Other·September 28, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health of a Complaint investigation during an Abbreviated Standard Survey. Complaint number: CA00694624 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 36526 The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for CA006694624

F580 SS=H Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 08/27/2020 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 1 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement a resident's plan of care and the facility's policy and procedures (P/P) to report to the physician several Change of Condition ([COC] a sudden clinically FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 2 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE deviation from a resident's baseline in physical, cognitive [thought process], behavioral, or functional domains) for one of three sampled residents (Resident 1). Resident 1, who exhibited several COCs that included refusal to eat and drink adequate amount of fluid, high and low blood sugar levels, weight loss and abnormal laboratory results, were not reported to the physician as stipulated Resident 1's care plan and the facility's P/P (crossed referenced to F692). These deficient practices resulted in the physician not being able to accurately assess, diagnose and provide adequate care and treatment for Resident 1. Resident 1 was found unresponsive (loss of consciousness), pulseless (with no pulse [heartbeat]) and not breathing, after 14 days of poor fluid and food consumption and was pronounced deceased. Findings: A review of the general acute care hospital (GACH) Transfer Report, dated 1/26/2020 and timed at 11:45 a.m., indicated Resident 1 to be transfer to a Skill Nursing Facility (SNF) for Intravenous ([IV] into the vein) antibiotic (medication to treat infections) therapy for treatment of sepsis (a potentially lifethreatening condition caused by the body's response to an infection) and urinary tract infection ([UTI] an infection in any part of the urinary system: kidneys, uterus, bladder and urethra). The transfer report indicated Resident 1 had history of infection in the urine with urine retention (unable to void voluntarily). The report indicated to not remove Resident 1's indwelling urinary catheter (thin flexible plastic tube inserted into the bladder to provide continuous urinary drainage). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 3 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on 1/26/2020. Resident 1's diagnoses included encephalopathy (brain damage), sepsis (infection in the blood), UTI, dementia (loss of memory, language, problemsolving and other thinking abilities that are severe enough to interfere with daily life) and diabetes mellitus (high blood sugar in the blood). A review of Resident 1's history and physical (H/P), dated 2/6/2020 and timed at 4:30 p.m. indicated Resident 1 did not have the mental capacity to understand and make medical decisions. The H/P indicated Resident 1 was a Full code (if a resident's heart stopped beating and/or stopped breathing, all resuscitation procedures such as chest compressions, intubation, and CPR would be provided to keep the resident alive. The H/P indicated Resident 1's sepsis had clinically improved and Resident 1 was not expected to die within six (6) months. A review of Resident 1's care plan titled, "Nutritional Problem or Potential Nutritional Problem related to Diabetes (high blood sugar levels)," created on 1/26/2020 indicated the resident will not experience weight loss/gain of three (3) pounds and will not experience signs and symptoms of malnutrition. The staffs' interventions included to offer meal replacement if the resident ate less than 50 percent (%), monitor and report to physician as needed for any signs and symptoms of decreased appetite, unexpected wight loss, monitor laboratory results, and monitor intake. A review of Resident 1's Nutritional/Hydration Risk Evaluation, dated 1/26/2020 indicated Resident 1 indicated a score of 10. The Risk FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 4 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Evaluation indicated any scores above 10 required the staff to initiate a protocol immediately and documented in the care plan (no other specifications were indicated). The Risk Evaluation indicated Resident 1 had a fluid intake of 1000 to 2000 milliliters (ml) a day [sic]. A review of Resident 1's Activities of Daily Living (ADL) report indicated Resident 1 consumed the following fluid: On 1/26/2020 consumed 120 ml On 1/27/2020 through 1/31/2020 (5 days), no fluids were documented as received the staff documented N/A (which indicated not applicable) On 2/1/2020 consumed 360 ml On 2/2/2020 consumed N/A On 2/3/2020 consumed 220 ml On 2/4/2020 consumed 120 ml On 2/5/2020 consumed 600 ml On 2/6/2020 consumed 100 ml On 2/7/2020 consumed 410 ml On 2/8/2020 consumed 120 ml On 2/9/2020 consumed 600 ml On 2/10/2020 consumed 503 ml On 2/11/2020 consumed 120 ml On 2/12/2020 consumed N/A A review of Resident 1's Activities of Daily Living (ADL) report indicated Resident 1 consumed the following amount of food percentage (%): On 1/26/2020 Resident 1 consumed 0% On 1/27/2020 consumed 76-100% of dinner On 1/28/2020 through 1/29/2020 consumed 0% On 1/30/2020 consumed 76-100% of dinner On 1/31/2020 consumed 25% of alternative dinner On 2/2/2020 consumed 76-100% of dinner FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 5 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 2/4/2020 consumed 76-100% of dinner On 2/6/2020 consumed 26-50% of dinner On 2/7/2020 consumed 51-75% of breakfast On 2/8/2020 consumed 0-25% of breakfast On 2/11/2020 consumed 0% consumed A review of Resident 1's Weight and Vitals Summary sheets, dated 1/27/2020 through 2/11/2020 indicated Resident 1 lost seven (7) pounds, 6.5 percent (%) of weight in 15 days as follow: 1/27/2020, 108 pounds, a day after admission 2/4/2020, 106 pounds 2/11/2020, 101 pounds A review of Resident 1's laboratory results collected on 1/28/2020 and received on 1/28/2020 at 11:12 a.m., indicated sodium was 137 (helps maintain normal blood pressure, supports the work of nerves and muscles, and regulates body's fluid balance [normal reference range [NRR 135-145 milliEquivalents per liter [mEq/L]), Blood Urea Nitrogen was 14 ([BUN] test measures the amount of nitrogen in the blood that comes from the waste product [NRR 7.0-24.0]), potassium was 4.3 ([NRR is 3.5 to 5.0 millimoles] electrolyte that the body needs to work properly by helping the nerves and muscles to contract) and creatinine was 0.6 (supplies energy to muscles) were within normal range. A review of Resident 1's laboratory results collected on 2/6/2020 at 3:20 a.m. and received on 2/6/2020 at 7:03 a.m., indicated the sodium was elevated at 156 mmol/L, BUN/Creatinine was elevated at 42.2 mg/dl, potassium was borderline low at 3.9 mEq/L, and the white blood cells ([WBC] cells of the immune system that protect the body against both infectious disease and foreign invaders) were high at 16.68 There was no documented evidence to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 6 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicate Resident 1's abnormal lab results were reported to the physician. A review of Resident 1's ADLs report from 1/26/2020 through 2/12/2020 indicated Resident 1 had no urine out-put documented by the CNAs. A review of Resident 1's physician order, dated 1/26/2020 indicated to administer 100 units/ml of regular Humulin (intermediate-acting insulin with a slower onset of action than regular insulin and a longer duration of activity up to 24 hours) insulin injected subcutaneously (under the skin) as per sliding scale: for blood sugars of 401 to 999 administer 12 units of insulin and call physician. A review of Resident 1's Order Summary Report with an order date of 1/30/2020 indicated to report blood sugar checks to the physician if above 400 milligrams (mg)/deciliters (dl) or below 70 mg/dl before meals and at bedtime. A review of Resident 1's Weight and Vitals Summary sheet for the month of 2/2020 indicated on 2/3/2020 at 1:20 p.m. Resident 1 had a high blood sugar level of 475 mg/dl. The summary sheet did not indicate insulin (protein hormone used as a medication to treat high blood sugar) was administered and the blood sugar levels rechecked 15 minutes after as indicated per physician orders and sliding scale (progressive increase scale in pre-meal or nighttime insulin doses needed daily). A review of Resident 1's Licensed Progress Note and the Medication Administration Record (MAR), dated 2/3/2020 did not indicate insulin was administered, physician notified, and blood sugar rechecked. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 7 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's physician order dated 1/26/2020 indicated to administer Glucagon (medication use to increase blood sugar levels) 1 milligram intramuscularly (into the muscle) for hypoglycemia (low blood sugar) of 70. The order indicated to administer and wait 15 minutes and recheck blood sugar and notify physician immediately. A review of Resident 1's Weight and Vitals Summary sheet for the month of 2/2020 indicated Resident 1 had a low blood sugar of 49 mg/dl (normal reference range [NRR]70-99 mg/dl) on 2/8/2020 at 3:50 p.m. and at 4 p.m. it was 122 mg/dl. There was no documented evidence to indicate Resident 1's physician was notified of the low blood sugar. A review of Resident 1's Licensed Progress Notes and the MAR, dated 2/8/2020 did not indicate Resident 1 received Glucagon as indicated per physician orders. There was no documented evidence to indicate Resident 1's physician was notified of the COC. A review of Resident 1's Licensed Progress Note, dated 1/26/2020 through 2/12/2020 there was no documentation the physician was notified Resident 1 was not eating, refusing to drink and losing weight. A review of Resident 1's Vital Signs (clinical measurement of pulse rate, temperature, respiration rate, and blood pressure the indicate the state of a resident's essential body function) for 2/12/2020, indicated no vital signs were taken for the morning of 2/12/2020. A review of a "Prehospital Care Report Summary," documented by the 911 paramedics emergency services, dated 2/12/2020 indicated a call was received from the facility at 10:01 a.m., and the paramedics FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 8 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were assisting Resident 1 at 10:08 a.m. The report indicated Resident 1 was pulseless, unresponsive, with pupils fix and dilated (pupils may become fixed and dilated before the heart and respiration stops, or it may occur after), pale, cold, and apneic (stop breathing). The resident had a blood pressure of 0 ([B/P] 90/60139/89 normal reference ranges [NRR]), respirations of 0 (NRR is 12-20 breaths per minutes [bpm]), pulse of 0 beats per minute 0 ([bpm] NRR 60-100 bpm) and oxygen saturation (oxygen in the blood) at 0 percent (%) room air ([NRR] 96-100%). The Report Summary indicated Resident 1 was pronounced deceased at 10:10 a.m. with no CPR attempted by the paramedics. On 6/29/2020 at 4:44 p.m., during a telephone interview, Resident 1's Responsible Party (RP) stated the facility neglected (failure to care for properly) the resident, did not provide adequate care and did not notify him of Resident 1's declining condition. Resident 1's RP stated while crying, "The facility killed her." The RP stated the facility was not feeding or providing fluid to Resident 1. On 7/27/2020 at 3:07 p.m., during a telephone interview, CNA 2 stated on 2/12/2020 CNA 1 notified LVN 2 Resident 1 was not feeling well and was refusing to eat but LVN 2 did not check on Resident 1. CNA 2 stated multiple Licensed Nurses were notified Resident 1 had several days of not feeling well and not eating but they would say it was fine. CNA 2 stated it was not the first time the CNAs reported to LVN 2 of a resident's change in condition (COC) and LVN 2 not assessing the residents. CNA 2 stated the supervisors had been made aware of LVN 2's disregarding to attend when resident's COC was reported by the CNAs. On 7/27/2020 at 3:38 p.m., during a telephone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 9 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interview, LVN 2 stated not remembering going into Resident 1's room after she was notified by CNA 1 of the resident not eating. LVN 2 stated, "I did rounds upon the start of my shift, after that, I did not go back to see the residents." LVN 2 stated not being able to go see Resident 1 because she was passing medications. On 8/10/2020 at 11:55 a.m., during a telephone interview, physician (Physician 1) stated not being informed by the facility's staff of Resident 1 having changes in conditions. On 8/10/2020 at 2:33 p.m., during a concurrent interview and record review of Resident 1's MARs, Licensed Progress Notes, Vital Signs Sheets and the Order Summary, in the presence of the MRD (medical records director), the DON stated there was no documentation of Physician 1 being notified of Resident 1's elevated blood sugar of 475 mg/dl on 2/3/2020 and the administration of insulin, as indicated per the resident's care plan and physician's orders. The DON stated the facility's staff should notify the physician every time the resident has a COC. On 8/11/2020 at 9:31 a.m., during a telephone interview, Resident 1's Nurse Practitioner ([NP] nurse qualified to treat certain medical conditions without the direct supervision of a doctor) stated the facility did not notify her regarding Resident 1 not eating, drinking or of the high/low blood sugars levels. The NP stated the facility had orders to notify the physician when Resident 1 had abnormal blood sugar levels and the facility's staff should have contacted her if the resident was having a COC. The NP stated Resident 1 was not a hospice (end of life care) resident and was not expected to die soon. On 8/12/2020 at 6:08 p.m., during a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 10 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interview and review of Resident 1's MARs, Licensed Progress Notes, Vital Signs sheet and the Order Summary, in the presence of the MRD, the DON stated and confirmed the facility's staff failed to notify Resident 1's physician and document the following: a. Resident 1's seven (7) pound weight loss from 1/27/2020 through 2/11/2020 (15 days). b. Resident 1's blood sugar levels of 475 mg/dl on 2/3/2020 without receiving insulin and rechecking 15 minutes after blood sugar levels as indicated per physician orders and resident's care plan. c. Resident 1's low blood sugar level of 49 mg/dl on 2/8/2020 without documentation and administration of glucagon as ordered by the physician. d. Resident 1's refusal to eat and drink fluids. On 8/13/2020 at 5:11 p.m., during a concurrent interview and record review, the DON stated the facility's staff was not documenting Resident 1's urine output. The DON stated Resident 1 was admitted to the facility with an indwelling urinary catheter (thin flexible tube that collects urine from the bladder and leads to a drainage bag) and staff members should have been monitoring the urine output. On 8/14/2020 at 1:10 p.m., during a telephone interview, the NP stated the facility has protocols for catheter output and they should have followed it. The NP stated per nursing standards of practice, the staff should have documented the urine output to make sure Resident 1 was having output since she had chronic urinary retention. The NP stated the staff should have monitored the urine output for sediment (particles that make urine look FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 11 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cloudy), color and amount and report to physician. A review of the facility's undated policy and procedures (P/P) titled, "Change in Condition," indicated all COCs would be communicated to the resident's physician. The P/P indicated the staff would notify the physician of the resident's status as soon as possible before, during or after the COC and document the information in the clinical chart. The P/P indicated any sudden or serious change in physical or mental status will be communicated to the physician with request for a physician visit promptly. The P/P indicated a comprehensive care plan would be completed. A review of the facility's undated P/P titled, "Intake and Output," indicated the facility staff was to maintain a record of the urine output to monitor residents' adequate fluid balance. The policy indicated at the end of each 24-hour cycle, the staff would document on the resident's chart the total input and output.

F692 SS=G Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 08/27/2020 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 12 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure nutritional and hydration (the absorption of or combination with water) care and services were provided to prevent weight loss and dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake) for one of three sampled residents (Resident 1). Resident 1, who required assistance from the staff with eating and drinking fluids, was not provided enough fluid and food as per the resident's plan of care and the facility's policy and procedure. This deficient practice of the staff not ensuring Resident 1 received adequate food and fluids resulted in Resident 1 losing 6.75 percent (%) of body weight in 15 days and had abnormal laboratory results due to inadequate hydration. Resident 1's death certificate indicated the resident expired on 2/12/2020 at 10:10 a.m., with the immediate cause of death listed as cardiopulmonary failure (sudden loss of blood flow) and sepsis (infection in the blood). Findings: A review of Resident 1's general acute care hospital (GACH) Transfer Report, dated 1/26/2020 and timed at 11:45 a.m. indicated for Resident 1 to be transfer to a Skill Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 13 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Facility (SNF) for Intravenous ([IV] into the vein) antibiotic (medication to treat infections) therapy for treatment of sepsis (infection in the blood) and urinary tract infection ([UTI] an infection in any part of the urinary system: kidneys, uterus, bladder and urethra). The transfer report indicated Resident 1 had history of infection in the urine with urine retention (unable to void voluntarily). The report indicated to not remove Resident 1's indwelling catheter (thin flexible plastic tube inserted into the bladder to provide continuous urinary drainage). A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on 1/26/2020. Resident 1's diagnoses included encephalopathy (brain damage), sepsis, UTI, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and diabetes mellitus (high blood sugar in the blood). A review of Resident 1's history and physical (H/P), dated 2/6/2020 and timed at 4:30 p.m. indicated Resident 1 did not have the mental capacity to understand and make medical decisions. The H/P indicated Resident 1's sepsis had clinically improved and to continue monitoring. The H/P indicated Resident 1, "was not expected to die within the next six (6) months." A review of Resident 1's care plan titled, "Nutritional Problem or Potential Nutritional Problem related to Diabetes (high blood sugar levels)," created on 1/26/2020 indicated the resident will not experience weight loss/gain of three (3) pounds and will not experience signs and symptoms of malnutrition. The staffs' interventions included to offer meal replacement if the resident ate less than 50 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 14 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE percent (%), monitor and report to physician as needed for any signs and symptoms of decreased appetite, unexpected wight loss, monitor laboratory results, and monitor intake. A review of Resident 1's Nutritional/Hydration Risk Evaluation, dated 1/26/2020 indicated Resident 1 indicated a score of 10. The Risk Evaluation indicated any scores above 10 required the staff to initiate a protocol immediately and documented in the care plan (no other specifications were indicated). The Risk Evaluation indicated Resident 1 had a fluid intake of 1000 to 2000 milliliters (ml) a day [sic]. A review of Resident 1's Activities of Daily Living (ADL) report indicated Resident 1 consumed the following: On 1/26/2020 consumed 120 ml On 1/27/2020 through 1/31/2020 (5 days), no fluids were documented as received the staff documented N/A (which indicated not applicable) On 2/1/2020 consumed 360 ml On 2/2/2020 consumed N/A On 2/3/2020 consumed 220 ml On 2/4/2020 consumed 120 ml On 2/5/2020 consumed 600 ml On 2/6/2020 consumed 100 ml On 2/7/2020 consumed 410 ml On 2/8/2020 consumed 120 ml On 2/9/2020 consumed 600 ml On 2/10/2020 consumed 503 ml On 2/11/2020 consumed 120 ml On 2/12/2020 consumed N/A A review of Resident 1's Activities of Daily Living (ADL) report indicated Resident 1 consumed the following amount of food percentage (%): FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 15 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 1/26/2020 Resident 1 consumed 0% On 1/27/2020 consumed 76-100% of dinner On 1/28/2020 through 1/29/2020 consumed 0% On 1/30/2020 consumed 76-100% of dinner On 1/31/2020 consumed 25% of alternative dinner On 2/2/2020 consumed 76-100% of dinner On 2/4/2020 consumed 76-100% of dinner On 2/6/2020 consumed 26-50% of dinner On 2/7/2020 consumed 51-75% of breakfast On 2/8/2020 consumed 0-25% of breakfast On 2/11/2020 consumed 0% consumed A review of Resident 1's Weight and Vitals Summary sheets, dated 1/27/2020 through 2/11/2020 indicated Resident 1 lost seven (7) pounds, 6.5 percent (%) of weight in 15 days as follow: 1/27/2020, 108 pounds, a day after admission 2/4/2020, 106 pounds 2/11/2020, 101 pounds A review of Resident 1's laboratory results collected on 1/28/2020 and received on 1/27/2020 at 11:12 a.m., indicated sodium was 137 (helps maintain normal blood pressure, supports the work of nerves and muscles, and regulates body's fluid balance [normal reference range [NRR 135-145 milliEquivalents per liter [mEq/L]), Blood Urea Nitrogen was 14 ([BUN] test measures the amount of nitrogen in the blood that comes from the waste product [NRR 7.0-24.0]), potassium was 4.3 ([NRR is 3.5 to 5.0 millimoles] electrolyte that the body needs to work properly by helping the nerves and muscles to contract) and creatinine was 0.6 (supplies energy to muscles) were within normal range. A review of Resident 1's laboratory results collected on 2/6/2020 at 3:20 a.m. and received FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 16 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on 2/6/2020 at 7:03 a.m., indicated the sodium was elevated at 156 mmol/L, BUN/Creatinine was elevated at 42.2 mg/dl, potassium was borderline low at 3.9 mEq/L, and the white blood cells ([WBC] cells of the immune system that protect the body against both infectious disease and foreign invaders) were high at 16.68 There was no documented evidence to indicate Resident 1's abnormal lab results were reported to the physician. A review of Resident 1's Licensed Progress Note, dated 1/26/2020 through 2/12/2020 there was no documentation the physician and/or NP were notified Resident 1 was not eating, refusing to drink and losing weight. A review of Resident 1's Licensed Progress Note, dated 2/12/2020 and timed at 5:16 p.m. indicated at 8 a.m., Resident 1 was in bed awake and refused to eat. On 6/29/2020 at 4:44 p.m., during a telephone interview, Resident 1's Responsible Party (RP) stated the facility's staff neglected (failure to care for properly) the resident. The RP stated the staff did not provide adequate care, which included feeding and providing fluid to Resident 1 and did not notify him of Resident 1's declining condition and he attempted to meet and/or communicate with the staff on several occasions to no avail. The RP stated on one occasion, while visiting the facility the staff was giving Resident 1 the wrong diet of regular texture food when she was supposed to have a pureed diet (consists of foods with a smooth pudding-like consistency, without chunks or different textures). The RP stated Resident 1 was not receiving the IV medications that were ordered and when he would complain nothing was done. The RP stated while crying, "the facility killed her." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 17 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 7/27/2020 at 3:07 p.m., during a telephone interview, Certified Nurse Assistant 2 (CNA 2) stated on 2/12/2020 CNA 1 notified Licensed Vocational Nurse 2 (LVN 2) Resident 1 was not feeling well and was refusing to eat but LVN 2 did not check on Resident 1. CNA 2 stated multiple Licensed Nurses were notified Resident 1 had several days not feeling well and not eating but they would say it was fine. CNA 2 stated it was not the first time the CNAs reported to LVN 2 of a resident's change in condition (COC) and LVN 2 not assessing the residents. On 7/27/2020 at 3:38 p.m., during a telephone interview, LVN 2 stated not remembering going into Resident 1's room after she was notified by CNA 1 of the resident not eating. LVN 2 stated, "I did rounds upon the start of my shift, after that, did not go back to see the residents." LVN 2 stated not being able to go see Resident 1 because she was passing medications. On 8/10/2020 at 1:52 p.m., during an interview and record review, the Medical Records Director (MRD) stated there was no notes from the Registered Dietitian ([RD] trained nutrition professional) visit. On 8/11/2020 at 9:31 a.m., during a telephone interview, Resident 1's Nurse Practitioner ([NP] nurse qualified to treat certain medical conditions without the direct supervision of a doctor) stated the facility did notify her regarding Resident 1 not eating or drinking. The NP stated the facility had orders to notify the physician when Resident 1 had a COC. The NP stated it was assumed the facility staff would contact her if a resident was having a COC. The NP stated Resident was not a hospice (end of life care) resident and was not expected to die soon. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 18 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055519 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY POST ACUTE 13007 Paramount Blvd Downey, CA 90242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 8/12/2020 at 6:08 p.m., during a concurrent interview and record review of the Medication Administration Records (MAR), Licensed Progress Notes, Vital Signs sheet and the Order Summary from 1/26/2020 through 2/12/2020 and in the presence of MRD, the Director of Nursing (DON) stated and confirmed the facility staff failed to notify Resident 1's physician (Physician 1) and document in the clinical chart Resident 1's seven (7) pound weight loss from 1/27/2020 through 2/11/2020 (15 days) and resident's refusal to eat and drink fluids. The DON stated the staff should had been notifying the physician of Resident 1's COCs. A review of the undated facility's policy and procedure titled "Hydration," indicated it was the policy of the facility to provide each resident with enough fluid intake to maintain proper hydration and health. The policy indicated abnormal laboratory values (elevated hemoglobin and hematrocrit, potassium, chloride, sodium, albumin, blood urea nitrogen (BUN), or urine specific gravity) were indicative of dehydration and fluids will be offered with each resident contact. The policy indicated the staff's interventions included to offer fluids at a minimum of every two (2) hours for the dependent resident, unless contraindicated and for the residents who refuse fluids, have propensity for dehydration or evidence a need for increased fluids, will be placed on a fixed schedule for monitoring intake. Results will be appropriately recorded on the Intake and Output form. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KRQ11 Facility ID: CA940000017 If continuation sheet 19 of 19