Downey Post Acute

In the surveyor’s words

From the most serious findings on record at Downey Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 29, 2021

  Based on interview and record review, the facility's staff failed to ensure a resident who exhibited high elopement (an act of leaving a safe area or safe premises unsupervised and undetected without permission) risk was provided with close supervision (an intervention and a means of mitigating accident risk) to prevent elopement for one of six sampled residents (Resident 1). Resident 1, who had wandering behavior (aimlessly move about within the building or grounds without appreciation of their personal safety) and was preoccupied with leaving the facility was not supervised and eloped from the facility twice within three hours (5 a.m. and 8:25 a.m.) on the same day (8/10/2021) after the facility failed to: 1. […]

• Actual harm, isolatedF689Aug 13, 2024

  Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from a wheelchair to the bed. This deficient practice caused Resident 1 to fall, sustain a right distal femur fracture (thigh broken bone), was admitted to a general acute care hospital (GACH), and had an open reduction internal fixation ([ORIF]-surgical procedure to stabilize and heal a broken bone). […]

• Actual harm, isolatedF689Jun 28, 2021

  Based on interview and record review, the facility failed to provide close supervision while a resident was ambulating (walking) as per the resident's plan of care and the facility's policy and procedure for one of three sampled residents (Resident 1). Resident 1, who had a recent fracture (broken bone), weakness, and risks for falling, was allowed to walk to the restroom without the assistance of the staff, use of a gait belt (device use for residents who have mobility problems to assist in stabilization and fall prevention by caregivers prior to moving residents) and/or use of Close Guard Assist ([CGA] to assist a resident and have one or two hands on the resident's body) as per Resident 1's care plan, felt dizzy and fell to the floor. […]

• No harm, potential for more than minimal, widespreadF812May 7, 2026

  Based on observation, interview, and record review, the facility failed to ensure food safety and food preparation practices was observed for all 95 residents. The facility failed to:1. Maintain cold food items at safe temperatures when glasses of milk and flan measured 50 to 61 degrees Fahrenheit ( F, a scale of temperature).2. Ensure staff did not wear a beaded bracelet during trayline service.3. Ensure one bottle of Martinelli's Sparkling Cider was labeled with the date received.These deficient practices had the potential to allow bacterial growth in potentially hazardous foods (PHFs- foods that require strict time and temperature control to prevent the growth of harmful bacteria or the formation of toxins) and increased the risk for food borne illness (a disease caused by consuming… […]

• No harm, potential for more than minimal, widespreadF761Mar 21, 2024

  Based on observation, interview, and record review, the facility failed to securely store discontinued controlled medications (medications regulated under federal law) in a locked drawer that was inaccessible by residents, visitors, and staff for one of one resident (Resident 46). This deficient practice had the potential to result in the unsafe access of medications by residents, staff, and visitors that could lead to adverse reactions due to accidental ingestion of unnecessary medication and the increased risk of drug diversion (when medications are obtained or used illegally). […]