Downey Community Health Center

In the surveyor’s words

From the most serious findings on record at Downey Community Health Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 28, 2021

  Based on observation, interview, and record review, the facility failed to ensure one of three residents were protected and free from abuse (Resident 1). Resident 1 was struck in the face with a water-filled pitcher by Resident 2. Resident 2, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 being physically assaulted by Resident 2 and sustaining a laceration (deep cut) to the left cheek, requiring wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: a.During a review of Resident 1's Admission Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Jul 2, 2026

  Based on observation, interview, and record review, the facility failed to ensure the following food safety and food preparation practices was observed by failing to ensure:1. Foods were stored and/or prepared under sanitary conditions.2. Proper sanitation and food handling practices were maintained to prevent outbreak or foodborne illness.3.Frozen vegetables were dated and labeled to prevent the potential for foodborne illness.4. One bag of hot dog buns, a container of black pepper, tarragon leaves, curry powder, and basil were labeled with an open date.5. Dietary Aide 1 (DA 1) properly explained thermometer calibration and did not reuse the same alcohol pad for multiple probe sanitizations during tray line observation. […]

• No harm, potential for more than minimal, widespreadF882Apr 10, 2025

  Based on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IPN) completed ten hours of continuing education in the field of Infection Prevention and Control on an annual basis. This deficient practice had the potential to result in the IPN being unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control. Findings: During a concurrent interview and record review on 4/8/2025 at 10:18 a.m., with the IPN, the IPN's Nursing Home Infection Preventionist Training Court Certification, dated 11/14/2023, was reviewed. […]

• No harm, potential for more than minimal, widespreadF943Apr 10, 2025

  Based on interview and record review, the facility failed to ensure the training provided to all facility staff, specifically related to abuse reporting, was consistent with federal reporting guidelines. This failure had the potential to affect all facility residents due to late reporting of abuse, and delayed investigations by the State Agency. Findings: During a concurrent interview and record review, on 4/10/2025 at 11:27 a.m., with the Director of Staff Development (DSD), the facility's lesson plan titled Abuse Definition, Prevention, Reporting, and Investigation, dated 3/30/2025 to 4/6/2025, was reviewed. The DSD stated the lesson plan indicated allegations of abuse were to be reported to the State Agency within 24 hours, unless the allegation involved injury. […]

• No harm, potential for more than minimal, widespreadF880Apr 4, 2024

  Based on observation, interview, and record review, the facility did not implement infection practices as outlined in the facility's infection control program when the facility did not perform the following: 1. Implement Enhanced Barrier Precautions ([EBP]-the use of gown and gloves for specific care activities that involve a high chance of the spread of infection), as mandated, to limit the spread of infections. 2. Ensure the Treatment Nurse wore proper personal protective equipment ([PPE] -a barrier precaution which includes use of gloves, gown, mask, face shield, shoe covers, head covers, respirators, etc. when you anticipate contact with blood or body fluids or other communicable toxins or agents) during Resident 88's wound treatment. 3. […]