Other·October 23, 2019

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 an investigation of a Complaint during an Abbreviated Survey. Complaint Number: CA00647599. Representing the Department of Public Health: Surveyor ID: 34180 RN, HFEN The inspection was limited to the specific Complaint incidents investigated and does not represent the findings of a full inspection of the facility. One deficiency was written for Complaint Number: CA00647599.

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 10/04/2019 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the 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: 715L11 Facility ID: CA910000041 If continuation sheet 1 of 7 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 09/23/2019 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 facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy and ensure a resident's rights were not denied for one of three sampled residents (Resident 1). Resident 1 was provided a seven (7) day bed hold upon a transfer to a general acute care hospital (GACH), but was denied readmission to the facility after four days. This deficient practice resulted in Resident 1's rights being denied and being admitted to another facility, which had the potential to interrupt Resident 1's continuity of care. Findings: A review of Resident 1's Admission Record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 715L11 Facility ID: CA910000041 If continuation sheet 2 of 7 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 09/23/2019 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 indicated the resident was initially admitted to the facility on 9/1/17 and last re-admitted on 7/8/19. Resident 1's diagnoses included sepsis (infection in the blood), urinary tract infection ([UTI] an infection of the urinary bladder), neuromuscular dysfunction of the bladder (lack bladder control), and quadriplegia (permanent immobility of both arms and both legs [all four limbs]). A review of Resident 1's Admission Assessment, dated 7/9/19, indicated the resident was alert, oriented and quick to comprehend. A review of a nurses' note, dated 7/8/19 and timed at 7:30 p.m., indicated Resident 1 was placed on contact isolation for VancomycinResistant Enterococcus ([VRE] bacteria that is resistant to antibiotics) of the rectum. A review of a "Change of Condition ([COC] a sudden, clinically important abnormality from a patient's baseline in physical, cognitive, behavioral or functional) assessment note, dated 7/18/19, indicated on 7/18/19 at 7:10 a.m., Resident 1 complained of having a headache, nausea and was hypotensive (low blood pressure). The note indicated on the same day at 7:45 a.m., Resident 1 was transported to the hospital by the paramedics for hypotension. A review of Resident 1's physicians' orders dated 7/18/19 and timed at 7:45 a.m., indicated to transfer Resident 1 to the GACH and provide a seven (7) day bed hold. The physician's order indicated Resident 1's seven-day bed hold was dated from 7/18/19 through 7/24/19. A review of Resident 1's GACH history and physical (H/P), dated 7/18/19, indicated Resident 1 was admitted to the hospital for a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 715L11 Facility ID: CA910000041 If continuation sheet 3 of 7 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 09/23/2019 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 diagnosis of septic shock (infection that spreads throughout the blood and tissues, caused by extremely low blood pressure and can result in organ failure) and UTI. The note indicated Resident 1 was administered two different antibiotics. A review of Resident 1's Infectious Disease Physician's ([ID] a physician who specializes in the treatment of organisms, infections, bacteria, viruses, fungi and/or parasites) progress note, dated 7/21/19, indicated Resident 1's urine culture was positive for VRE and Carbapenemresistant Enterobacteriaceae ([CRE] a family of germs that are difficult to treat and are highly resistant to antibiotics). The H/P indicated a plan for Resident 1 that included administering different antibiotics, repeating a urinalysis ([UA] a urine test to assess all range of disorders including infection) and contact precautions. The H/P indicated Resident 1 verbalized feeling better, tolerating antibiotics, was afebrile (without a fever) and expressed a desire to return to the skilled nursing facility (SNF). A review of a letter from the Administrator dated 8/2/19, indicated on 7/22/19, the facility received a telephone call from the GACH, indicating Resident 1 was ready to return back to the facility. The SNF Administrator's letter indicated Resident 1 required isolation for VRE and CRE of the urine, the facility did not have any isolation beds available or any rooms which Resident 1 could cohort (a group of people joined together who share a defining characteristic) with. According to the Department of Public Health Acute Communicable Disease Control, residents with CRE may have a private room if feasible, if private rooms are not available, efforts to cohort with other patients with CRE, or residents with a lowest risk for acquiring FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 715L11 Facility ID: CA910000041 If continuation sheet 4 of 7 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 09/23/2019 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 CRE such as no indwelling devices, no open wounds and residents less dependent on the staff. On 7/26/19 at 2:27 p.m., during an interview, the facility's Admission Coordinator (AC) stated when residents are re-admitted, the hospital sends a referral for readmission. The AC stated the Director of Nursing (DON) reviews the referral and makes the final determination when residents require isolation. The AC stated the facility inquires about the type of antibiotic, the total days the antibiotic was administered and the type of isolation. The AC was asked about circumstances where residents were not readmitted to the facility, the AC replied when the facility was not able to accommodate residents. The AC stated the facility currently did not have any isolation rooms available and was instructed by the DON to inform the GACH, there were no isolation rooms available in the facility and we were not able to accommodate Resident 1. The AC was asked to provide phone communications she had with the GACH, but the AC stated she did not document any telephone conversations or communication she had with the GACH's Social Services (SS) or Discharge Planner (DCP) regarding Resident 1's readmission. On 7/26/19 at 3:13 p.m. and 4 p.m., during a telephone interviews, the DON stated if Resident 1 was on antibiotics for 72 hours and remain asymptomatic, then Resident 1 would be able to cohort with other residents and would have to remain in contact isolation forever. On 7/26/19 at 3:28 p.m., during a concurrent interview, the Assistant DON (ADON) stated the facility had an open bed in Room 255C for Resident 1. The ADON stated both residents in Room 255 did not have any open wounds or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 715L11 Facility ID: CA910000041 If continuation sheet 5 of 7 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 09/23/2019 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 invasive devices. On 7/26/19 at 3:43 p.m., during a telephone interview, the GACH's SS stated Resident 1 was asymptomatic and was cleared by the ID physician to return to the facility, however the facility refused to readmit Resident 1. On 8/9/19 at 12:34 p.m., during a telephone interview, the DON stated the facility did not readmit Resident 1 back to the facility and stated according to the Center of Disease Control (CDC), the resident would remain on isolation for a long time. On 8/19/19 at 10:40 a.m., during a telephone interview, the Administrator stated the facility could not readmit Resident 1 from the GACH due to isolation purposes and would have to ask other residents to move. The Administrator was asked about Room 255C that was indicated by the ADON on 7/26/19, as an available bed for cohorting, the Administrator stated the facility did not make any efforts to create an isolation room, accommodate Resident 1 and ask other residents to move temporarily. On 8/20/19 at 11:54 a.m., the Administrator stated the GACH did not call the facility regarding readmitting Resident 1 back to the facility within seven days. The Administrator was informed that during an interview the AC stated the GACH's SS called to readmit Resident 1 within the 7-day bed hold, but was instructed by the DON to refuse Resident 1's readmission. The Administrator stated per the facility's policy on communication, the AC did not document every conversation that took place with the GACH's SS and it was not a requirement to document proof of communication with the GACH regarding a residents' readmission. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 715L11 Facility ID: CA910000041 If continuation sheet 6 of 7 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 09/23/2019 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 undated policy titled "Procedure for Bed Hold," indicated when a resident of this facility is transferred to a general acute care hospital, the facility shall afford the resident a Bed Hold for seven (7) days which may be exercised by the resident or the resident's representative. The policy indicated a licensee who fails to meet these requirements shall offer to the resident the next available bed appropriate for the resident's needs. A review of the facility's undated policy titled "Infection Control," indicated residents with multi-drug resistant organisms ([MDRO] common bacteria (germs) that developed resistance to multiple types of antibiotics) may be placed on contact precautions include cohorting with who do not have any invasive devices or open wounds will be considered, cohorting considerations will include containment of the infected site and the compliance of the resident. The policy indicated room placement for residents cohorting with similar infections and/or the same MDRO, similar colonized MDRO and are asymptomatic. On 8/22/19 at 11:30 a.m., during a telephone interview, the Administrator stated the facility refused to readmit Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 715L11 Facility ID: CA910000041 If continuation sheet 7 of 7