Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure the resident, who underwent an open
reduction internal fixation ([ORIF] a surgical procedure that puts pieces of a broken bone into place using
screws, plates, sutures, or rods) surgery of the right ankle fracture (break in the bone), did not have the
surgical wound infected with exposed surgical hardware (pins, plates, or screws used to help fix a broken
bone, torn tendon, or to correct an abnormality in a bone) for one of three sampled residents (Resident 1).
The facility failed to:
Residents Affected - Few
1. Ensure treatment nurses (TN 1 and TN 2) followed Resident 1's orthopedic surgeon's treatment orders to
stop using an antibiotic ointment (a substance used on the skin to soothe or heal wounds) on Resident 1's
right medical ankle and to use a Betadine (a solution used to prevent infection in minor cuts, scrapes, and
burns) soaked gauze treatment to Resident 1's right ankle starting on 2/7/2024. TN 1 and TN 2 continued to
apply ointment to Resident 1's surgical wound from 2/7/2024 to 2/10/2024 (three days).
2. Ensure TN 1 and TN 2 followed Resident 1's Care Plan dated 1/19/2024 and 2/1/2024 to notify Resident
1's physician and/or Resident 1's orthopedic surgeon when Resident 1's surgical hardware was observed
being exposed through Resident 1's right ankle surgical site on 2/10/2024.
3. Ensure TN 1 documented a Change of Condition (COC-communication tool use to share information
about resident) when she identified for the first time Resident 1's surgical hardware was visible through the
resident's right ankle surgical incision (a cut that is made in skin during a surgery) on 2/10/2024.
4. Ensure TN 1 notified Resident 1's physician and orthopedic surgeon (a doctor who specializes in the
prevention, diagnosis, and treatment of disorders of the bones, joints, ligaments, tendons, and muscles)
when identified Resident 1's surgical hardware became visibly exposed through the resident's surgical
incision on a right ankle on 2/10/2024.
5. Ensure TN 2 notified Resident 1's physician and orthopedic surgeon when first noted Resident 1's
surgical hardware became visibly exposed through the resident's surgical incision on a right ankle on
2/20/2024.
These deficient practices resulted in Resident 1's right ankle surgical incision becoming infected and
Resident 1's transfer to a General Acute Care Hospital (GACH 1) where Resident 1 underwent a surgical
procedure to remove infected hardware with irrigation and debridement (washout and removal of dead,
infected, or contaminated tissue) of the infected wound and placement of a wound vacuum (a vacuum
device that promotes healing by gently pulling fluid from the wound over time, reducing
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
056446
Printed: 05/15/2026
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
056446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paramount Convalescent Hosp.
8558 East Rosecrans Avenue
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 0684
swelling, cleaning the wound and removing bacteria).
Level of Harm - Actual harm
Findings:
Residents Affected - Few
During a review of Resident 1's Change in Condition (COC) dated 12/08/2024, the COC indicated Resident
1 used a shower chair to climb out of a bathroom window and was found sitting on the ground outside of
the facility under the window holding her right ankle and grimacing from pain. The COC indicated Resident
1's physician was notified, and the physician ordered for Resident 1 to be transferred to GACH 2 for further
evaluation.
During a review of GACH 2's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the GACH
2 on 12/08/2024 with a diagnosis of a right tibia (the inner and typically larger of the two bones between the
knee and the ankle) and fibula (the outer and usually smaller of the two bones between the knee and the
ankle) fracture.
During a review of Resident 1's Discharge Summary from GACH 2 dated 1/18/2024, the Discharge
Summary indicated on 12/9/2023 Resident 1 ORIF surgery of the right ankle. The Discharge Summary
indicated Resident 1 was discharged from GACH 2 on 1/18/2024.
During a review of Resident 1's admission Record (Face Sheet) to the facility, the Face Sheet indicated
Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses
including a history of falling and a displaced comminuted (type of broken bone where the bone snaps into
two or more parts and moves so that the two ends are not lined up straight) fracture of the shaft of the right
fibula and right tibia.
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening
tool) dated 1/22/2024, the MDS indicated Resident 1's cognitive (thinking and reasoning) skills for daily
decision-making were moderately impaired. The MDS indicated Resident 1 required moderate to maximum
assistance from staff to complete most activities of daily living ([ADLs] eating, drinking, toileting, and
dressing).
During a review of Resident 1's Physician's Order dated 1/19/2024, the Physician's Order indicated to
cleanse Resident 1's right medial (toward the middle or center) ankle with normal saline ([NS] a non-toxic
solution that does not damage healing tissues), pat dry, apply betadine then cover with a dry island
dressing (a dressing that is ideal for the treatment of wounds with light drainage) daily and as needed.
During a review of Resident 1's Care Plan dated 1/19/2024, the Care Plan indicated Resident 1 had a
potential/actual impairment of the skin integrity to the surgical site on her right medial ankle. The Care Plan
indicated Resident 1 had sutures (row of stitches holding together the edges of a wound or surgical
incision) to her right medial ankle and was at continued risk for skin breakdown related to her fragile skin
and infection. Under this Care Plan a goal was for Resident 1 to have no complications through the next
review date (1/27/2024). The Care Plan's interventions included reporting declines in skin integrity to
Resident 1's physician.
During a review of Resident 1's COC note dated 2/1/2024, the COC note indicated Resident 1's surgical
wound on the medial ankle had a moderate amount of pus (thick yellowish or greenish liquid produced from
an infected tissue), redness, swelling and warmth. The COC note indicated Resident 1's surgical wound
was cleansed with NS, following application of Betadine (a solution that kills germs to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056446
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
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
056446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paramount Convalescent Hosp.
8558 East Rosecrans Avenue
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 0684
Level of Harm - Actual harm
Residents Affected - Few
prevent infection) and Mupirocin ointment (an antibiotic ointment used to treat bacterial skin infections)
according to the wound physician's recommendation. The COC note indicated Resident 1's primary
physician was notified of the COC.
During a review of Resident 1's Care Plan dated 2/1/2024, the Care Plan indicated Resident 1 had
drainage coming from the surgical wound site on the right ankle surgical site. Under this Care Plan the goal
for Resident 1 was to be free from any complications related to the surgical site on the right ankle. The Care
Plan's interventions included to notify the physician regarding any Resident 1's COC.
During a review of Resident 1's Physician's Order dated 2/6/2024, the Physician's Order indicated to apply
Mupirocin to Resident 1's right medial suture/wound every day shift, cleanse the wound with NS, pat dry,
apply Bactroban (an antibiotic ointment used to treat skin infections) then cover with an abdominal ([ABD] a
pad used to absorb discharges from the abdominal and other heavily draining wounds) pad dressing and
wrap with a Kerlix (hypoallergenic gauze rolls that provides fast-wicking [quickly moving fluid to the fabric's
outer surface] action, superior aeration (circulation of air), and excellent absorbency).
During a review of Resident 1's orthopedic surgeon Progress Note dated 2/7/2024, the Progress Note
indicated the orthopedic surgeon ordered a Betadine-soaked gauze, no ointment, to apply to Resident 1's
right ankle medial incision, every two to three days.
During a review of Resident 1's Nursing Progress Notes dated 2/10/2024 and timed at 9:17 a.m., the
Nursing Progress Notes indicated a hardware was visible in Resident 1's right lower leg.
During a review of Resident 1's Skin and Wound Evaluation dated 2/13/2024, the Skin and Wound
Evaluation indicated the hardware was visible in Resident 1's wound bed on the right ankle and the section
that indicated if Resident 1's physician was notified was left blank.
During a review of the Wound Physician's Consult Note dated 2/13/2024, the Wound Physician's Consult
Note indicated Bactroban, and a dry dressing were applied to Resident 1's surgical wound on a right ankle.
The Physician's Wound Consult Note indicated there was exposed hardware at the distal (a part of the
body that is farther away from the center of the body than another part) end of Resident 1's surgical wound
on the right ankle.
During a review of Resident 1's Treatment Record dated 2/2024, the Treatment Record indicated the
following:
1. From 2/7/2024 - 2/10/2024 Mupirocin and Bactroban was applied to Resident 1's right ankle medial
suture/wound daily (when order from orthopedic surgeon on 2/7/2024 indicated no ointment to be used).
2. There was no documentation that Resident 1's right ankle medial suture/wound was treated with a
Betadine-soaked gauze every two to three days as ordered on 2/7/2024.
During a review of Resident 1's Physician Orders dated 2/7/2024, the Physician's Order indicated Resident
1 had a follow up appointment with the orthopedic surgeon on 2/21/2024 at 9:45 a.m.
During a review of Resident 1's orthopedic surgeon Progress Note, dated 2/21/2024, the Progress
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056446
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
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
056446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paramount Convalescent Hosp.
8558 East Rosecrans Avenue
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 0684
Level of Harm - Actual harm
Note indicated there was no wet to dry (Betadine-soaked gauze) dressing done at the facility, Resident 1's
surgical incision was noted with drainage (fluid) and an exposed screw at the surgical incision site on a
right ankle. The orthopedic surgeon Progress Note indicated Resident 1 was referred to the emergency
room for intravenous ([IV] in the vein) antibiotics and a Wound Care Consult for an exposed screw.
Residents Affected - Few
During a review of Resident 1's Nursing Progress Notes dated 2/21/2024 and timed at 1:22 p.m., the notes
indicated Resident 1 went to orthopedic surgeon appointment and returned with a new order to transfer
Resident 1 to the emergency room (ER) due to infected right tibia with exposed hardware.
During a review of Resident 1's Physician's Order, dated 2/21/2024 the Physician's Order indicated to
transfer Resident 1 to a GACH due to an infected right tibia with exposed hardware.
During a review of GACH 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to GACH 1 on
2/22/2024 with diagnoses including a right ankle surgical wound infection with exposed orthopedic
hardware.
During a review of GACH 1's History and Physical (H&P) dated 2/22/2024, the H&P indicated during the
physical exam of Resident 1's right ankle, there was a two centimeter ([cm] a unit of measurement) wound
in length with an exposed screw (part of the hardware) on Resident 1's right medial malleolus (the inside of
the ankle formed by the tibia).
During a review of Resident 1's Orthopedic Medicine Progress Note dated 2/24/2024, the Orthopedic
Medicine Progress Note indicated Resident 1's right lower extremity hardware was removed, the wound
was irrigated and debrided (the process of removing dead skin and foreign material from a wound), closed
and a wound vacuum was placed in the wound.
During a review of GACH 1's Discharge Order, dated 2/26/2024, GACH 1's Discharge Orders indicated to
leave the dressing to the right ankle in place until follow up appointment with orthopedic surgeon in one to
two weeks.
During an observation of Resident 1 on 2/29/2024 at 12:15 p.m., at the facility, Resident 1 was observed in
her room with a small wound vacuum machine attached to the resident's right ankle with a cannister at the
foot of her bed.
During an interview on 2/29/2024 at 1:30 p.m., and a subsequent interview on the same day at 3:30 p.m.,
Treatment Nurse 2 (TN 2) stated Resident 1's right medial ankle surgical wound was treated with Mupirocin
from 2/7/2024 until 2/10/2024. TN 2 stated when she (TN 2) was treating Resident 1's wound on 2/20/2024,
she could see the top of a metal button that looked like the top of a screw, on Resident 1's right medial
lower leg surgical incision. TN 2 stated she was not sure if the metal hardware was supposed to be visible
through the incision site, but the incision did not look normal because there was no skin covering the
hardware. TN 2 stated she did not notify Resident 1's physician or the orthopedic surgeon that the
hardware was visible, and stated she did not create a COC form and could offer no explanation why. TN 2
stated if there was no skin covering Resident 1's wound to protect it, the wound could get infected.
During an interview on 2/29/2024 at 2:35 p.m., and a subsequent interview on 3/1/2024 at 2:22 p.m., TN 1
stated on 2/10/2024 she noticed hardware was visible in Resident 1's right ankle surgical wound. TN 1
stated she reported to the wound doctor that the hardware in Resident 1's surgical incision
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056446
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
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
056446
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paramount Convalescent Hosp.
8558 East Rosecrans Avenue
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 0684
Level of Harm - Actual harm
Residents Affected - Few
was visible, and he (the wound doctor) did not provide any new orders for treatment of the visible hardware.
TN 1 stated she did not notify the orthopedic surgeon on 2/10/2024 when she noticed the visible hardware
because Resident 1 had a follow up appointment with the orthopedic surgeon in a few days on 2/21/2024,
(11 days after the hardware was noticed in Resident 1's wound) and she thought the surgeon could
evaluate it then. TN 1 stated she should have notified the orthopedic surgeon about the visible hardware in
Resident 1's surgical wound incision on 2/10/2024 when she first noticed it and documented what she saw
as a COC. TN 1 stated she overlooked treating Resident 1's wound with Betadine-soaked gauze and she
should have stopped using the ointments (Mupirocin and Bactroban) on Resident 1's incision site, per the
orthopedic surgeon's order on 2/7/2024. TN 1 stated the physician's orders should have been carried out as
the orders were written and the resident's physician should be called if clarification of the order was
needed.
During an interview on 3/1/2024 at 4:11 p.m., the Director of Nursing (DON) stated if there was a COC to
resident's skin, the nurse should have notified Resident 1's physician and documented that change on a
COC form. The DON stated visible hardware was a COC, but she was not sure if Resident 1's physician or
the orthopedic surgeon were notified. The DON stated if hardware was visible through Resident 1's incision,
that meant the incision was open and there was a higher chance of infection to occur. The DON stated
properly transcribing and implementing physician orders helps ensure residents receive proper treatment to
promote healing and prevent an infection.
During a review of the facility's policy and procedure (P/P) titled, Notification of Changes, dated 12/2022,
the P/P indicated the facility must consult with the resident's physician when there is a significant change in
the resident's physical condition which may include clinical complications, circumstances that require a
need to alter treatment.
During a review of the facility's P/P titled Provision of Physician Ordered Services, dated 12/2022, the P/P
indicated qualified nursing personnel will administer therapeutic treatments as ordered by the physician.
During a review of the facility's Job Description for a Treatment Nurse dated 2003, the Job Description
indicated the job functions of the treatment nurse include examining the resident's records and charts and
discriminate between normal and abnormal findings to refer the resident to a physician for evaluation and
supervision. The treatment nurse's job function included providing assessments and diagnostic services to
the residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056446
If continuation sheet
Page 5 of 5
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the March 1, 2024 survey of PARAMOUNT CONVALESCENT HOSP.?
This was a inspection survey of PARAMOUNT CONVALESCENT HOSP. on March 1, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PARAMOUNT CONVALESCENT HOSP. on March 1, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.