Other·December 19, 2019

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 California Department of Public Health during the investigation of one Entity Reported Incident (ERI) during an abbreviated standard survey. ERI number: CA00659922 Representing the Department: Health Facilities Evaluator Nurse 36292. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written for ERI number CA00659922.

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 12/16/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced 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: I1D611 Facility ID: CA940000057 If continuation sheet 1 of 5 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: _______________ 555128 (X3) DATE SURVEY COMPLETED 11/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY COMMUNITY HEALTH CENTER 8425 Iowa St Downey, CA 90241 (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 by: Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 1) was free from physical abuse from Certified Nursing Assistant 1 (CNA 1). CNA 1 grabbed Resident 1's hair and forcefully transferred Resident 1 to the shower chair. As a result, CNA 1 violated Resident 1's right to be free from physical abuse. Findings: On 10/24/19, an unannounced visit was conducted to the facility to investigate an Entity Reported Incident (ERI) of an allegation of employee to resident abuse. A review of Resident 1's Admission Record (Face Sheet) indicated the facility re-admitted Resident 1 on 11/2/18, with diagnoses including Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills) and dementia (long-term, gradual decrease in the ability to think and remember, severe enough to affect a person's daily functioning). A review of Resident 1's Minimum Data Set (MDS - standardized assessment and carescreening tool), dated 8/23/19, indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. Resident 1 required extensive assistance with bed mobility, transfers, eating, and personal hygiene. Resident 1 was always incontinent (unable to control) of bowel and bladder functions. A review of Resident 1's Care Plan dated 10/16/19 indicated Resident 1 had altered behavior with tendency to become physically FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I1D611 Facility ID: CA940000057 If continuation sheet 2 of 5 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: _______________ 555128 (X3) DATE SURVEY COMPLETED 11/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY COMMUNITY HEALTH CENTER 8425 Iowa St Downey, CA 90241 (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 aggressive towards staff related to dementia, as evidenced by striking out, hitting staff during care and episodes of crying. The interventions included providing physical and verbal cues to alleviate anxiety; giving positive feedback, assisting verbalization of source of agitation, and encourage seeking out of staff member when agitated; when the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation and if response is aggressive, and staff to walk calmly away and approach later. A review of Resident 1's Care Plan dated 3/8/18 indicated Resident 1 had communication problem related to language barrier, dementia and speaking a language other than English. The interventions included allowing adequate time to respond, repeat as necessary, do not rush, and request clarification from the resident to ensure understanding; providing translator as necessary to communicate with the resident. Spanish speaking. A review of the facility's Conclusion of the Investigation dated 11/7/19, indicated, CNA 1 was terminated on 10/25/19 for proceeding to put Resident 1 in the shower chair when Resident 1 resisted. CNA 1 did not remove herself from the situation and did not seek help with the situation. A review of the Progress Note for Resident 1 dated 10/16/19 and timed at 8:28 p.m., indicated Resident 1 only spoke a foreign language, became aggressive with staff at times, and had episodes of striking out behavior and hitting staff during care with episodes of crying. Certified Nursing Assistant 1 (CNA 1) was giving care to Resident 1 and the Licensed Vocational Nurse 1 (LVN 1) noticed CNA 1 grabbing Resident 1's and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I1D611 Facility ID: CA940000057 If continuation sheet 3 of 5 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: _______________ 555128 (X3) DATE SURVEY COMPLETED 11/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY COMMUNITY HEALTH CENTER 8425 Iowa St Downey, CA 90241 (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 releasing it quickly, while trying to place Resident 1 on the shower chair. A body assessment was done and Resident 1's skin revealed as intact, no discoloration to forehead or facial area and the resident denied pain. A review of the SBAR Communication Form dated 10/16/19 indicated suspicious abuse on 10/16/19. The form indicated the witness saw CNA 1 pulled Resident 1's hair. On 10/23/19 at 1:30 p.m., during an interview, LVN 1 stated on 10/16/19 at 9:30 a.m., she observed CNA 1 and Resident 1 fighting. Resident 1 was throwing broken pieces of an incontinent brief to CNA 1. CNA 1 was forcefully trying to put Resident 1 on a shower chair and grabbed Resident 1 by the hair. Resident 1 was heard saying something in a foreign language to CNA 1. CNA 1 proceeded to give a shower to Resident 1. LVN 1 informed LVN 2 (charge nurse) to check Resident 1 because Resident 1 was heard crying. On 10/23/19, at 1:40 p.m., during an interview, LVN 2 (the Charge Nurse on 10/16/19) stated he talked to CNA 1, and removed CNA 1 from caring for Resident 1. LVN 2 stated Resident 1 did not want to be changed and be showered by CNA 1. LVN 2 found torn pieces of the incontinent brief on the floor in Resident 1's room. On 10/23/19 at 2:15 p.m., during an interview, Registered Nurse (RN 1) stated, CNA 1 should have asked an interpreter to translate Resident 1's concerns and seek for help accordingly. RN 1 stated CNA 1 failed to respect Resident 1's right to refuse care. On 10/24/19 at 10:35 a.m., during an interview, CNA 1 stated on 10/16/19 at 8:20 a.m., it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I1D611 Facility ID: CA940000057 If continuation sheet 4 of 5 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: _______________ 555128 (X3) DATE SURVEY COMPLETED 11/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOWNEY COMMUNITY HEALTH CENTER 8425 Iowa St Downey, CA 90241 (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 not Resident 1's shower day but Resident 1 needed to be changed because she was wet. CNA 1 did not speak Resident 1's language and could not explain to Resident 1 what procedure she was trying to do. Resident 1 became combative and aggressive towards CNA 1. Resident 1 stood up and ripped up the diaper in half. CNA 1 got Resident 1 in the shower chair by herself with no assistance. According to CNA 1, Resident 1 was grabbing, hitting, twisting, pitching extremely hard, so CNA 1 placed one hand on the side of Resident 1's head so she would not spit on CNA 1 and to let go off CNA 1's arm. On 10/24/19, at 11:30 a.m., during an interview, the Director of Staff Development (DSD) stated CNA 1 should have sought help in explaining the care to Resident 1 before removing Resident 1's pants and incontinent brief. A review of the facility's policy titled, "Abuse Prevention- Agitated and Combative Residents," dated 12/2018, indicated that staff will identify and remove sources of the problem, if known. Staff will approach resident calmly in a reassuring manner. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I1D611 Facility ID: CA940000057 If continuation sheet 5 of 5