Imperial Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan to address one of one sampled residents' (Resident 2) refusal to use the call light prior to toileting. This failure resulted in Resident 2 using the bathroom unassisted and sustaining a fall.

Inspectors wroteBased on interview and record review, the facility failed to notify the primary physician of Resident 2's fall in the bathroom. This failure had the potential to result in missed or delayed diagnosis and interventions for serious injuries.

Inspectors wroteBased on interview and record review, the facility failed to report one of one sampled resident's (Resident 1) abuse allegation to the State Agency (California Department of Public Health [CDPH]), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement when Resident 1 alleged he was grabbed by his right arm without his consent. This failure resulted in a delay of an onsite investigation and had the potential to result in further potential abuse to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care in accordance with professional standards of practice when the facility did not:1. Obtain vital signs and conduct 72-hour monitoring after Resident 2 sustained a fall in the restroom on 6/9/2026.2. Conduct 72-hour psychosocial monitoring after Resident 1 alleged his arm was grabbed without his consent on 5/28/2026. These failures had the potential for undetected changes in Resident 2's physical or neurological (how the brain, spinal cord, and nerves work) status and Resident 1's psychosocial condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely physician notification for a significant change in condition for one of three sampled residents (Resident 1). This deficient practice had the potential to delay physician evaluation, timely medical intervention, and result in the deterioration of Resident 1's condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the outside patio was safe and in functional condition when a nail stuck out from the water drain securement clip and the plastic tabletop was cracked and missing pieces. This deficient practice had the potential for residents to sustain injuries from the exposed nail and from the cracked plastic tabletop.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent for psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) was obtained in accordance with the facility's policy and procedures for one of five sampled residents (Resident 4). This deficient practice placed Resident 4 at risk for experiencing unexpected and/or unwanted adverse effects or complications of the medication, including increased cognitive impairment (problems with a person's ability to think, learn, remember, use judgment, and make decisions), over sedation (excessive drowsiness, loss of response to verbal command, inappropriate movement, hearing abnormalities, visual disturbances, sweating, or nausea), and tardive dyskinesia (a chronic movement disorder that causes involuntary, repetitive movements in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were kept within reach for two of 22 sampled residents (Resident 33 and Resident 75). This deficient practice removed Resident 33's and 75's ability to exercise their right to request assistance from staff and created the potential for accidents and/or delays in care.

Inspectors wroteBased on interview and record review, the facility failed to provide information related to Notice of Medicare Non-Coverage (NOMNC, a document that informs Medicare beneficiaries when their covered services are ending) and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, a document that informs beneficiaries about potential non-coverage for specific items or services and informs beneficiaries they may have to pay for the service out-of-pocket), to one of three sampled residents (Resident 98), who was self-responsible and had the capacity to understand and make decisions. This deficient practice removed Resident 98's right to file an appeal if he disagreed with the discontinued coverage, including rehabilitation services (i.e., physical therapy [the treatment of disease, injury, or deformity by physical methods rather than by drugs or surgery]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for two of two sampled residents' (Resident 10 and 68) use of side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility). This deficient practice had the potential to result in Resident 10 and 68 not receiving the necessary care to safely utilize the side rails. Cross Reference F700.

Inspectors wroteBased on interview and record review, the facility failed to conduct an interdisciplinary team (IDT) conference (a meeting to discuss the resident's plan of care, involving the IDT [physician, registered nurse, certified nursing assistant, dietary staff, the resident, and other pertinent staff]), and develop a care plan for one of two sampled residents (Resident 26) following a resident-to-resident altercation that occurred on 11/17/2024. These deficient practices had the potential for Resident 26 to be involved in another resident-to-resident altercation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of five sampled residents (Resident 11 and Resident 72) were provided with communication tools. This deficient practice placed Residents 11 and 72 at risk of not having their needs met and potentially negatively affecting their psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 21) low air loss mattress ([LALM], a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) was accurately set to Resident 21's weight. This deficient practice had the potential to result in the avoidable development of pressure ulcers ([PU], localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and the complications associated with impaired skin integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a hazard-free environment for two of 22 sampled residents (Resident 4 and Resident 87) by failing to ensure: 1. Staff responded timely to Resident 4's bed alarm. 2. Resident 4, who had a Wander Guard alarm (a security system designed to prevent residents from wandering outside of designated areas) did not exit the building unsupervised. 3. Resident 87 had a functioning bed alarm. These deficient practices placed Resident 4 and Resident 87 at risk for injuries related to unsafe wandering and/or falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility) for two of two sampled residents (Residents 10 and 68) by failing to: 1. Ensure Resident 10 had grab bars (short side rails used to assist in bed mobility), instead of half side rails (longer side rails attached to the side of the bed, covering about half the length of the bed), were installed onto the bed. This deficient practice had the potential to result in Resident 10 unable to optimally utilize the half side rails in turning and repositioning in bed. 2. Ensure Resident 68 had an order for grab bars. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was less than five percent (%), when Licensed Vocational Nurse (LVN) 3 failed to administer two of five randomly selected residents' (Residents 28 and 66) medications in accordance with the physicians' orders. The outcome was two medication errors out of 30 opportunities for errors, which resulted in a Medication Administration Error Rate of 6.67%, based on the following: 1. LVN 3 did not administer Resident 28's metoprolol (medication to treat high blood pressure) with food. 2. LVN 3 did not administer Resident 66's aspirin (an antiplatelet medication used to prevent blood clots from forming) with food. This deficient practice had the potential to result in Residents 28 and 66 to experience stomach pain and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure one out of eight sampled residents (Resident 72) did not store medications at the bedside when: 1. Resident 72 had a medication bottle of Adderall (a stimulant that helps improve focus, attention, and impulse control in people with attention deficit hyperactivity disorder [ADHD, chronic condition including attention difficulty, hyperactivity, and impulsiveness]) at the bedside. 2. Resident 72 had a medication bottle of Atarax (medication for anxiety [a feeling of worriedness, dread, and uneasiness]) at the bedside. 3. Resident 72 had a medication bottle of Diovan (medication for high blood pressure [the force of blood pushing against the walls of the arteries is consistently too high]) at the bedside. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food to meet individual needs for one out of eight sampled residents (Resident 19) by: 1. Not ensuring Resident 19 received a regular diet during mealtime. This deficient practice did not meet Residents 19's individual needs and placed resident 19 to feel unsatisfied with the meal.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) was provided to and signed by an individual with decision making capacity for two of three sampled residents (Resident 104 and 105). This deficient practice resulted in Resident 104 and 105 being unaware that their right to resolve a dispute in court was waived after entering into the binding arbitration agreement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place one of five sampled residents (Resident 253) on enhanced barrier precaution ([EBP], infection control intervention to reduce the transmission of multi-drug-resistant organisms [MDRO] from staff to patient). This deficient practice had the potential to result in staff members, who provided direct care to Resident 253, transmitting MDRO and other bacteria to Resident 253 and other residents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure safe smoking practices were maintained for one of 10 sampled residents (Resident 79). This deficient practice placed Resident 79 at risk for burn injuries and accidents related to unsupervised cigarette smoking, and placed all facility residents at risk due to the fire hazard associated with unsafe smoking practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services for and monitor a resident with a pacemaker (a device that delivers electrical impulses to control the rhythm of the heart) for one out of three sampled residents (Resident 1), by failing to: 1. Ensure Resident 1's pacemaker information (insertion date, paced rate, type of pacemaker, the name of the cardiologist, type of leads [an insulated wire that is connected to the pulse generator in the heart], manufacturer and model, and serial number) was obtained upon admission, as indicated in the facility's policy, Resident 1's pacemaker care plan, and physician orders. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not sleep at the nurses' station, use a cellular device while working, and ensure call lights were answered promptly for two out of three sampled residents (Resident 2 and Resident 3). These failures had the potential to make the residents feel less dignified and uncared for.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Notify both designated emergency contacts listed on a resident ' s admission Record for one out of three sampled residents (Resident 1) when Resident 1 suffered a fall, and was sent to the General Acute Gare Hospital (GACH). These findings resulted in Responsible Party (RP) 1 becoming upset that she was not notified and was unaware that her father fell, and was transported to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective infection prevention measures during a Coronavirus Disease outbreak ([COVID-19], an infectious disease that affects a person's organs and tissues that aid in breathing) in the facility. The facility failed to: 1. Minimize Resident 1's exposure to COVID-19. 2. Stock face shields in eight of eight isolation carts (storage unit for personal protective equipment [PPE, protective clothing or equipment designed to protect the wearer's body from infection, such as a gown, gloves, mask, and face shield]) designated for the COVID-19 positive and COVID-19 exposed rooms. 3. Ensure face shields were used by staff members prior to entering Residents 2 and 3 rooms, who were COVID-19 positive. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete set of vital signs (a group of the four to six most crucial medical signs that indicate the status of the body's vital functions) were taken, documented, and monitored as ordered by the physician for one out of three sampled residents (Resident 1). This deficient practice had the potential to delay the care provided to Resident 1, who exhibited an acute episode of desaturation (respiratory distress) and tachycardia (fast heart rate). Resident 1 was sent to the general acute care hospital (GACH) on 5/20/2024, and diagnosed with acute renal failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), hyperkalemia (elevated potassium [an electrolyte] in the blood) , and sepsis (an infection in the blood).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of eight sampled residents (Residents 74 and 78) by failing to: a. Ensure Resident 74 was consistently turned and repositioned (during the month of March [2024]) as indicated on a pressure ulcer ([PU]-injury to skin and underlying tissue resulting from prolonged pressure on the skin) care plan to prevent the development of an unstageable (full thickness tissue loss) pressure ulcer. b. Develop and implement a care plan for Resident 78's multiple and consecutive RNA refusals. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an Interdisciplinary Team Meeting (meeting with a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) records were completed, organized, and readily accessible for three of three sampled residents (Resident 64, 78, and 194). These deficient practices resulted in staff being unaware where Resident 64, 78, and 194's medical records were located and had the potential to delay and negatively affect the delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain infection control procedures for one of six sampled residents (Resident 36) when the Restorative Nursing Aide 1 (RNA 1) did not clean and disinfect shared resident equipment, a front wheeled walker ([FWW] mobility device with two wheels in the front used for support when standing or walking), after resident use and before placing the FWW into the Utility Room with other clean equipment. This deficient practice had the potential to result in the spread of infection to facility staff, residents, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapy mat (an adjustable padded surface used for therapy treatment) in the rehabilitation room was clear of miscellaneous items including a black bag, office supplies, a large black mat, a large therapy ball (large inflatable ball used for exercise), a graded rainbow arc (device used in therapy to assist with arm exercises), two bins containing multiple balls, a foam roller, a backpack, two large cardboard boxes, and four plastic bins containing various items to ensure adequate space was available for resident use during therapy treatments. This deficient practice had the potential to minimize equipment use and usable treatment space for residents during therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain informed consent prior to administration of psychotropics (medications that affect the mind, emotions, and behavior) for three out of five residents (Resident 3, 48, and 149) by failing to: 1. Ensure an informed consent was obtained and signed by the responsible party (RP) of Resident 3 who could not make medical decisions for treatment with psychotropics. 2. Ensure Resident 48's verification signature was included on the informed consent for treatment with psychotropics. 3. Ensure Resident 149 had an informed consent for treatment with psychotropics. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 86) when the privacy curtain was left open while Resident 86 was left exposed (without any clothes on) in only their diaper. This failure had the potential to result in Resident 86 having a decreased feelings of self-worth and self-confidence and the potential for feelings of humiliation.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent an avoidable pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) for one out of three residents (Resident 30). This deficient practice resulted in Resident 3 having a stage II pressure ulcer (an open wound with partial thickness loss where the top layer of the skin has been damaged). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall measures were implemented to prevent the occurrence of further falls and injuries for two out of two sampled residents (Resident 64 and Resident 194) who sustained major injuries after a fall within the facility when the facility staff failed to: 1. Ensure bilateral fall mats were in place for Resident 64. 2. Ensure a falling star sticker was placed to the name plates of Resident 64 and Resident 194. These failures had the potential for Resident 64, who had fallen on 4/10/2024, sustained a broken left hip and underwent an open reduction internal fixation ([ORIF]- surgery to repair the hip) of the left hip (because of the fall), to endure another fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care services according to professional standards for Resident 30 by failing to: 1. Change Resident 30's oxygen tubing and humidifier (a device used to keep oxygen delivery moist to prevent irritation to the airway) within one (1) week according to facility policy and procedure. 2. Providing care/treatment/services to strengthen lungs due to history of recurring pneumonia (infection of the lungs). As a result of these deficient practices, Resident 30 had the potential to have a relapse in pneumonia. A review of Resident 30's admission Record, indicated the facility originally admitted Resident 30 on 3/12/2023 and readmitted on [DATE]. Resident 30's admitting diagnoses included but were not limited to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure doors remained closed to residents' rooms that tested positive for COVID-19 (highly contagious respiratory disease) for five of five sampled residents (Resident 6, Resident 7, Resident 8, Resident 9, and Resident 10). This deficient practice had the potential to expose all residents, staff, and visitors to COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered care plan (document helps nurses and other team care members organize aspect of resident care) for three of 10 sampled residents (Resident 4, 5, and 7) by failing to: 1. Develop a care plan for Resident 4 who had a temperature of 100 degrees Fahrenheit (F, scale for measuring temperature, typical body temperature is between 97 degrees Fahrenheit to 99 degrees Fahrenheit), congestion (a buildup of mucus in the lungs and lower breathing tubes), body weakness, and was prescribed Levaquin (an antibiotic, which is a medication to treat bacterial infection) as treatment. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective infection prevention measures for four of 10 sampled residents (Resident 6, 7, 9, and 10) when the facility failed to: 1. Drape the privacy curtain between Resident 6 and Resident 9, and drape the privacy curtain between Resident 7 and Resident 10, who were all on droplet precautions (used to prevent the spread of pathogens that are passed through respiratory secretions). 2. Ensure the Activities Assistant (AA) 1 performed hand hygiene (a way of cleaning one ' s hands that substantially reduces the potential germs on the hands) prior to entering and upon exiting a droplet precaution room. These failures had the potential to transmit infectious microorganisms and increase the risk of infection for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) met for an IDT meeting (meeting to coordinate care and document communication between all members of the team related to residents ' plan of care and treatment goal) after a physical altercation took place between two of 10 sampled residents (Resident 1 and 2). This failure had the potential to negatively affect the provision of care and services for Resident 1 and Resident 2.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for one of three sample residents (Resident 1) by failing to 1. Develop an Activity of Daily Living (ADL) care plan for Resident 1 with extensive assistance daily care. 2. Develop an intervention in a mobility care plan. This deficient practice had a potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility's staff failed to adhere to resident's plan of care to notify the physician when the resident's abnormal heart rate and blood pressure for one of 24 sampled residents (Resident 23). Resident 23's heart rate and blood pressure were low with 66 episodes of low blood pressure (hypotension) and 26 episodes of low heart rate (bradycardia) for 60 days and there were no documented evidence the physician was notified of the resident's change of condition (COC). This deficient practice resulted in Resident 23 experiencing a COC and required the physician to be notified and medications reevaluated and had the potential for the resident to experience dizziness, weakness, tiredness, fainting and shortness of breath which could have rsulted in an emergency situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the plan of care was implemented to ensure resident's needs could be met and the call light was accesible for one of 19 sampled residents (Resident 80). Resident 80's left arm was impaired, and the call light was observed dangling from the left side of the bed and was not accessible to her. This deficient practice create a safety concern and had the potential to result in a delay in care or inability for the resident to obtain the necessary care and services timely.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a black box medication warning (strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration [FDA, a government agency responsible for protecting the public health]) when there is reasonable evidence of an association of a serious hazard with the drug) care plan for Resident 23 that met professional standards of care for one of 24 sampled residents (Resident 23). Residents 23 did not have a care plan for Amiodarone (medication used for irregular heart rhythms [antiarrhythmic]), a black box warning medication for over 180 days. [...]

Inspectors wroteBased on interview and record review, the facility's staff failed to ensure a resident received the necessary care and services as per the care plan for one of 24 sampled residents (Resident 23). Resident 23's plan of care stipulated the resident's blood pressure and/or heart would be monitored and any abnormal results would be reported to the physician, but nurses failed to notify the physician for 60 days. This deficient practice resulted in Resident 23 experiencing 66 episodes of hypotension (low blood pressure) and 26 episodes of bradycardia (low heart rate) for 60 days, which had the potential for Resident 23 to experience dizziness, weakness, tiredness, fainting and shortness of breath.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 10) room was free from cluttered to prevent accidents. Resident 10, who uses devices for mobility, room was cluttered with many items which included personal items on the bed and surrounding space. This deficient practice had the potential to result in an accident with injuries that could negatively impact the resident's safety and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility's staff failed to ensure residents with urinary catheters (a flexible tube used to drain urine from the bladder into a drainage bag) receive the necessary care and services for two of 11 residents (Residents 81 and 239). The staff failed to adhere to the resident's plan of care and facility's policy and procedure to prevent kinking and dislodgement (to remove or force out from a position or dwelling previously occupied) by not using catheter straps. This deficient practice had the potential to cause pain, urinary blockage, bleeding and impede progress of the residents wellness.

Inspectors wroteBased on observation and interview the facility failed to observe infection control measures by failing to: 1. Ensure certified nurse assistant (CNA 3) performed hand hygiene before and after resident care for one of 19 sampled residents. 2. Ensure the housekeeping staff (HK 1) donned (put on) a gown while cleaning a contact precaution (measures that are intended to prevent transmission of infectious agent which are spread by direct or indirect contact with the resident or the resident's environment) isolation room for one of one sampled room. These deficient practices were a safety concern and had the potential to result in transmission of infectious microorganisms and increase the risk of exposure to infection for the residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 10) room was free from cluttered and was a safe environment. Resident 10, who uses devices for mobility, room was cluttered with many items which included personal items on the bed and surrounding space (crossed reference to F689). This deficient practice resulted in Resident 10's room being an unsafe, uncomfortable and dysfunctional area and had the potential to result in an accident.