Inspection·April 19, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few This deficient practice placed the residents ' wounds at increased risk for wound infection. Findings: a). A review of Resident 1 ' s admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of muscle weakness (physical weakness or a lack of energy), type 2 diabetes mellitus (abnormal sugar levels), and acute osteomyelitis, left ankle and foot (bacterial or fungal infection of the bones, leading to inflammation and potential complication). A review of Resident 1 ' s history and physical (H&P) dated 4/12/2024 indicated Resident 1 was awake, not alert, unresponsive, nonverbal. A review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 1/24/2024, indicated Resident 1 ' s cognitive skills (thought process) was rarely/never understood by others. The MDS indicated Resident 1 required dependent assistance with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). A review of Resident 1 ' s physician orders dated 4/12/2024, indicated Resident 1 had an order for Povidone-Iodine (antiseptic used for skin disinfection) external solution, to apply to left (L) plantar below 5th toe, (L) 5th toe, (L) big toe, (L) 2nd toe, (L) lateral foot, topically every day shift for diabetic ulcer for 30 days, cleanse with normal saline (NS, a solution), pat dry, apply treatment and cover with dry dressing, abdominal pads, wrap with kerlix (uncompressed gauze roll). During an observation on 4/19/2024 at 9:50 a.m., in Resident 1 room, Licensed Vocational Nurse 2 (LVN2) applied iodine gauze on the left below, (L) 5th toe, without cleaning the wound with NS as ordered. The LVN2 picked up another iodine gauze and realized that he needed to clean the wound first with NS. The LVN2 stated, I forgot to clean. After the LVN2 cleansed and applied betadine on the (L) 5th toe, the treatment nurse left the foot wound uncovered. The (L) 5th toe touched the mattress. b). A review of Resident 2 ' s admission record, indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with type 2 diabetes mellitus, muscle weakness, and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555719 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)