Inspection·May 16, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage (bleeding in the brain caused by the rupture of a damaged blood vessel in the head), type 2 diabetes mellitus ([DM] a chronic condition that affects the way the body processes blood sugar) and epilepsy (a brain condition that causes recurring seizures). A review of Resident 1's History and Physical (H&P), dated 5/1/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS], an assessment and care screening tool), dated 5/6/2024, indicated Resident 1 required total assistance in toileting hygiene and lower and upper body dressing. A review of Grievance Report, dated 5/8/2024, the Grievance Report indicated, Resident 1 reported that Licensed Vocational Nurse 1 (LVN 1) verbally threatened him on 5/7/2024. During an interview on 5/15/2024 at 12:30 p.m., with Resident 1 in his room, Resident 1 stated LVN 1 went to his room and offered his medicine and stated, no matter what, I still get paid, whether you take your medicine or not. Resident 1 stated he felt terrified and upset hearing that comment made by LVN 1. Resident 1 stated he deserved to be respected as an individual and considering as resident in this facility. LVN 1 stated he did not say anything to LVN 1 that would made him upset. During an interview on 5/15/2024 at 1:20 p.m., with the Social Service Director (SSD), SSD stated LVN 1's behavior was unprofessional, unacceptable, and violated Resident 1's dignity. During an interview on 5/15/2024 at 4:35 p.m., with the Director of Nursing (DON), the DON stated LVN 1 did not have any right to say anything that could hurt Resident 1 feelings whether direct or (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 05/16/2024 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)