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 (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 4 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 09/20/2024 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)