Other·July 6, 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 of a Complaint Investigation during an Abbreviated Survey. Complaint Number: CA00568039 Representing the Department of Public Health: Surveyor ID Number: 37198, RN, HHEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. There were two deficiencies issued for CA00568039

F580 SS=G Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 07/13/2018 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); 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: JVB411 Facility ID: CA940000115 If continuation sheet 1 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy and procedure to notify the physician of a change in condition FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 2 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 for one of three sampled residents (Resident 1). Resident 1 had an episode of vomiting with loose stool at the time the facility had a viral (tiny organisms that may lead to mild to severe illnesses) gastroenteritis (inflammation of the stomach and the intestines characterized by nausea, vomiting, diarrhea, and cramps) outbreak with many other residents, but the physician was not notified. This failure of not notifying Resident 1's physician, per the facility's policy, resulted in the resident's condition worsening, a delay in diagnosis, care, and treatment. Resident 1 expired in the Emergency Department (ED) six hours later. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 6/3/17. Resident 1's diagnoses included sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), Parkinson's disease (a disorder of the nervous system that primarily affects bodily movement), and dementia (a group of symptoms that affects memory, thinking and interfering with daily life). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 12/13/17, indicated Resident 1 had the ability to sometimes understand and be understood by others. The MDS indicated Resident 1 required extensive assistance in most activities of daily living (ADLs). According to the MDS, Resident 1 had dysphagia (difficulty in swallowing) and required the use of a feeding tube (gastrostomy tube [G-tube], a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 3 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 tube placed surgically into the stomach to provide nutrition and hydration). A review of a Physician Orders for LifeSustaining Treatment ([POLST] a legal document stating the type of care a person would like in an emergency medical situation.), prepared 12/26/14, indicated Resident 1 did not want cardiopulmonary resuscitation ([CPR] the action or process of reviving someone from unconsciousness or apparent death). A review of Resident 1's Order Summary Report for the month of 12/2017, indicated the resident had a physician's order for no resuscitation, for treatments to be comfort focused, and for the resident to have long term artificial nutrition including feeding tubes. A review of Resident 1's Care Plan, dated 6/30/17, indicated the resident had the potential risk for diarrhea due to decrease in mobility, pain medications, and psychotropic medications (affecting mental activity, behavior, or perception, as a mood-altering drug). The staff's interventions included to observe Resident 1 for episodes of diarrhea (watery stool). A review of a Licensed Nurses (LN) Progress Note, dated 12/30/17, and timed at 6:30 a.m., indicated Registered Nurse 1 (RN 1) documented that at the beginning of the shift, RN 1 spoke to Resident 1's family member (FM 1) at the bedside. The note indicated FM 1 informed RN 1 that she was going to stay in the facility with Resident 1 because the resident was becoming sick. According to the note, Resident 1 had one episode of vomiting and loose stool with occasional moaning. There was no documentation what the staff's interventions were at that time. The note also did not indicate if any vital signs (signs of life; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 4 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 specifically: the heart rate, respiratory rate [number of breaths per minute], body temperature, and blood pressure of a person) were taken at that time. A review of a LN Progress Note, dated 12/30/17, and timed at 5 a.m., indicated Charge Nurse 1 (CN 1) observed Resident 1 pale and breathing fast with a respiration rate of 25 (Normal Reference Range [NRR] = 1220). According to the note, Resident 1's blood pressure was 71/64 (NRR for the top number = 90 - 120 and the bottom number = 60 - 80) and the heart rate was 59 beats per minute (NRR = 60 -100). The note indicated that FM 1 requested for Resident 1 to be transferred to the general acute care hospital (GACH) so the facility staff called 911. A review of Resident 1's Physician's Order, dated 12/30/17, and timed at 6 a.m., indicated to transfer the resident to the GACH via 911 due to hypotension (low blood pressure) and low oxygen saturation (the amount of oxygen circulating into your bloodstream). A review of the Fire Department's Prehospital Care Report Summary, dated 12/30/17, indicated a call was received at 5:56 a.m. from the facility. The report summary indicated the chief complaint was altered level of consciousness ([ALOC] means that you are not as awake, alert, or able to understand or react as normal) for a duration of eight hours. The report summary further indicated Resident 1 was unconscious with a blood pressure of 67/37. Resident 1's Glasgow Coma Score ([GCS] a standardized system for assessing response to stimuli by assessing eye opening, verbal response, and motor ability) was 1-1-1 (1 point = no eye opening response, 1 point = no verbal response, 1 = no motor response). The report summary indicated the facility called FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 5 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 911 due to Resident 1 having low oxygen saturation, low blood pressure, and an ALOC. A review of the GACH's notes in the Emergency Department (ED), dated 12/30/17, and timed at 7:04 a.m., indicated Resident 1's oxygen saturation while receiving two (2) liters of oxygen via nasal cannula (plastic tubing which runs under the nose and is used to administer oxygen) was 92 percent (%) (NRR = 95-100 percent). At 9 a.m., the same date (12/30/17) the ED note indicated that Resident 1 had bloody diarrhea and FM 1 who was at bedside reported that the resident vomited twice the day prior and had diarrhea since early that morning. At 11:11 a.m., on 12/30/17, the ED note indicated that Resident 1 was asystole (a form of cardiac arrest in which the heart stops beating and there is no electrical activity in the heart) and there was no pulse present. Resident 1 was pronounced dead at that time. A review of Resident 1's Certificate of Death, indicated Resident 1 expired on 12/30/17 at 11:11 a.m., with cardiopulmonary failure as the immediate cause and septic shock (a lifethreatening condition that happens when blood pressure drops to a dangerously low level after an infection) as the underlying cause. On 3/14/18 at 10:55 a.m., during a telephone interview, RN 1 stated Resident 1 had a "Do Not Resuscitate" (DNR) order. RN 1 stated FM 1 informed her that Resident 1 was not looking good at that time. RN 1 stated Resident 1 had an episode of vomiting but she did not think it was a significant amount. On 5/21/18 at 2:54 p.m., during a subsequent telephone interview, RN 1 stated Certified Nursing Assistant 1 (CNA 1) and FM 1 informed her that Resident 1 had an episode of loose stool. RN 1 stated when a resident has FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 6 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 an episode of loose stool, they should observe the resident first and if there was more than one episode of loose stool, they should call the physician. RN 1 confirmed that the physician was not notified initially about the episode of loose stool and vomiting and she did not assess and document Resident 1's vital signs and should have. During an interview with the Director of Nursing (DON), on 5/21/18 at 4:30 p.m., the DON stated RN 1 should have contacted the physician regarding Resident 1's episode of vomiting. The DON confirmed that at the time this happened on 12/30/17, the outbreak had not yet been cleared. The DON stated the facility was not cleared of the gastroenteritis outbreak until 1/2/18. A review of a letter sent by the facility to the Department on 12/27/17 indicated the facility was reporting a possible viral gastroenteritis outbreak in their facility that involved a total of 11 residents on 12/25/17. A review of a line list (a table that summarizes information about persons who may be associated with an outbreak) attached to the letter indicated the symptoms associated with the outbreak were vomiting, diarrhea, and fever. The letter indicated that as of 12/27/17, there were two residents who still continued to show symptoms of vomiting that developed on 12/25/17. A review of the facility's policy and procedure, titled, "Change in a Resident's Condition or Status," revised on 2/2014, indicated the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a significant change in the resident's physical/emotional/mental condition. A "significant change" of condition is a decline or improvement in the resident's status that will FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 7 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 not normally resolve itself without intervention by staff or by implementing standard diseaserelated clinical interventions (is not "selflimiting"). A review of the facility's policy and procedure, titled, "Acute Condition Changes - Clinical Protocol," revised on 12/2012, indicated before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician; for example, history of present illness and previous and recent test results for comparison. The policy indicated phone calls to the attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status.

F684 SS=G Quality of Care CFR(s): 483.25

F684 07/13/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to adhere to its policy and procedure for change in condition for one of three sampled residents (Resident 1). Resident 1, who had altered level of consciousness ([ALOC] not as awake, alert, or able to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 8 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 understand or react as normal) and episodes of vomiting and loose stool that was not adequately assessed and reported to the physician timely. This deficient practice resulted in delay in diagnoses, care and treatment and Resident 1 being transferred to a general acute care hospital (GACH) via 911 emergency, which lead to Resident 1 expiring in the GACH's Emergency Department (ED) six (6) hours later. Findings: A review of a letter sent to the Department on 12/27/17 indicated the facility reported a possible viral gastroenteritis (an intestinal infection marked by watery diarrhea, abdominal cramps, nausea or vomiting, and sometimes fever) outbreak in the facility that involved a total of 11 residents on 12/25/17. A review of a line list (a table that summarizes information about persons who may be associated with an outbreak) attached to the letter indicated the symptoms associated with the outbreak were vomiting, diarrhea, and fever. The letter indicated that as of 12/27/17, there were two residents who still continued to have symptoms of vomiting that developed on 12/25/17. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 6/3/17. Resident 1's diagnoses included sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), Parkinson's disease (a disorder of the nervous system that primarily affects bodily movement), and dementia (a group of symptoms that affects memory, thinking and interfering with daily life). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 9 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 12/13/17, indicated Resident 1 had the ability to sometimes understand and be understood by others. The MDS indicated Resident 1 required extensive assistance in most activities of daily living (ADLs). According to the MDS, Resident 1 had dysphagia (difficulty in swallowing) and required the use of a feeding tube (gastrostomy tube [G-tube], a tube placed surgically into the stomach to provide nutrition and hydration). A review of a Physician Orders for LifeSustaining Treatment ([POLST] a legal document stating the type of care a person would like in an emergency medical situation.), prepared 12/26/14, indicated Resident 1 did not want cardiopulmonary (relating to the heart and lungs) resuscitation ([CPR] the action or process of reviving someone from unconsciousness or apparent death), only comfort-focused treatments. A review of Resident 1's Order Summary Report for the month of 12/2017, indicated the resident had a physician's order for no resuscitation (the action or process of reviving someone from unconsciousness or apparent death), for treatments to be comfort focused, and for the resident to have long term artificial nutrition including feeding tubes. A review of Resident 1's Care Plan, dated 6/30/17, indicated the resident had the potential risk for diarrhea due to decrease in mobility, pain medications, and psychotropic medications (affecting mental activity, behavior, or perception, as a mood-altering drug). The staff's interventions included to observe Resident 1 for episodes of diarrhea (watery stool). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 10 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 a Licensed Nurses (LN) Progress Note, dated 12/30/17, and timed at 6:30 a.m., indicated Registered Nurse 1 (RN 1) documented that at the beginning of the shift (11 p.m. on the previous day), RN 1 spoke to Resident 1's family member (FM 1) at the bedside. The note indicated FM 1 informed RN 1 that she was going to stay in the facility with Resident 1 because the resident was becoming sick. According to the note, Resident 1 had one episode of vomiting and loose stool with occasional moaning. There was no documentation what the staff's interventions were at that time. The note also did not indicate if any vital signs (signs of life; specifically: the heart rate, respiratory rate [number of breaths per minute], body temperature, and blood pressure of a person) were taken at that time. Further review of the note indicated at approximately 5 a.m., Charge Nurse 1 (CN 1) observed Resident 1 to be pale and breathing fast with a respiration rate of 25 (Normal Reference Range [NRR] = 12-20). According to the note, Resident 1's blood pressure was 71/64 (NRR for the top number = 90 - 120 and the bottom number = 60 - 80) and the heart rate was 59 beats per minute (NRR = 60 -100). The note indicated that FM 1 requested for Resident 1 to be transferred to the general acute care hospital (GACH) so the facility staff called 911. A review of Resident 1's Physician's Order, dated 12/30/17, and timed at 6 a.m., indicated to transfer the resident to a GACH via 911 due to hypotension (low blood pressure) and low oxygen saturation (the amount of oxygen circulating into your bloodstream). A review of the Fire Department's Prehospital Care Report Summary, dated 12/30/17, indicated a call was received at 5:56 a.m. from the facility. The report summary indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 11 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 chief complaint was altered level of consciousness ([ALOC] not as awake, alert, or able to understand or react as normal) for a duration of eight hours. The report summary further indicated Resident 1 was unconscious with a blood pressure of 67/37. Resident 1's Glasgow Coma Score ([GCS] a standardized system for assessing response to stimuli by assessing eye opening, verbal response, and motor ability) was 1-1-1 (1 point = no eye opening response, 1 point = no verbal response, 1 = no motor response). The report summary indicated the facility called 911 due to Resident 1 having low oxygen saturation, low blood pressure, and an ALOC. A review of the GACH's Emergency Department (ED), dated 12/30/17, and timed at 7:04 a.m., indicated Resident 1's oxygen saturation while receiving two (2) liters of oxygen via nasal cannula (plastic tubing placed into the nose to administer oxygen) was 92 percent (%) (NRR = 95-100 percent). At 9 a.m., on 12/30/17, the ED note indicated that Resident 1 had bloody diarrhea and FM 1 who was at bedside reported that the resident vomited twice the day prior and had diarrhea since early that morning. At 11:11 a.m., the same day (12/30/17), the ED note indicated that Resident 1 was in asystole (a form of cardiac arrest in which the heart stops beating and there is no electrical activity in the heart) and there was no pulse present. Resident 1 was pronounced dead at that time. A review of Resident 1's Certificate of Death indicated Resident 1 expired on 12/30/17 at 11:11 a.m., with cardiopulmonary failure as the immediate cause and septic shock (a lifethreatening condition that happens when blood pressure drops to a dangerously low level after an infection) as the underlying cause. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 12 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 3/14/18 at 10:55 a.m., during a telephone interview, RN 1 stated Resident 1 had a "Do Not Resuscitate" (DNR) order. RN 1 stated FM 1 informed her that Resident 1 was not looking good at that time (12/30/17). RN 1 stated Resident 1 had an episode of vomiting, but she did not think it was a significant amount. On 5/21/18 at 2:54 p.m., during a subsequent telephone interview, RN 1 stated Certified Nursing Assistant 1 (CNA 1) and FM 1 informed her that Resident 1 had an episode of loose stool. RN 1 stated when a resident has an episode of loose stool, they should observe the resident first and if there was more than one episode of loose stool, then they should call the physician. RN 1 confirmed that the physician was not notified initially about the episode of loose stool and vomiting and she did document Resident 1's vital signs. RN 1 stated Resident 1's vital signs should have been assessed and documented during the resident's change in condition. During an interview with the Director of Nursing (DON), on 5/21/18 at 4:30 p.m., the DON stated RN 1 should have contacted the physician regarding Resident 1's episodes of vomiting. The DON confirmed that at the time of Resident 1's change in condition on 12/30/17, the facility's viral outbreak had not yet been cleared. The DON stated the facility was not cleared of the gastroenteritis outbreak until 1/2/18. During a telephone interview with a Licensed Vocational Nurse 1 (LVN 1), on 5/22/18 at 3:20 p.m., LVN 1 stated during the time of the viral outbreak, she documented a Situation, Background, Assessment, Recommendation ([SBAR] used to facilitate prompt and appropriate communication) for every resident who vomited or had diarrhea. LVN 1 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 13 of 14 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: _______________ 056115 (X3) DATE SURVEY COMPLETED 06/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IMPERIAL HEALTHCARE CENTER 11926 La Mirada Blvd La Mirada, CA 90638 (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 she does not know or remember why she did not include Resident 1. During a telephone interview, on 5/23/18 at 3:20 p.m., LVN 2 stated when a resident had a change of condition, the SBAR was started and the physician was notified. LVN 2 stated for episodes of vomiting, an SBAR should be completed right away. A review of the facility's policy and procedure titled, "Change in a Resident's Condition or Status," revised on 2/2014, indicated the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a significant change in the resident's physical/emotional/mental condition. A "significant change" of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard diseaserelated clinical interventions (is not "selflimiting"). A review of the facility's policy and procedure, titled, "Acute Condition Changes - Clinical Protocol," revised on 12/2012, indicated before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician; for example, history of present illness and previous and recent test results for comparison. The policy indicated phone calls to the attending or on-call physician should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JVB411 Facility ID: CA940000115 If continuation sheet 14 of 14