Health inspection·September 20, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a serious condition that occurs when the lungs are unable to provide enough oxygen to the blood or remove enough carbon dioxide), unspecified (unknown), unspecified whether with hypoxia (low levels of oxygen in the body ' s tissues) or hypercapnia (too much carbon dioxide in the blood). During a review of Resident 1 ' s History and Physical (H&P), dated 9/11/2024, the H&P indicated Resident 1 had the capacity for medical decision making. During an interview on 9/19/2024 at 2:46 p.m. with Respiratory Therapist (RT) 1, RT 1 stated Resident 1 ' s family member (FM) had notified RT 1 of an allegation that RT 2 slapped Resident 1 on the face on 9/12/2024. RT 1 stated the Administrator (Admin) was notified regarding the allegation on 9/12/2024, however, RT 1 was unable to provide documentation the Admin was notified. During a review of Resident 1 ' s progress notes dated 9/12/2024, the progress notes did not indicate documented evidence the allegation of RT 2 slapped Resident 1 on the face on 9/12/2024 was reported to CDPH. During a concurrent interview and record review on 9/20/2024 at 1:13 p.m. with Administrator (Admin), the facility P&P titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, dated 9/2022, was reviewed. The Admin stated he was not notified by RT 1 on 9/12/2024 regarding the abuse allegation until 9/18/2024. The Admin stated they would have sent a report to CDPH and conducted an investigation. The Admin stated if abuse was not reported in a timely manner, there was a chance for more abuse to take place. During a review of facility ' s P&P titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, dated 9/2022, the P&P indicated, if resident abuse is suspected, the Page 1 of 4 555719 555719 09/20/2024 Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250

F 0609 suspicion must be reported immediately to the Administrator and to the State licensing/certification agency responsible for surveying/licensing the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555719 Page 2 of 4 555719 09/20/2024 Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few This failure had the potential for Resident 1 to receive continued abuse and placed Resident 1 at risk for further physical and psychosocial harm. Findings: During a review of Resident 1 ' s admission Record, dated 9/20/2024, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a serious condition that occurs when the lungs are unable to provide enough oxygen to the blood or remove enough carbon dioxide), unspecified (unknown), unspecified whether with hypoxia (low levels of oxygen in the body ' s tissues) or hypercapnia (too much carbon dioxide in the blood). During a review of Resident 1 ' s History and Physical (H&P), dated 9/11/2024, the H&P indicated Resident 1 had the capacity for medical decision making. During an interview on 9/19/2024 at 2:46 p.m. with Respiratory Therapist (RT) 1, RT 1 stated Resident 1 ' s family member (FM) had notified RT 1 of an allegation that RT 2 slapped Resident 1 on the face on 9/12/2024. RT 1 stated the Administrator (Admin) was notified about the allegation on 9/12/2024, however, RT 1 was unable to provide documentation the Admin was notified. During an interview on 9/19/2024 at 3:50 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that if there was any allegation of abuse, staff should assess the affected resident and notify the Registered Nurse (RN) Supervisor and the Admin to ensure whatever process needed to be done, were started. During a review of Resident 1 ' s progress notes dated 9/12/2024, the progress notes did not indicate documentation that the allegation when RT 2 slapped Resident 1 on the face on 9/12/2024, was investigated and interventions provided by the facility. During an interview on 9/19/2024 at 4:24 p.m. with the Director of Nursing (DON), the DON stated the facility must investigate any allegation of abuse and provide interventions if the abuse had occurred. During an interview on 9/20/2024 at 10:58 a.m. with RN Supervisor 1, RN Supervisor 1 stated the Admin must be notified right away if there were any allegations of abuse. RN Supervisor 1 stated abuse needs to be further investigated and investigation must be documented in the clinical records. During a concurrent interview and record review on 9/20/2024 at 1:13 p.m., the facility P&P titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, dated 9/2022, was reviewed with the Admin. The Admin stated any allegations of abuse needs to be investigated. 555719 Page 3 of 4 555719 09/20/2024 Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of facility ' s P&P titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, dated 9/2022, the P&P indicated, upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents. The P&P also indicated that, all abuse allegations should be thoroughly investigated. The P&P indicated, the Administrator should initiate the investigation and the Administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of investigation. 555719 Page 4 of 4