Deficiency Records for Downey Community Health Center
Updated as of April 01, 2018
This is not the most recent data for Downey Community Health Center. For the most recent information, click here.
A list of the most recent deficiencies for Downey Community Health Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-17 | 2018-02-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-08 | 2018-02-09 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2018-01-08 | 2018-02-09 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-01-08 | 2018-02-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-01-08 | 2018-02-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-01-08 | 2018-02-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-01-08 | 2018-02-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-01-08 | 2018-02-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-01-08 | 2018-02-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-08 | 2018-02-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-01-08 | 2018-02-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-01-08 | 2018-02-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-08 | 2018-02-09 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-01-08 | 2018-02-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-01-08 | 2018-02-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-01-08 | 2018-02-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-01-08 | 2018-02-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2018-01-08 | 2018-02-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-01-08 | 2018-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-08 | 2018-02-09 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2018-01-08 | 2018-02-09 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-12-05 | 2018-01-04 | Y |
| Tell the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2017-12-27 | 2018-01-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-15 | 2017-07-11 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-06-17 | 2017-07-10 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-17 | 2017-07-10 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-06-28 | 2017-07-05 | Y |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-06-16 | 2017-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-16 | 2017-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-19 | 2017-06-23 | Y |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-12-19 | 2017-04-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-12-19 | 2017-04-05 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-12-19 | 2017-04-05 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-12-19 | 2017-04-05 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-12-19 | 2017-04-05 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-19 | 2017-04-05 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-12-19 | 2017-04-05 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-19 | 2017-04-05 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-19 | 2017-04-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-12-19 | 2017-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-19 | 2017-04-05 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2016-12-19 | 2017-02-16 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-12-19 | 2017-02-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-12-19 | 2017-02-16 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-12-19 | 2017-02-16 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-12-19 | 2017-02-16 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-12-19 | 2017-02-16 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-12-19 | 2017-02-16 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-12-19 | 2017-02-16 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2016-12-19 | 2017-02-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2017-01-18 | 2017-02-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2016-12-19 | 2017-01-14 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-11-11 | 2016-11-23 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-11-11 | 2016-11-23 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2016-11-11 | 2016-11-23 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-11-10 | 2016-11-21 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-11-10 | 2016-11-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2015-10-15 | 2015-12-28 | Y |
| Properly maintained smoke detectors. | Fire Safety | 2015-09-25 | 2015-10-14 | N |
| Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2015-09-25 | 2015-10-14 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2015-09-25 | 2015-10-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2015-09-25 | 2015-10-13 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2015-09-25 | 2015-10-13 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-09-25 | 2015-10-13 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2015-09-25 | 2015-10-13 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2015-09-25 | 2015-10-13 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-09-25 | 2015-10-13 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2015-09-25 | 2015-10-13 | N |
