Health inspection·March 24, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: Residents Affected - Few 1. Report an injury of unknown source within 2 hours, to the California Department of Public Health (CDPH), for 1 of 4 residents (Resident 1), who had a fractured (broken bone) right wrist on 3/3/2025. 2. Ensure the result of all investigations were reported to CDPH within five (5) working days of the incident. These failures resulted in the delayed investigation by CDPH and placed the resident at risk for further injuries. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE].Resident 1 ' s diagnoses included dementia (a progressive state of decline in mental abilities), cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to the death of brain cells) and psychotic disorder with delusions (a mental health condition characterized by persistent and false beliefs (delusions) that are not based on reality). During a review of Resident 1 ' s Minimum Dat Set (MDS a federally mandated resident assessment tool) dated 1/3/2025, the MDS indicated Resident 1 had clear speech, was able to understand and had the ability to express ideas and wants. The MDS indicated Resident 1 required supervision or touching assistance from staff with eating, oral hygiene and personal hygiene. The MDS indicated Resident 1 required set-up assistance with sit to stand. The MDS indicated Resident 1 required supervision or touching assistance with chair/bed-to-chair transfer, toilet transfer and walking 10 feet to 150 feet. During a review of Resident 1 ' s Change of Condition (COC) Evaluation, dated 3/3/2025 at 11:37 a.m., the COC indicated Resident 1 had a swollen right wrist. The COC indicated the resident was guarding (protecting) the right hand. The COC indicated the primary physician was notified of the swollen right wrist and ordered an x-ray (process of taking pictures of tissues and structures inside the body for diagnosis and treatment). During a review of Resident 1 ' s right wrist x-ray result dated 3/3/2025 at 10:35 p.m., the result indicated an acute mildly displaced fracture on the distal (outer) radial metaphysis (a broken bone Page 1 of 5 055519 055519 03/24/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0609 in the radius bone near the wrist), and an acute fracture of the ulnar styloid (bony area near the wrist). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s progress notes dated, 3/3/2025 at 11:37 a.m. to 3/3/2025 at 11 p.m., the progress notes did not indicate documented evidence of an investigation conducted regarding Resident 1's right wrist fracture and documentation that injury was reported to CDPH. Residents Affected - Few During a review of the facility ' s investigation report titled, Wrist Injury Investigation, dated 3/4/2025 (time not indicated), the report indicated on 3/3/2025, during Resident 1 ' s therapy session, a therapist (unidentified) noted Resident 1 ' s right wrist was swollen and was guarding his right hand. The report indicated, during the facility investigation, interviews were conducted with therapists and Certified Nursing Assistants (CNA) that were directly involved in Resident 1 ' s care. The report indicated, due to Resident 1 ' s erratic (unpredictable) behavior, he was placed in a room with 2 other residents with one CNA caring for three residents and received care 24 hours a day. The report indicated, Resident 1 ' s injury occurred because the resident stroked (hit) a hard object during one of his erratic (unpredictable) behavior episodes (dates not specified). During an observation and interview on 3/12/2025 at 10:07 a.m. with Resident 1, Resident 1 had a soft brace (used to provide support, protect, and potentially immobilize the wrist and hand, helping to relieve pain, reduce inflammation, and facilitate healing) on the right forearm to wrist area. Resident 1 stated he fell out of bed 2-3 days ago (unable to specify day/date) and hurt his wrist. Resident 1 stated a staff (unable to recall name) assisted him off the floor. During an interview on 3/12/2025 at 11:30 a.m. with CNA 4, CNA 4 stated on 2/28/2025, Resident 1 was being assisted with feeding, repositioning, diaper changes and was not aware if resident fell to hurt the right wrist. During a telephone interview on 3/12/2025 at 4:50 p.m., with Family Member 1 (FM1), FM1 stated he visited Resident 1 on 2/28/2025 and Resident 1 was fine. The FM1 stated before Resident 1 left the facility for out on pass to a family event on 3/1/2025, he noticed Resident 1 was guarding his right wrist and informed a licensed nurse (not identified). The FM1 stated at the family event, Resident 1 continued to guard his right arm and hand, and refused to shake hands with relatives. During a telephone interview on 3/18/2025 at 4:32 p.m., with the Director of Nursing (DON), the DON stated Resident 1 ' s Wrist Injury Investigation report dated 3/4/2025, was not reported and sent to CDPH until after the Surveyor ' s initial visit on 3/12/2025. The DON stated failure to report a serious injury may delay the resident ' s necessary care. During a telephone interview on 3/19/2025 at 9:30 a.m., with the Administrator (ADM), the Admin stated the Wrist Injury Investigation report dated 3/4/2025 was not sent to CDPH until after the Surveyor ' s initial visit on 3/12/2025 because the facility did not suspect abuse, neglect or injury of unknown origin. The Admin stated Resident 1 injured himself. During a telephone interview on 3/20/2025 at 1:29 p.m., with CNA 3, CNA 3 stated on 3/1/2025, at the beginning of her shift (7 a.m. to 3 p.m.), Resident 1 was guarding his right arm and complained of pain. CNA 3 stated, she then reported Resident 1 ' s condition to the Charge Nurse. CNA 3 stated the Charge Nurse went to Resident 1 ' s room and observed Resident 1 guarding his right arm, complained of pain. CNA 3 stated Resident 1 told the Charge Nurse he fell in the bathroom last night (2/28/2025, time not known). 055519 Page 2 of 5 055519 03/24/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility ' s policy and procedure (P&P) titled, Abuse: Prevention of and Prohibition Against, the P&P indicated it is the facility ' s policy that each resident has the right to be free from abuse, neglect and the facility provide oversight and monitoring to ensure that its staff deliver care and services in a way that promote the rights of the residents to be free from abuse or neglect. The P&P indicated in some cases, abuse is not directly observed, understanding the resident outcomes of abuse can assist in identifying whether abuse has occurred. The P&P indicated possible indicators included bruises, skin tears and injuries of unknown source, extensive injuries or injuries in an unusual location. The P&P indicated, allegations of abuse, neglect should be reported to the SA in the applicable timeframe, as per this policy and applicable regulations. During a review of the facility ' s P&P titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, dated 12/2023, the P&P indicated all alleged violations involving abuse or neglect, including injuries of unknown source, should be reported immediately but, not later than 2 hours after the allegation is made, if the events that caused the allegation results in serious bodily injury. The P&P indicated; the facility should ensure the results of all investigations are reported to the SA within five (5) working days of the incident. 055519 Page 3 of 5 055519 03/24/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Few 1. Develop a care plan for for 1 of 4 residents, Resident 1, who had behavior of thrashing (swinging) arms and with erratic (unpredictable) behaviors. 2. Implement its policy and procedure (P&P), titled Significant Change of Condition, Response, for Resident 1, who was guarding (protecting) his right wrist and had complained of pain. These failures resulted in the lack of safe interventions and poor-quality care, resulting in the resident ' s transfer to a general acute care hospital (GACH) on 3/3/2025. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1 ' s diagnoses included dementia (a progressive state of decline in mental abilities), cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to the death of brain cells) and psychotic disorder with delusions (a mental health condition characterized by persistent and false beliefs (delusions) that are not based on reality). During a review of Resident 1 ' s Minimum Dat Set (MDS a federally mandated resident assessment tool) dated 1/3/2025, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and was able to understand. The MDS indicated Resident 1 requiredsupervision or touching assistance from staff with eating, oral hygiene and personal hygiene. The MDS indicated Resident 1 required set-up assistance with sit to stand. The MDS indicated Resident 1 required supervision or touching assistance with chair/bed-to-chair transfer, toilet transfer and walking 10 feet to 150 feet. During a review of Resident 1 ' s Change of Condition (COC) Evaluation, dated 3/3/2025 at 11:37 a.m., the COC indicated Resident 1 had a swollen right wrist. The COC indicated the resident was guarding (protecting) the right hand. The COC indicated the primary physician was notified of the swollen right wrist and ordered an x-ray (process of taking pictures of tissues and structures inside the body for diagnosis and treatment). During a review of Resident 1 ' s right wrist x-ray result dated 3/3/2025, the result indicated an acute mildly displaced fracture on the distal (outer) radial metaphysis (a broken bone in the radius bone near the wrist), and an acute fracture of the ulnar styloid (bony area near the wrist). During a review of Resident 1 ' s GACH emergency department (ED) records dated 3/3/2025 at 11:48 p.m., the ED records indicated Resident 1 was seen due to upper extremity pain and right wrist pain, with diagnosis of distal radius and ulna fracture. During an observation and interview on 3/12/2025 at 10:07 a.m. with Resident 1, Resident 1 had a soft brace (used to provide support, protect, and potentially immobilize the wrist and hand, helping to relieve pain, reduce inflammation, and facilitate healing) on the right forearm to wrist area. Resident 1 stated he fell out of bed 2-3 days ago (unable to specify day/date) and hurt his wrist. 055519 Page 4 of 5 055519 03/24/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0656 Resident 1 stated a staff (unable to recall name) assisted him off the floor. Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 3/12/2025 at 4:50 p.m., with Family Member 1 (FM1), FM1 stated he visited Resident 1 on 2/28/2025 and Resident 1 was fine. The FM1 stated before Resident 1 left the facility for out on pass to a family event on 3/1/2025, he noticed Resident 1 was guarding his right wrist and informed a licensed nurse (not identified). The FM1 stated at the family event, Resident 1 continued to guard his right arm and hand, and refused to shake hands with relatives. Residents Affected - Few During a telephone interview on 3/18/2024 at 4:03 p.m., with CNA 1, CNA 1 stated 1 she was assigned to Resident 1 several weeks prior to the wrist incident (3/3/2025). CNA 1 stated Resident 1 could get irritated and impulsive and used his arms to keep staff away. CNA 1 stated Resident 1 would thrash his arms and strike a furniture while thrashing. CNA 1 stated she reported the episodes of thrashing and striking of the furniture to the Charge Nurse. During a telephone interview on 3/18/2025 at 4:32 p.m. with the Director of Nursing (DON), the DON stated Resident 1 did not have a care plan related to resident ' s behavior of thrashing of the arms or striking a furniture. The DON stated Resident 1 had dementia and failure to target specific behaviors may lead to improper care. During a telephone interview on 3/20/2025 at 1:29 p.m., with CNA 3, CNA 3 stated on 3/1/2025, at the beginning of her shift (7 a.m. to 3 p.m.), Resident 1 was guarding his right arm and complained of pain. CNA 3 stated, she then reported Resident 1 ' s condition to the Charge Nurse. CNA 3 stated the Charge Nurse went to Resident 1 ' s room and observed Resident 1 guarding his right arm, complained of pain. CNA 3 stated Resident 1 told the Charge Nurse he fell in the bathroom last night (2/28/2025, time not known). During a telephone interview on 3/20/2025 at 2:55 p.m. with Registered Nurse (RN 1), RN 1 stated when she went to Resident 1 ' s room on 3/1/2025 and 3/2/2025, she observed Resident 1 was guarding his right arm. RN 1 stated a COC was not done because the hand and arm did not look swollen. RN 1 stated pain medication or any pain-relieving interventions were not provided to Resident 1. RN 1 stated she should have documented a COC and provided care because Resident 1 ' s pain could have gotten worse. During a review of the facility ' s policy and procedure (P&P) titled, Significant Change of Condition, Response, dated 12/2023, the P&P indicated, if at anytime a team member recognized a resident changed in condition, the nurse should perform and document assessment of the resident and identify the need for interventions, considering implementation of existing orders or nursing interventions or through communication with the resident ' s provider using SBAR (Situation, Background, Assessment, Recommendation- is a verbal or written communication tool that helps provide essential, concise information) or similar process to obtain new orders or interventions. During a review of the facility ' s P&P titled, Comprehensive Person-Centered Care Planning, dated 12/2023, the P&P indicated the interdisciplinary team (IDT) should develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 055519 Page 5 of 5