Imperial Crest Health Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 2 sampled residents (Resident 2) was received shower as scheduled. This failure resulted in a poor quality care as evidenced by very poor grooming state, oily hair and presence of dandruff on the resident's hair, and the potential to affect the resident's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its Policy and Procedure (P/P) titled, Sharps Disposal which indicated to remove and replace Sharps Disposible containers when 75% to 80% full, in 1 of 2 shower rooms (shower room [ROOM NUMBER]). This failure had the potential to cause injuries, accidents and infections to residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to: Implement Resident 1's care plan titled, Incontinence which indicated interventions of assisting with toileting needs and/or provide incontinence (inability to control the flow of urine from the bladder or the escape of stool from the rectum) care after incontinent episodes. Follow the physician orders to monitor and document Resident 1's output (all liquids that leave the resident's body to monitor for issues such as kidney complications) in milliliters (mls- measurement of volume) every shift for 30 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitary food storage and preparation practices were maintained in the kitchen, by failing to:Ensure one container of Italian dressing was labeled with an opened date and/or use-by date. Maintain cold food items at safe temperatures when three-bean salads measured 57 to 66 degrees Fahrenheit ( F, a scale of temperature) during meal service. Ensure bowls of vanilla mousse were properly immersed in an iced-holding bin or storage, to maintain a safe, cold holding temperatures of 41 F and below during tray line pre-service handling. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eleven residents (Resident 49) observed during medication administration (MedPass) was administered Humalog insulin (a fast-acting prescription medication used to lower blood sugar [BS] in people with diabetes- a chronic condition in which the body either does not produce enough insulin [a hormone that removes excess sugar from the blood] or cannot use insulin effectively, resulting in high levels of blood sugar) within 15 minutes of a meal and injection site rotated after each injection, as ordered and in accordance with manufacturer's specifications. This deficient practice increased the risk of Resident 49 experiencing harmful effects from uncontrolled blood sugar, which could lead to dizziness, confusion, unconsciousness, coma, and hospitalization. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 22) was provided interpreter to ensure the language used was understood. This deficient practice resulted in the resident not understanding instructions and had the potential to violate respect and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive care plans were developed and implemented for five (5) of 5 sampled residents (Residents 59, 1, 22, 50 and 92), by failing to ensure a comprehensive care plan was developed and implemented for:Resident 59's peripheral intravenous (IV) catheter (a thin, flexible tube inserted into a peripheral vein [small vein] to administer IV fluids and medications). Resident 1's heparin (blood thinner medicine) medication. Resident 22's influenza vaccine (shots to prevent infections) refusal and a care plan to address the resident's psychosocial needs identified in the comprehensive assessment. Resident 50 and Resident 92, who refused to wear the facility's identification (ID) bands. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure care plans for two of ten residents (Resident 41 and Resident 58) were reviewed and updated quarterly as indicated in the facility's policy and procedures (P&P) titled, Comprehensive Person-Centered Care Plans. This failure had the potential to affect the residents' care and interventions to address the problems will not be implemented.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure effective communication services and language assistance were provided to one of five sampled residents (Resident 22). This deficient practice had the potential to prevent accurate communication between Resident 22 and facility staff, resulting in unmet needs, delayed intervention, and increased risk for resident harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order was obtained to keep the peripheral intravenous (PIV) line, of one of ten residents (Resident 59), and ensure the IV dressing was dated. This failure placed the resident at risk for IV site infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain medication one of seven sampled residents (Resident 11), were available and did not miss four doses of scheduled pain medications. This deficient practice had the potential to result in the resident not receiving pain medicine timely, pain not being managed and placing the resident at risk for severe pain, including hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct monthly Medication Regimen Review (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) of one of five sampled residents' (Resident 50) medical record. This failure had the potential for the facility to not identify irregularities, significant risks, or actual or potential adverse consequences which may result from or be associated with the resident's current medication. This failure had the potential to affect in maintaining the resident's highest practicable level of physical, mental and psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment for three of three sampled residents (Residents 103, 41, and 54) by failing to ensure:1). Humidifier bottles (devices used with oxygen to add moisture to the oxygen being delivered, enhancing comfort and effectiveness during oxygen therapy) and oxygen tubings were dated when changed. 2). Resident 54, who had a tracheostomy (a surgical opening in the neck for an airway) tube and with mouth open, had a room free of flies. These failures had the potential to cause cross contamination and placed Residents 103, 41, and 54 at risk for infections.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents (Resident 4) an accusation of sexual abuse was reported within two hours. This deficient practice of not reporting the accusation of sexual abuse by Resident 4 had the potential to cause psychosocial harm (factors that could harm someone ' s mental health).

Inspectors wroteBased on record review and interview, facility licensed staff failed to ensure the Medical Director (a licensed physician who oversees and manages the medical aspects of a healthcare organization or facility) was notified after licensed staff could not reach the primary physician for one out of three sampled residents (Resident 1). This deficient practice resulted in facility staff had to call 911 to transport the resident to the General Acute Care Hospital (GACH) .

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1). Ensure expired one opened bottle of vitamin B1 (one of the B vitamins) medication was not kept in the medication cart 1. This deficient practice had the potential to result in administering expired medication to the residents with orders. 2). Label with an opened date, the Ipratropium with Albuterol Solution (a combined inhalation solution to treat and prevent shortness of breath) pouch in medication cart 1 for Resident 33, that had a pharmacy fill date of 7/3/2024. 3). Ensure expired one pouch of Ipratropium with Albuterol Solution for Resident 83 was not kept in medication cart 1. These failures had the potential for the affected residents to receive expired medications. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the juice connectors for the apple, grape, and pineapple juice was free of sticky residue. This deficient practice had the potential to result in cross contamination (movement of bacteria from one place to another) in the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure three dumpsters (trash container) were kept closed. This deficient practice had the potential to result in rodents and insects being attracted to the facility and cause contaminations and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 52) had a call light (call bell) device within easy reach. This deficient practice had the potential to result in the resident being unable to alert health care workers for assistance for activities of daily living and care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the use of an anti-psychotic (a class of drug used to treat mental health conditions) medication was accurately documented in the Minimum Data Set ([MDS] a resident assessment tool) for one of eight sampled residents (Resident 38). This deficient practice resulted in Resident 38's inaccurate medical condition submitted to the Centers for Medicare/Medicaid Services (CMS).

Inspectors wroteBased on interview and record review, the facility failed to ensure weekly weight order was conducted weekly for one of 4 sampled residents (Resident 149). This deficient practice had the potential to result in the facility not knowing the resident had excessive weight loss or weight gain which could lead to delay in providing interventions needed for the resident.

Inspectors wroteBased on observation, interview and record review the facility failed to place the low air loss mattress (LALM- a pressure relieving mattress for the management of pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence]) at the proper setting, according to the manufacturer's recommendation, for one of five sampled residents (Resident 58). This deficient practice had the potential to cause discomfort, new pressure injuries, poor wound healing and deterioration of the current pressure ulcers for Resident 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on tube feeding received treatment and care in accordance with professional standards of practice, by failing to: 1. Ensure the head part of Geri-chair (a fully reclining chair designed for individuals with limited mobility, offering multiple positions for comfort and support) was elevated while one of three residents, (Resident 10), was lying in and received gastrostomy tube ([GT] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feedings. This deficient practice placed the resident at risk of aspiration (inhalation of foreign materials) that can lead to pneumonia (lung infection), hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 42) was evaluated by a physician every 60 days and document his visit in resident's clinical records. This deficient practice had the potential for Resident 42's current medical condition not timely assessed by a physician that can lead to delay in necessary care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 42) was evaluated by a physician every 60 days and document his visit in resident's clinical records. This deficient practice had the potential for Resident 42's current medical condition not timely assessed by a physician that can lead to delay in necessary care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer accurate amount of medication, to one of 29 residents (Resident 10), according to the physician's order. This failure had the potential for the medication to provide ineffective effect to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure, one of eight sampled residents' (Resident 16), Complete Blood Count ([CBC]- a blood test that measures the number and type of cells in your blood) and Albumin (a blood test to check the level of protein in the blood) orders were implemented, as ordered by the physician on 12/11/2024. This deficient practice resulted in inadequate monitoring of Resident 16's health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the foley catheter (a thin, flexible tube inserted into the bladder to drain urine) removal for one of one sampled resident (Resident 85) was documented, according to the facility's policy and procedure (P&P). This deficient practice had the potential to result in the lack of communication between staff and a delay in the provision of care or interventions for Resident 85.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection control practices for one of two residents (Resident 52) who was on enhanced barrier precautions [EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs)]. This deficient practice had the potential to result in spread of infectious disease.

Inspectors wroteBased on observation and record review, the facility failed to meet the required 80 square feet for each resident in rooms [ROOM NUMBER]. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for residents in rooms [ROOM NUMBER].

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH), within two hours, when one out of three residents, Resident 1, alleged a Registered Nurse (RN) hit her on the right side of the face on 3/1/2025. This deficient practice had the potential to place Resident 1 at risk for further abuse and resulted in a delay in investigation of alleged abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to ensure: 1). Oral care was provided for one of three sampled residents, (Resident 3). 2). Restorative Nurse Assistants (RNAs) staff were assigned to provide exercises per resident-centered care plan to two out of three residents, (Residents 2 and 3). This failure had the potential to cause tooth decay and oral infections. This failure had the potential for all residents with ROM plan of care/ orders to not receive the services and could affect in maintaining the highest practicable physical, mental, and psychosocial well-being of the affected residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe storage of two tube feeding formula bottles for one of three sampled residents (Resident 3.) This deficient practice had the potential for other residents to access and drink the formula and cause adverse reactions like diarrhea or upset stomach.

Inspectors wroteBased on observation, interview, and record review, the facility failed to readmit Resident 1 to the facility after being cleared by the general acute care hospital (GACH) to return to the facility. This deficient practice of not allowing Resident 1 to be readmitted to the facility had the potential to displace the resident.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, which indicated the facility should report allegations of abuse immediately to the State licensing/certification agency responsible for surveying/licensing the facility (California Department of Public Health [CDPH]). This failure delayed the investigation by the CDPH.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one of 3 sampled residents (Resident 1), which indicated, all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property, are thoroughly investigated by facility management. This failure had the potential for Resident 1 to receive continued abuse and placed Resident 1 at risk for further physical and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to provide care in a manner that maintained or enhanced resident's dignity and respect in full recognition of his individuality for one of three sampled residents (Resident 1) when LVN 1 verbally threatened Resident 1. This deficient practice resulted in Resident 1 feeling upset and had the potential to negatively affect his psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, the undressed, cleaned wounds for the two of 2 residents (Residents 1 and 2), did not touch the bed's mattress after the wound care was done. This deficient practice placed the residents ' wounds at increased risk for wound infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure laundry rubber gloves were properly cleaned and stored after use. This deficient practice of not having the laundry rubber gloves cleaned stored placed the Residents at risk for the spread of infection. 2. Ensure there is a comprehensive water management program in place to prevent Legionella (a bacteria that causes Legionnaires [a severe form of pneumonia - lung infection/inflammation usually caused by infection] and other waterborne pathogens (any organisms or agent that can cause disease) to grow and spread in the facility. This deficient practice had the potential for residents of the facility to contract a waterborne pathogen including Legionella.

Inspectors wroteb. During a review of Resident 81's admission Record (Face Sheet), the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord) motor system that manifest as rigidity and tremors of the body), hydrocephalus (a condition in which excess cerebrospinal fluid buildup), and ataxia (a lack of balance coordination and trouble walking). During a review of Resident 81's History and Physical (H&P), dated 1/19/2024, the H&P indicated, Resident 81 has the capacity for medical decision making. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure resident and/or responsible party (RP) was informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in altercations in perception, mood, consciousness, or behavior) for one of three sampled residents (Resident 25). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan for one out five Residents (Resident 11). This deficient practice of not having a revised care plan placed Resident 11 at risk of not having the appropriate interventions for a contracted (a tightening of the muscles that causes the joint to shorten and become stiff) neck.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out five Residents (Resident 11) had a comprehensive assessment completed. This deficient practice of not having a comprehensive assessment completed for Resident 11's contracted neck placed the resident at risk for worsening condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to groom one out five Residents (Resident 139). This deficient practice of not grooming Resident 139 had the potential of not receiving the necessary goods and services.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a PICC line dressing was changed every 7 days and as needed if the dressing is soiled or lifting at the edges for 1 of 2 sampled residents (Resident 86). This deficient practice had the potential to cause an infection in Resident 86.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was a physician order for one out of five Residents (Resident 81) to wear an Aspen collar (a device to help the neck to heal by supporting the bones in the neck). This deficient practice of not having a physician order placed Resident 81 at risk for inadequate monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure an enteric coated (a coating on a medication to prevent it from dissolving in the stomach) medication was not crushed for 1 of 4 residents (Resident 57). This deficient practice had the potential for Resident 57 to experience adverse drug reactions from the medication being administered differently from how they were ordered.

Inspectors wroteBased on interview and record review the facility failed to follow up with the Pharmacist's Medication Regiment Review ([MRR] an evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) for one out of five Residents (Resident 8). This deficient practice of not following the MRR recommendations had the potential for Resident 8 to have an adverse effect from not reviewing the insulin sliding scale (varies the dose of insulin based on blood glucose level).

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure an expired and discontinued bottle of Pro-Stat (Concentrated Liquid Protein Medical food) was discarded from medication cart #3. This deficient practice had the potential for unintentional administration of the expired and discontinued medication which can result in adverse drug effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had 80 square feet of living space. This deficient practice had the potential to interfere with residents being able to move around freely or store their personal items.