Health inspection·September 3, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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)). Residents Affected - Some 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. Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of enterostomy (a surgical procedure to create an opening [called a stoma] through the stomach wall into the small or large intestine to allow for intestines to drain) malfunction (failure to work properly). During a review of Resident 4 ' s History and Physical (H&P) dated 8/5/2024, the H&P indicated that Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4 ' s Minimum Data Set ( [MDS] a standardized assessment and care screening tool), dated 8/25/2024, the MDS indicated Resident 4 was dependent (staff does all the effort, resident does none of the effort to complete the activity or, the assistance of two or more helps is required for the resident to complete the activity) with Activities of Daily Living (ADLs) such as showering/bathing, upper and lower body dressing, and lying to sitting on side of bed. During a review of Resident 4 ' s physician ' s order dated 9/3/2024, the order indicated to place Resident 4 on EPB d/t (due to) the presence of J-tube ([jejunostomy tube] a soft plastic tube placed through the skin of the abdomen to deliver food and medicine). During a concurrent observation and interview on 9/3/2024 at 9:37 a.m. with the Infection Prevention Nurse (IPN) outside of Resident 4 ' s room, IPN stated Resident 4 required EBP and the resident ' s entrance to the room did not have signage to indicate Resident 4 was on EBP. During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with a diagnoses of hyperosmolality (a condition in which the body (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 2 Event ID: 555128 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 555128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Downey Community Health Center 8425 Iowa Street Downey, CA 90241 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)