Other·March 9, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during a complaint investigation. Complaint Number: CA00560606 Representing the Department of Public Health: Evaluator ID#: 38551, RN, HFEN Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of Complaint CA00560606.

F325 SS=G MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE CFR(s): 483.25(g)(1)(3)

F325 02/19/2018 (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KL0C11 Facility ID: CA910000041 If continuation sheet 1 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555719 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL CREST HEALTH CARE CENTER 11834 Inglewood Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to ensure one of three sampled residents (Resident 1) received adequate nutrition when the gastrostomy tube [(GT) tube placed inside the stomach to administer nutrition, water, and medications] was dislodged. This deficient practice resulted in Resident 1 not being fed, receiving water and/or medications via GT for 14 days and worsening pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) which required an admission to the general acute care hospital (GACH) for evaluation, treatment, blood transfusion and surgical debridement (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of the pressure sore wounds. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on 8/14/06 and re-admitted on 4/9/17. Resident 1's diagnoses included dysphagia (difficulty swallowing), hypertension (high blood pressure), diabetes (high blood sugar), pressure ulcers (injuries to the skin caused by pressure) and malnutrition (lack of nutrients needed for proper health and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KL0C11 Facility ID: CA910000041 If continuation sheet 2 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555719 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL CREST HEALTH CARE CENTER 11834 Inglewood Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE development). A review of Resident 1's History and Physical (H/P), dated 4/20/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 7/16/17, indicated the resident required total assistance with bed mobility, dressing, eating, toileting, and personal hygiene. The MDS, dated 10/2/17, indicated Resident 1 had a feeding tube, open lesions other than ulcers, rashes, cuts on the body, and was at risk of developing pressure ulcers. A review of Resident 1's Admission Assessment, dated 4/9/16, indicated the resident had pressure ulcers to the left hip measuring 3 by 3 centimeters (cm), right hip measuring 2 cm by 2 cm, left heel measuring 4 cm by 4 cm, left big toe measuring 3 cm by 3 cm, and the right lateral foot measuring 2 cm by 2 cm, none with any depth measurements. A review of Resident 1's care plan, dated 4/10/17, indicated the resident had altered skin integrity. Resident 1's goal was to provide and encourage adequate nutrition to promote wound healing. Another care plan, dated 4/13/17, indicated Resident 1 was receiving Jevity (tube feeding) at 65 centimeters per hour (cc/hr) for twenty hours a day. The goal was that Resident 1 would have adequate nutrition and decreased risk for weight loss. A review of Resident 1's Dehydration Risk Assessments, dated 4/10/17 and 10/10/17, indicated the resident had a score of 40. The assessment indicated a score of 25-49 was a moderate risk for dehydration (a harmful FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KL0C11 Facility ID: CA910000041 If continuation sheet 3 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555719 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL CREST HEALTH CARE CENTER 11834 Inglewood Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reduction in the amount of water in the body). A review of Resident 1's physician order, dated 4/8/17, indicated the resident was to have medications crushed and administered via the G-tube. The physician's order indicated for Resident 1's feeding to be turned off for a total of four hours a day during activities of daily living (ADL) care. A review of Resident 1's Interdisciplinary Team ([IDT] group of disciplines working towards a common goal for a resident) Note, dated 10/24/17, indicated the resident's GT dislodged and the stoma (surgical opening) site was breaking down. The physician assistant (PA) for a wound care company suggested for the resident to have a new GT site placement. The IDT Team also had concerns that Resident 1 was at risk for osteomyelitis (bone infection), poor wound healing and lack of nutrition. The resident's physician was notified, but she refused to order hospitalization for a new GT site replacement. A review of Resident 1's Physician's Order Summary Report, dated 10/30/17, indicated the resident was to be off tube feedings until the GT was replaced. There was no time frame written and there was no order for any other nutritional supplements. A review of a Surgical Consult Note, dated 10/31/17, indicated Resident 1's GT was dislodged and the primary physician did not reorder a replacement. A review of a Gastroenterology [(GI) physician who specialized in the study of the throat, intestines stomach and anus] Patient Note, dated 11/7/17, indicated Resident 1 was sent for a consultation regarding placement of the GT, since Resident 1 had not received GT FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KL0C11 Facility ID: CA910000041 If continuation sheet 4 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555719 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL CREST HEALTH CARE CENTER 11834 Inglewood Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE feeding for a week. Another GI Patient Note, dated 11/14/17, seven days later, indicated Resident 1 was to have the GT replaced, but needed a consent for the procedure. A review of Resident 1's laboratory (lab) records, from 10/4/17 through 10/10/17, indicated Resident 1's potassium (K) level was low at 3.3 (normal reference range [NRR] 3.55.5 mEq/L), BUN/Creatinine Ratio was elevated at 25.9 (NRR 10-20), Calcium level was low at 7.7 (NRR 8.6-10.3), pre-albumin, which was an indication of the resident's nutritional status, was 5g/dl (NRR 17-34), hemoglobin was low at 6.1 grams per deciliter (g/dl) (NRR 13.7-17.5) and the hematocrit was low at 19.9 percent (%) (NRR 40.1-51.0) A review of the GACH's lab results, dated 11/10/17, indicated Resident 1's potassium level had dropped lower at 2.8 mEq/L, The resident's calcium had decreased to at 7.5 mg/dL and the albumin was low at 1.4 g/dl (NRR 3.4-5.0 g/dL), BUN/Creatinine Ratio 10, Troponin 0.56 Nano gram per milliliter (ng/mL), urine color was orange (normal= yellow), turbid (cloudy appearance) urine with protein (normal=clear without protein), BUN/Creatinine Ratio 21. There was no pre-Albumin level indicated on the lab records. A review of Resident 1's emergency room (ER) physician's progress note, dated 11/10/17, indicated the resident was brought to the ER on 11/10/17. Resident 1 was assessed to be pale, sweaty, with bedsores ([pressure sores] no measurements provided) and abnormal lab results. The note indicated that the physicians had concerns regarding elder abuse. The physician's progress note indicated Resident 1 was emaciated (abnormally weak or thin due to illness or lack of food), frail and chronically ill looking. According to the ER note Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KL0C11 Facility ID: CA910000041 If continuation sheet 5 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555719 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL CREST HEALTH CARE CENTER 11834 Inglewood Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was to be admitted and placed on total parenteral nutrition [(TPN) way of providing nutritional needs of the body through the veins and not through the stomach], and for possible surgical wound debridement of the wounds and a GT replacement. Another ER note, dated 11/10/17, indicated the resident's GT had not been used for food or medications for a week and Resident 1's pressure ulcers were foul-smelling. A GI note, dated 11/11/17, indicated the resident had a large open wound on the abdominal wall at the site of the previous GT requiring a surgical closure. A review of the GACH's progress note, dated 11/12/17, indicated the resident received a unit of packed red blood cells ([PRBCs] red blood cells that have been collected, processed, and stored in bags as blood product units available for blood transfusion purposes when blood count is low) and that the resident was unstable for transfer. The ER note also indicated that Resident 1 could not be fed through the feeding tube because it would leak out of the abdominal wall. A review of the GACH physician progress note, dated 11/13/17, indicated Resident 1 was receiving TPN and lipids (fat-like substances) and that the resident was to receive two additional units of PRBCs. A review of the physician progress note, dated 11/14/17, indicated Resident 1 needed to be on long-term TPN until the open wound at the site of the GT healed. The note indicated that there was brown colored drainage from the previous GT site that was damaging Resident 1's skin. According to the GACH's progress note, dated 11/14/17, Resident 1 had a GT replaced through the existing abdominal site. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KL0C11 Facility ID: CA910000041 If continuation sheet 6 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555719 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL CREST HEALTH CARE CENTER 11834 Inglewood Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 11/16/17, at 8:15 a.m., during an interview and a concurrent record review, Registered Nurse 1 (RN 1) stated Resident 1's GT dislodged on 10/18/17 and the physician ordered the resident to have nothing by mouth (NPO) and a GI consult, but failed to indicate which GI physician would see the resident. According to RN 1, he called and scheduled a GI consult for Resident 1 on 11/7/17. RN 1 stated the resident remained NPO from 10/28/17 to 11/10/17, for 14 days, and was only receiving intravenous ([IV] through the vein) fluids infusing 50 centiliters of Dextrose (form of sugar) with sodium chloride (salt solution) [(D5 1/2 NS) a treatment for dehydration] per hour (cc/hr). At 8:24 a.m. on 11/16/17, during a subsequent interview, RN 1 stated Resident 1 went for a GI consult on 11/7/17, but his GT was not replaced. RN 1 stated the resident was scheduled for GT placement on 11/14/17 and the GI specialist was made aware the resident remained NPO. RN 1 stated Resident 1's lab results indicated a low Hgb and Hct at 6.1/19.9, but the physician initially refused transferring the resident to the hospital. RN 1 stated that the facility's Director of Nursing (DON) insisted for the resident to be transferred to the hospital before the physician gave the orders. RN 1 stated the physician was aware that Resident 1 was scheduled to have a GT placement on 11/14/17 and that the resident remained NPO. RN 1 also stated that he should have convinced the physician to transfer Resident 1 to the hospital sooner. On 11/16/17 at 9:16 a.m., during an interview, the DON stated the PA recommended for Resident 1 to go to the hospital where a GI consult and insertion could be done, but the physician refused to order the hospital transfer. The DON stated she told the physician that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KL0C11 Facility ID: CA910000041 If continuation sheet 7 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555719 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL CREST HEALTH CARE CENTER 11834 Inglewood Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident was only receiving IVF [intravenous fluids] and needed some nutrients. The DON stated since the physician continued to refuse a transfer to the GACH, she told the physician that she was going to call the facility's Medical Director for the resident to be transferred to the GACH. On 11/16/17 at 9:32 a.m., during an interview, the DON stated that she was upset because the resident went without food for many days and she was afraid the resident was going to die in the facility. On 11/16/17 at 9:42 a.m., during a telephone interview, the PA stated Resident 1's GT came out many times before and she stated the physician was resisting to order a transfer to GACH. On 11/16/17 at 11:36 a.m., during an interview, the facility's Administrator (ADM) stated that it was surprising the resident went for 14 days without food. He stated that he did not know the magnitude and he should have contacted the physician himself. On 11/16/17 at 11:58 a.m., during an interview, Resident 1's physician stated she was not aware Resident 1 was without GT feeding for 14 days. The physician stated that an alternative would be TPN, but the resident cannot be hospitalized just for TPN. According to the physician, the resident was being well hydrated with IVF, though not an ideal form of nutrition. On 11/16/17 at 1:54 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated a resident should not be left on IVF without feeding for more than 12 hours because of the risk of dehydration and poor wound healing because of the lack of nutrients. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KL0C11 Facility ID: CA910000041 If continuation sheet 8 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555719 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL CREST HEALTH CARE CENTER 11834 Inglewood Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's policy titled "Dehydration Risk Assessment" with a revision date of 1/24/17, indicated the facility would address resident's dehydration risk factors based on each residents' assessment. A review of the facility's policy titled "Nutritional Risk" with a revised date of 1/24/17, indicated the goal was to increase nutrient consumption without increasing food volume for residents with skin breakdown or other conditions, which increased calorie needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KL0C11 Facility ID: CA910000041 If continuation sheet 9 of 9