Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Downey Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, ESRD, and dependence in ADLs did not receive care consistent with professional standards when an LVN administered Tylenol for reported pain but failed to document the dose, assessment, and reassessment in the MAR in a timely manner, contrary to facility medication administration policy. In addition, the same resident, who had a Foley catheter and a care plan addressing prior hematuria, was observed without a StatLock or other securement device, despite a care plan intervention to secure the catheter to promote urine flow and prevent kinking and accidental removal. Staff acknowledged that the care plan and standard of care were not followed, and the DON noted the resident’s risk for penile trauma due to prolonged Foley use and the need for a securement device.
A resident with a history of falls, cognitive impairment, and recent femur fracture was left unsupervised on the toilet by a CNA, despite requiring maximal assistance and supervision. The resident attempted to stand, fell, and sustained a head laceration requiring sutures. Staff interviews confirmed the resident should not have been left alone, and the care plan lacked specific instructions for supervision during toileting.
Nurses and nurse aides failed to demonstrate the competencies needed to care for residents in a manner that maximizes their well-being, resulting in a deficiency related to staff qualifications and resident care.
The facility failed to develop comprehensive care plans for four residents, leading to potential delays and negative impacts on their care. A resident did not receive a prescribed nutritional supplement due to staff unfamiliarity, while two residents with vision impairments had inappropriate or missing care plans. Another resident's medication refusal was not addressed with a care plan, risking delays in necessary treatment.
The facility failed to document a resident's medication refusal and educate them on the risks, while also not informing a physician of another resident's change in condition. One resident refused medications due to timing issues, and the staff did not document or educate as required. Another resident's brownish urine was noted post-dialysis, but the staff failed to notify the doctor, potentially delaying care.
A resident with cataracts was not referred to an ophthalmologist as recommended by an optometrist, due to the Social Services Director's failure to review consultation notes and follow up on the referral. This oversight delayed necessary treatment for the resident's eye condition.
A resident requiring dialysis did not receive appropriate post-dialysis care when the facility failed to remove the pressure dressing from the AV shunt site as ordered. The resident, with conditions including ESRD and diabetes, returned from dialysis with the dressing still intact, leading to potential complications. The oversight was acknowledged by the LVN and ADON, highlighting a failure to adhere to the facility's post-dialysis care policy.
A facility failed to accurately document the administration of lorazepam for a resident with multiple diagnoses, including seizure disorder and major depressive disorder. The MAR showed three doses administered, but a review revealed a missing nurse's signature and an incorrect tablet count. An LVN admitted to not signing the NCS immediately, which was confirmed as a medication error by the ADON. The facility's policy requires immediate documentation, which was not adhered to, resulting in the deficiency.
A resident with a history of stroke and gastrointestinal issues was nearly given a chewable aspirin tablet instead of the prescribed delayed-release form by an LVN, who did not have a physician's order for the change. The LVN was stopped by a surveyor, and the ADON confirmed the need for physician clarification before altering medication forms.
The facility failed to implement proper infection control practices for two residents. A resident's nebulizer mask was improperly stored on a nightstand without a protective bag, contrary to infection control policies. Another resident's dirty clothes and linen were left unattended on the bed, violating the facility's procedures for handling soiled items. Staff acknowledged these lapses, which posed potential infection risks.
A facility failed to conduct weekly skin IDT meetings for a resident who developed redness on the left hip and iliac crest. Despite the resident's dependency on staff and a history of pressure-induced damage, no meetings were held between January 2025 and February 2027, contrary to facility policy. The DON confirmed that meetings should have been conducted, especially after a change in the resident's skin condition was noted.
The facility failed to meet the required room size of 80 sq. ft. per resident in multiple-resident rooms, with four rooms measuring below the standard. Despite this, observations showed that residents had privacy, space for personal items, and maneuverability for wheelchairs. The administrator acknowledged the deficiency, and a room waiver was recommended by the California Department of Public Health.
A resident with dementia and other medical conditions sustained a fractured wrist of unknown origin, but the facility did not report the injury to CDPH within the required two-hour timeframe or submit the investigation results within five working days, as mandated by policy. The delay in reporting was confirmed through staff and family interviews and review of facility records.
A resident with dementia and psychotic disorder exhibited erratic behaviors, including thrashing arms and striking furniture, but did not have a care plan addressing these actions. Staff and family observed the resident guarding a painful wrist over several days, but a change of condition assessment and pain interventions were not provided, resulting in an undiagnosed wrist fracture and hospital transfer.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency. One resident's call light was clipped to a curtain, and they rely on it for assistance due to a history of falls and other conditions. Another resident also had their call light out of reach and often cannot find it, despite needing assistance due to difficulty walking. Both residents have the mental capacity to make medical decisions, and the facility's policy requires call lights to be accessible.
A resident's legal representative requested medical records, but the LTC facility failed to release them within the 24-hour timeframe as per policy. Despite multiple follow-ups, the records were delayed by about a month, violating the resident's rights. The facility's policy requires records to be accessible within 24 hours of a request.
A resident fell and sustained a femur fracture due to a CNA's failure to provide a two-person assist during a Hoyer Lift transfer. The CNA did not inspect the sling, which broke during the transfer. Facility staff did not follow procedures for checking and maintaining lift slings, contributing to the incident.
A resident experienced a fall due to a broken Hoyer lift sling, resulting in a right distal femur fracture. Despite severe pain and an X-ray confirming the fracture, the transfer to a general acute care hospital was delayed by 10 hours. The facility's Director of Nursing acknowledged the delay and the risk it posed for delayed care and treatment.
A facility failed to provide restorative nursing exercises as ordered for three residents, leading to a deficiency in care. Residents with conditions like hemiplegia and end-stage renal disease were not consistently receiving prescribed range of motion exercises. Documentation showed multiple days without exercises, marked as not applicable or resident refused. Interviews confirmed the lack of adherence to physician orders, with residents not receiving exercises as frequently as required.
Two residents with moisture-associated skin damage (MASD) did not have individualized care plans developed, despite receiving treatment. Interviews with staff revealed that care plans are essential for guiding treatment and preventing further skin breakdown, but the facility's policies were not followed, leading to potential negative impacts on care delivery.
The facility failed to obtain authorization from the responsible party of a resident with severe cognitive impairment before discharging the resident to another facility. The primary emergency contact was not notified, and the discharge was not properly documented, contrary to the facility's policy.
A resident with impaired cognitive skills and complete dependence on staff developed a Stage III pressure ulcer. Despite documented high risk and ongoing treatments, the facility failed to create a care plan for over a month, as confirmed by the Treatment Nurse and Director of Nursing.
Failure to Document Pain Medication Timely and to Secure Foley Catheter per Care Plan
Penalty
Summary
The facility failed to meet professional standards of quality for one resident by not ensuring timely documentation of pain assessment and medication administration, and by not following the resident’s catheter care plan. The resident had severe cognitive impairment, lacked decision-making capacity, and was dependent for ADLs, with diagnoses including metabolic encephalopathy, muscle weakness, and ESRD. On one observed date, an LVN stated she had administered Tylenol 325 mg for the resident’s 2/10 pain but did not document the administration, assessment, or reassessment in the MAR right away because she had to attend to another resident. The facility’s own Medication Administration policy required the person administering the medication to record the administration on the MAR after the medication pass and to review the MAR at the end of each pass to ensure doses were administered and documented. Another LVN acknowledged that late documentation of medication administration could result in another dose being given. The facility also failed to follow the resident’s care plan related to an episode of blood in the urine. During an observation, the resident was noted to have an indwelling Foley catheter without a StatLock or other securement device in place. Review of the resident’s care plan titled “Resident with an episode of blood in the urine” showed an intervention to secure the catheter to facilitate urine flow and prevent kinking and accidental removal. An LVN confirmed that the facility did not follow the resident’s care plan or the standard of care when the catheter was not secured. The DON stated that the resident was at risk for penile trauma due to long-term Foley catheter use and needed a StatLock to prevent trauma and skin irritation. The facility’s Indwelling Urinary Catheter policy indicated that residents with indwelling catheters receive catheter care daily and PRN, and that staff may secure the tubing with a securement device PRN to prevent migration, friction, or tension of the catheter.
Failure to Provide Adequate Supervision During Toileting for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a resident, assessed as high risk for falls due to a history of right femur fracture, Alzheimer's disease, osteoporosis, and severely impaired cognition, was left unsupervised on the toilet by a CNA. The resident required maximal assistance with toileting hygiene and was dependent on staff for toilet transfers, as documented in the Minimum Data Set and care plan. Despite these documented needs, the CNA left the resident alone in the restroom to inform another resident she was assisting the high-risk resident, during which time the resident attempted to stand, fell, and sustained a forehead laceration requiring five sutures at a general acute care hospital. Interviews with facility staff, including the CNA, LVN, RN, Director of Rehabilitation, and Assistant Director of Nursing, confirmed that the resident should not have been left unattended due to cognitive deficits, poor understanding of safety measures, and toe-touch weight-bearing status following a recent femur fracture. Staff acknowledged that supervision should have been maintained, and the CNA admitted it was unsafe to leave the resident alone. The care plan for the resident lacked specific instructions regarding the type and level of assistance required during toileting, which staff indicated could lead to miscommunication and increased risk of avoidable mistakes. The facility's policy on fall management required individualized care plans and interventions for high fall risk residents, but the care plan in this case did not specify the necessary supervision or assistance. The lack of clear guidelines and staff adherence to supervision protocols directly contributed to the resident's fall and injury while using the toilet.
Nursing Staff Lacked Required Competencies
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of appropriate skills and knowledge among the nursing staff, which impacted the quality of care provided to residents. There were no specific details provided about individual residents, their medical histories, or their conditions at the time of the deficiency. The report focuses on the general failure of staff to meet competency requirements necessary for resident care.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential delays and negative impacts on their care. Resident 27, who had severe cognitive impairment and was entirely dependent on staff for activities of daily living, did not receive a magic cup, a nutritional supplement, with his lunch as ordered by his physician. This oversight was due to a lack of awareness among the staff, as the Certified Nursing Assistant (CNA) was unfamiliar with the magic cup, and the Dietary Supervisor confirmed that it was not included on the meal tray. Resident 71, who was legally blind due to diabetic retinopathy, had a care plan that included inappropriate activities such as playing cards, cooking, and gardening, which were not suitable for someone with vision impairment. The Assistant Director of Nursing (ADON) acknowledged that these interventions were not resident-centered and did not cater to the resident's needs, highlighting a failure to develop a care plan that was beneficial and safe for the resident. Resident 78, who had cataracts and required bifocal glasses, did not have a care plan addressing his vision impairment, which could affect his quality of life and the meeting of his needs. Similarly, Resident 62, who had end-stage renal disease and other conditions, refused several medications on multiple occasions, yet there was no care plan to address this refusal. The ADON confirmed that a care plan should have been developed to manage the medication refusal, as it is standard practice to ensure proper care and avoid delays in necessary treatment.
Failure to Document Medication Refusal and Report Change in Condition
Penalty
Summary
The facility failed to meet professional standards of care for two residents, Resident 62 and Resident 142, as identified in a survey. For Resident 62, the facility did not document the resident's refusal of medications in the Progress Notes, nor did they educate the resident on the risks and benefits of refusing medications. Resident 62, who had diagnoses including end-stage renal disease, peripheral vascular disease, and diabetes mellitus, refused medications such as auryxia, clopidogrel, atorvastatin, and Rena Vite on multiple occasions in March 2025. The resident expressed a preference to take medications with dinner and reported that the nursing staff did not offer the medications at the appropriate time or provide an explanation for the delay. Interviews with the Licensed Vocational Nurse and the Assistant Director of Nursing confirmed that the standard practice of documenting medication refusals and educating the resident was not followed. Additionally, the facility failed to inform Resident 142's doctor of a change in the resident's condition, specifically the presence of brownish urine, which was noted on the Nurse's Dialysis Communication form. Resident 142, who was dependent on renal dialysis and had diabetes mellitus, reported brown urine and pain during urination to the nursing staff. However, the licensed nurse did not review the dialysis communication form or notify the physician of this change, which could indicate a potential urinary tract infection. The Assistant Director of Nursing acknowledged that the licensed nurses should have reviewed the dialysis nurse's comments and informed the doctor of the change in condition. The facility's policies and procedures, as well as job descriptions, emphasize the importance of documenting medication refusals, educating residents on medication compliance, and reporting changes in residents' conditions to physicians. The failure to adhere to these standards resulted in deficiencies in the care provided to Residents 62 and 142, potentially delaying necessary medical care.
Failure to Refer Resident for Ophthalmology Consultation
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 78, was referred to an ophthalmologist as recommended by an optometrist. Resident 78, who was admitted with diagnoses including diabetes mellitus and a left below-the-knee amputation, was found to have cataracts in both eyes during an optometry consultation. The optometrist recommended bifocal glasses and an ophthalmology referral due to the cataracts. However, the Social Services Director (SSD) was not aware of the need for this referral and did not review the consultation notes, resulting in a failure to make the necessary appointment. Interviews with the SSD and the Assistant Director of Nursing (ADON) revealed that the optometry consultation notes were supposed to be followed up by the SSD, who should have informed the nursing staff to obtain an order for the referral. The ADON emphasized the importance of timely follow-up on referrals to prevent further vision impairment. The facility's job description for the social services manager indicated that the SSD was responsible for referring residents to appropriate services when needed. The lack of follow-up on the ophthalmology referral delayed necessary treatment for Resident 78's cataracts.
Failure to Provide Appropriate Post-Dialysis Care
Penalty
Summary
The facility failed to provide appropriate post-dialysis care for a resident, identified as Resident 62, who required dialysis treatment. The deficiency occurred when the facility did not remove the pressure dressing from Resident 62's arteriovenous (AV) shunt site as ordered by the physician. The physician's order specified that the pressure dressing should be removed two hours after dialysis on designated days. However, observations and interviews revealed that the dressing was not removed until the following day, which was contrary to the care plan and physician's orders. Resident 62, who had diagnoses including end-stage renal disease, peripheral vascular disease, and diabetes mellitus, returned from dialysis with the pressure dressing still intact. The resident reported itching at the AV shunt site and confirmed that the dressing had not been changed after returning from dialysis. The Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) acknowledged the oversight, noting that the failure to remove the dressing could lead to complications such as clotting of the shunt, fluid overload, and electrolyte imbalance. The facility's policy on post-dialysis care was not followed, resulting in this deficiency.
Failure to Document Lorazepam Administration
Penalty
Summary
The facility failed to accurately account for and document the administration of lorazepam, a controlled medication, for a resident. The resident, who was admitted with diagnoses including seizure disorder, autistic disorder, and major depressive disorder, had an active order for lorazepam to be administered as needed for crying without apparent reason. The Medication Administration Record (MAR) indicated that the resident received three doses of lorazepam over two days. However, a discrepancy was found during a review of the Narcotic Count Sheet (NCS) and the bubble pack, revealing one missing nurse's signature and an incorrect count of tablets. During an interview, a Licensed Vocational Nurse (LVN) admitted to forgetting to sign the NCS after administering the medication, acknowledging it as a medication error and dangerous practice. The Assistant Director of Nursing (ADON) confirmed that the nurse should sign the MAR and NCS immediately after administration to ensure the narcotic count is correct and to avoid medication errors. The facility's policy on controlled substances requires immediate documentation of administration details, which was not followed in this instance, leading to the deficiency.
Medication Error Due to Unauthorized Change in Aspirin Form
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Licensed Vocational Nurse (LVN) administered a chewable aspirin tablet without a physician's order. During a medication pass observation, the LVN was stopped by a surveyor from administering a crushed mixture of aspirin chewable tablet and applesauce to the resident. The resident's active aspirin order indicated the administration of an 81 mg delayed-release (DR) tablet once daily for stroke prevention, which should not be crushed. The LVN admitted to changing the medication form without physician approval, mistakenly believing the chewable and DR forms were the same. The resident involved had a history of cerebral infarction, gastritis with bleeding, and gastroesophageal reflux disease (GERD). The resident's care plan highlighted the risk of bleeding or bruising related to anticoagulant therapy, specifically aspirin. The Assistant Director of Nursing (ADON) confirmed that the nurse should have clarified the order with the physician before changing the medication form, as the DR tablet was likely prescribed to minimize gastrointestinal risks. The facility's policy required medications to be administered according to the physician's written orders.
Infection Control Deficiencies in Nebulizer and Linen Handling
Penalty
Summary
The facility failed to implement proper infection control practices for two residents, leading to potential risks of infection. For Resident 33, the deficiency involved the improper handling of a nebulizer mask. The mask, which was used to deliver medication for respiratory conditions, was repeatedly observed placed directly on the nightstand surface without being stored in a plastic bag as required by the facility's infection control policy. This oversight was noted during multiple observations and interviews, where both the resident and staff acknowledged the improper storage of the nebulizer mask. The resident expressed concerns about the risk of infection and feelings of neglect due to the nurse's actions. In the case of Resident 62, the deficiency involved the improper handling of dirty clothes and linen. Observations revealed that dirty clothes and linen were left unattended on the resident's bed for extended periods. Despite the resident's preference for staff to clean the bed in his presence, the staff failed to remove the soiled items in a timely manner. Interviews with the resident and staff confirmed that the dirty clothes and linen were not properly managed, which was against the facility's infection control policy. The staff acknowledged the importance of removing soiled items to prevent infection and maintain resident dignity. The facility's infection control policies were not adhered to in both cases, as evidenced by the improper storage of medical equipment and the mishandling of soiled linen. The Infection Preventionist Nurse and other staff members recognized the deficiencies and the potential for infection due to these lapses in protocol. The facility's policies clearly outlined the need for proper storage and handling of items to prevent infection, yet these guidelines were not followed, leading to the identified deficiencies.
Failure to Conduct Weekly Skin IDT Meetings
Penalty
Summary
The facility failed to conduct weekly skin interdisciplinary team (IDT) meetings for a resident who developed redness on the left hip and left anterior iliac crest. This deficiency occurred between January 9, 2025, and February 27, 2027, for one of the six sampled residents. The resident, who was entirely dependent on staff for activities of daily living, had a history of dysphagia, cerebral infarction, hemiplegia, and pressure-induced deep tissue damage. Despite the facility's policy requiring weekly skin reviews and IDT meetings after any change in skin condition, no such meetings were conducted during the specified period. The Director of Nursing (DON) acknowledged that the normal practice was to conduct weekly skin IDT meetings and additional meetings whenever there was a change in the resident's skin condition. The DON confirmed that an IDT meeting should have been conducted after the resident developed skin redness on February 10, 2025. The facility's policy and procedure documents, revised in December 2023, also indicated the necessity of these meetings to monitor pressure injuries and document the collaboration in the resident's clinical record. The absence of these meetings had the potential to result in worsening skin impairments for the resident.
Room Size Deficiency in Multiple-Resident Rooms
Penalty
Summary
The facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. During a review of the facility's Client Accommodations Analysis form dated March 24, 2025, it was found that four rooms did not meet this requirement. The rooms measured 217, 232, 238, and 234 square feet, respectively, and each housed three residents. Despite the deficiency in room size, observations indicated that the rooms provided privacy with curtains and had enough space for bedside tables, dressers, and maneuverability for wheelchairs. Interviews and observations conducted on March 27, 2025, revealed that the residents in these rooms were comfortable and had sufficient space for personal property, nursing care, and treatments. The administrator confirmed the deficiency, acknowledging that the rooms did not meet the size requirement but emphasized that the residents had privacy, dignity, and safety. The California Department of Public Health recommended a room waiver, indicating an acknowledgment of the deficiency but no immediate corrective action was detailed in the report.
Failure to Timely Report Injury of Unknown Source and Investigation Results
Penalty
Summary
The facility failed to report an injury of unknown source within the required two-hour timeframe to the California Department of Public Health (CDPH) for a resident who sustained a fractured right wrist. The resident, who had diagnoses including dementia, cerebral infarction, and a psychotic disorder with delusions, was noted to have a swollen right wrist during a therapy session. The injury was later confirmed by x-ray to be an acute, mildly displaced fracture of the distal radial metaphysis and an acute fracture of the ulnar styloid. Despite these findings, there was no documented evidence that the injury was reported to CDPH as required. Additionally, the facility did not ensure that the results of its internal investigation into the injury were reported to CDPH within five working days of the incident. Interviews with staff and family revealed that the resident had been observed guarding his right wrist and complaining of pain prior to the x-ray, and that these concerns had been reported to nursing staff. The facility's investigation concluded that the injury occurred during an episode of erratic behavior, but the reporting to CDPH was delayed until after the surveyor's initial visit. The facility's own policies require immediate reporting of all alleged violations involving abuse, neglect, or injuries of unknown source, especially those resulting in serious bodily injury, and mandate that investigation results be submitted to the state agency within five working days. The failure to adhere to these policies and regulatory requirements resulted in delayed notification to CDPH and delayed investigation by the authorities.
Failure to Develop and Implement Care Plan for Behavioral and Medical Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident exhibiting erratic behaviors, including thrashing and swinging arms, and did not address the resident's behavioral risks in the care plan. Despite staff observations and reports of the resident's impulsive and potentially harmful actions, such as striking furniture, these behaviors were not formally documented or targeted in the resident's care plan. The Director of Nursing confirmed that no care plan was in place to address these specific behaviors, which could have contributed to improper care. Additionally, the facility did not follow its own policy and procedure regarding significant changes of condition. The resident was observed by staff and family members to be guarding his right wrist and complaining of pain over several days. Although these changes were reported to nursing staff, a formal change of condition assessment was not completed in a timely manner, and pain-relieving interventions were not provided. The registered nurse acknowledged that a change of condition assessment should have been performed and that care should have been provided, as the resident's pain could have worsened. The lack of a care plan for the resident's behavioral issues and the failure to implement the facility's significant change of condition policy resulted in the resident not receiving appropriate interventions. This ultimately led to the resident sustaining an acute, mildly displaced fracture of the distal radius and ulnar styloid, requiring transfer to a general acute care hospital for further evaluation and treatment.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for two residents, leading to a deficiency in accommodating their needs and preferences. During an observation and interview, it was found that Resident 3's call light was clipped to a curtain and not visible, which was confirmed by a CNA who stated that the call light should be within the resident's reach. Resident 3, who has a history of falls, diabetes, and hypertension, and requires supervision for activities of daily living, stated that they rely on the call light to request assistance from nurses. Similarly, Resident 4's call light was also found clipped to a curtain, out of reach. The resident, who has a history of falls and difficulty walking, expressed that they often cannot find the call light and instead go directly to the nurses for help. Both residents have the mental capacity to understand and make medical decisions, as indicated in their medical records. The facility's policy requires call lights to be within residents' reach, which was not adhered to in these cases.
Delayed Release of Medical Records Violates Resident Rights
Penalty
Summary
The facility failed to release medical records requested by a resident's legal representative within the 24-hour timeframe as stipulated in their policy and procedure on Residents Rights, Release of Information. The resident, who had been admitted and readmitted with diagnoses including dementia, cardiac pacemaker, and hypertension, had fluctuating capacity to understand and make medical decisions. Despite the resident's ability to make themselves understood and understand others, the facility did not provide the requested medical records in a timely manner, resulting in a violation of the resident's rights. The request for the resident's medical records was initially sent by a legal services office via fax and followed up multiple times via email. The Medical Records Director acknowledged the delay, stating that the request was sent to the facility's legal team, which approved the release, but the records were not sent to the legal services office until nine days later. The Director of Nursing emphasized the importance of timely release of medical records, acknowledging that it was unacceptable for the resident and their representative to wait for about a month for the records to be released. The facility's policy indicated that residents should have access to their records within 24 hours of a written or oral request, excluding weekends or holidays.
Failure to Ensure Safe Transfer Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) provided a two-person physical assist when using a Hoyer Lift to transfer the resident from a wheelchair to the bed. This resulted in the resident falling and sustaining a right distal femur fracture, which required surgical intervention. The resident was admitted to a general acute care hospital for an open reduction internal fixation surgery. The incident occurred when the CNA attempted to transfer the resident alone, despite the resident's care plan indicating the need for a two-person assist. During the transfer, the Hoyer lift sling broke, causing the resident to fall. The CNA admitted to not checking the sling for damage prior to use and acknowledged that assistance should have been sought. The facility's Director of Nursing confirmed that the CNA should have asked for help and that CNAs were responsible for inspecting the lift sling before use. Interviews with staff revealed that the facility's procedures for checking and maintaining the Hoyer lift slings were not followed. The laundry aid and maintenance supervisor were responsible for inspecting and replacing damaged slings, but records showed no entries for sling checks during the days leading up to the incident. The facility's policy required a safe environment free of accident hazards, but the failure to inspect and maintain equipment contributed to the resident's fall and injury.
Delayed Transfer to Hospital After Resident's Fall
Penalty
Summary
The facility failed to transfer a resident immediately to a general acute care hospital (GACH) after the resident experienced an unavoidable fall that resulted in a right distal femur fracture. The incident occurred when a Certified Nursing Assistant (CNA) was transferring the resident from a wheelchair to a bed using a Hoyer lift, and the sling broke, causing the resident to fall. Despite the resident reporting severe pain and an X-ray confirming an acute comminuted supracondylar fracture, the transfer to the hospital was delayed by 10 hours. The resident, who had been admitted to the facility with diagnoses including diabetes, hypertension, and muscle weakness, was totally dependent on staff for transfers. After the fall, the resident reported a pain level of 10 out of 10, and the facility's Director of Nursing (DON) was notified. An X-ray was ordered, and the results, received at 11:00 p.m., confirmed the fracture. However, the resident was not transferred to the GACH until the following morning, resulting in a significant delay in receiving necessary medical evaluation and treatment. Interviews with the resident, the responsible party, and the DON revealed that the facility did not provide an explanation for the delay in transfer. The facility's policy and procedure for significant changes in condition and fall management were reviewed, indicating that immediate attention was warranted in such circumstances. The DON acknowledged that the facility should not have waited longer than one hour to transfer the resident, and the delay placed the resident at risk for delayed care and treatment.
Failure to Provide Prescribed Restorative Nursing Exercises
Penalty
Summary
The facility failed to provide restorative nursing exercises as per physician orders for three residents, leading to a deficiency in care. Resident 1, diagnosed with hemiplegia and hemiparesis, was ordered to receive passive range of motion (PROM) exercises five times a week. However, documentation showed that these exercises were not consistently provided, with several days marked as not applicable or resident refused. Similarly, Resident 2, with end-stage renal disease and diabetes, was ordered active assisted range of motion exercises, but records indicated multiple days without documentation of these exercises being performed. Resident 5, also diagnosed with hemiplegia and hemiparesis, was ordered PROM exercises five times a week. The documentation for Resident 5 showed numerous days without evidence of exercises being conducted, with some days marked as not applicable or resident refused. Interviews with the residents revealed that they were not receiving the prescribed exercises as frequently as ordered, with Resident 5 stating they only received exercises once or twice a week. During interviews, the RNA staff and the Director of Nursing acknowledged the lack of adherence to the physician's orders for restorative exercises. The RNA staff mentioned that residents often refused the exercises, but there was no indication that refusals were consistently reported to the charge nurse. The facility's policy on restorative care emphasized providing services according to individual needs and desires, but the documentation and interviews indicated a failure to meet these standards.
Failure to Develop Care Plans for Residents with MASD
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans with measurable objectives, timeframes, and interventions for two residents who had moisture-associated skin damage (MASD). This deficiency was identified during a review of the records and interviews with staff. Resident 1, who had peripheral vascular disease and was dependent on renal dialysis, did not have a care plan for MASD despite receiving treatment for it. Similarly, Resident 3, who had peripheral vascular disease and diabetes mellitus, also lacked a care plan for MASD, even though treatment was being administered. Interviews with the Treatment Nurse, Licensed Vocational Nurse, MDS Nurse, and Director of Nursing revealed that the facility's policy required all skin issues, including MASD, to be care planned. The staff emphasized the importance of care plans in providing guidance for treatment and prevention of further skin breakdown. However, the absence of care plans for these residents meant that staff might not have been fully informed about the residents' conditions and the necessary interventions. The facility's policies on change of condition reporting and comprehensive resident-centered care planning were not followed, as evidenced by the lack of updated care plans for the residents with MASD. This oversight had the potential to negatively affect the delivery of skin treatments and the prevention of further skin breakdown for the affected residents.
Failure to Obtain Authorization and Notify Responsible Party Before Resident Discharge
Penalty
Summary
The facility failed to ensure a written or verbal authorization was obtained from the responsible party of a resident prior to the resident's discharge to another facility. This resulted in the resident's primary responsible person not being aware of the discharge. The resident, who had severe cognitive impairment and was unable to make decisions, was admitted with diagnoses including dysphagia and cognitive communication deficit. The admission record indicated that the resident's family member 1 (FM1) was the first emergency contact person, and family member 2 (FM2) was the second emergency contact person. However, the facility did not document when FM2 requested the resident to be transferred out of the facility, nor did they notify FM1 of the discharge. Interviews with the Social Services Director (SSD), Licensed Vocational Nurse (LVN) 1, and the Director of Nursing (DON) revealed that the facility's protocol was to notify the first emergency contact person listed in the admission record if a resident was unable to make decisions. The DON emphasized that documentation of any communication with the family regarding discharge was necessary to protect the resident. A review of the facility's policy and procedure indicated that for resident-initiated transfers or discharges, the resident or their representative must provide verbal or written notice of intent to leave, and this must be documented in the medical record. The failure to follow these procedures led to the deficiency noted in the report.
Failure to Develop Timely Care Plan for Stage III Pressure Ulcer
Penalty
Summary
The facility failed to develop an individualized person-centered care plan addressing a Stage III pressure ulcer for a resident. The resident was admitted with moisture-associated skin damage, which progressed to a Stage II and then a Stage III pressure ulcer. Despite the resident's high risk for pressure ulcers and the presence of a Stage III ulcer documented in the Treatment Administration Record and Wound Doctor Notes, the care plan was not developed until over a month after the pressure ulcer was discovered. This delay in care planning was confirmed by both the Treatment Nurse and the Director of Nursing during interviews. The resident's Minimum Data Set indicated impaired cognitive skills and complete dependence on staff for all activities of daily living. The resident was receiving various interventions for pressure injury, including a pressure-reducing device, nutrition, hydration interventions, and topical treatments. However, the care plan for the Stage III pressure ulcer was only created after a significant delay, which the Director of Nursing acknowledged as a failure to provide timely and necessary care. The facility's policy required the development of a comprehensive care plan upon the discovery of such conditions, which was not adhered to in this case.
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Nursing homes near Downey
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paramount Convalescent Hosp. | 1.2 mi | — | 24 | 0 |
| California Post-acute Care | 1.4 mi | — | 22 | 0 |
| Lynwood Post Acute Care Center | 1.4 mi | — | 34 | 0 |
| Granada Post Acute | 1.4 mi | — | 0 | 0 |
| Lakewood Healthcare Center | 1.8 mi | — | 42 | 0 |
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