 had an unwitnessed fall. This failure had the potential for Resident 36's cause of fall to be undetermined and increased the potential for reoccurrence of future falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 621) were free from significant medication errors when Resident 621 received Potassium Chloride ER ([ER- Extended Release] a medication used to prevent or treat low potassium levels in the body) crushed and administered as a mixture with other medications, which was not in accordance with the manufacturer's specifications, and the facility's Policy & Procedure (P&P) titled, Medication Administration-General Guidelines, dated 5/2016 and/or as indicated on the form titled, Medications Not To Be Crushed, list dated 7/2015. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure tortillas served during lunch time were served in accordance with a physician order for mechanical soft diet (a type of texture-modified diet for people who have difficulty chewing and swallowing) for one of three sampled residents (Resident 81). This failure had the potential to result in Resident 81 being unable to properly chew the tortilla that could result in Resident 81 choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the need for modifications to the call light system for one out of eight sampled residents (Resident 124), who had difficulty activating the call light. This deficient practice had the potential to result in a delay in obtaining necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of three sampled residents (Resident 2 and Resident 3) were free from avoidable falls. As a result, this failure had the potential to cause a fracture (a complete or partial break of a bone) or head injury for Resident 2 and Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and 4) who had a physicians' orders to receive two liters of oxygen (O2) by a nasal cannula ([NC] a device used to deliver supplemental oxygen) instead of three liters of O2, per minute. This deficient practice had the potential to result in Resident 1 and r 4 receiving more oxygen than required amount of oxygen which can negatively impact their health.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) clinical record was maintained in accordance with accepted professional standard and practice, by not documenting activities of daily living (ADL) sheet correctly by Certified Nursing Assistant (CNA) This deficient practice can result in a lack of or a delay in communication between the staff and can interrupt provision of care/intervention to Resident 1.