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Deficiency Records for Imperial Care Center
A list of the most recent deficiencies for Imperial Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Imperial Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-15 | 2024-08-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-15 | 2024-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-15 | 2024-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-15 | 2024-08-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-15 | 2024-08-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-15 | 2024-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-15 | 2024-08-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-15 | 2024-08-05 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-07-12 | 2024-08-02 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-07-12 | 2024-08-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-12 | 2024-08-02 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-07-12 | 2024-08-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-12 | 2024-08-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-12 | 2024-08-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-12 | 2024-08-02 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-07-12 | 2024-08-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-12 | 2024-08-02 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-07-12 | 2024-08-02 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-07-12 | 2024-08-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-12 | 2024-08-02 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-07-12 | 2024-08-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-12 | 2024-08-02 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-07-12 | 2024-08-02 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-07-12 | 2024-08-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-12 | 2024-08-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-12 | 2024-08-02 | Y |
| Keep all essential equipment working safely. | Health | 2024-07-12 | 2024-08-02 | Y |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-07-12 | 2024-08-02 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-07-12 | 2024-08-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-13 | 2024-06-29 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-06-13 | 2024-06-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-10 | 2024-06-06 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-04-02 | 2024-04-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-20 | 2024-04-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-20 | 2024-04-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-20 | 2024-04-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-20 | 2024-04-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-20 | 2024-04-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-12 | 2024-01-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-12 | 2024-01-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-01 | 2023-12-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2023-12-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-09 | 2023-11-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-18 | 2023-07-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-18 | 2023-07-13 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-06-18 | 2023-07-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-18 | 2023-07-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-18 | 2023-07-13 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-18 | 2023-07-13 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-06-18 | 2023-07-13 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-06-18 | 2023-07-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-30 | 2023-06-16 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-30 | 2023-06-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-10 | 2023-06-16 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-10 | 2023-06-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-23 | 2023-06-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-10 | 2023-05-22 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-05-10 | 2023-05-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-10 | 2023-05-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-10 | 2023-05-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-10 | 2023-05-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-10 | 2023-05-22 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-10 | 2023-05-22 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-10 | 2023-05-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-10 | 2023-05-22 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-08 | 2023-03-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-07 | 2023-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-26 | 2022-11-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-30 | 2022-10-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-14 | 2022-10-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-10-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-05 | 2022-08-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-05 | 2022-08-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-07-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-15 | 2022-04-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-17 | 2022-04-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-27 | 2022-03-16 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-12-27 | 2022-01-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-27 | 2022-01-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-20 | 2021-06-14 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-05-20 | 2021-06-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-20 | 2021-06-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-05-20 | 2021-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-20 | 2021-06-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-20 | 2021-06-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-20 | 2021-06-14 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-05-20 | 2021-06-14 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-20 | 2021-06-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-20 | 2021-06-14 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-05-20 | 2021-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-20 | 2021-06-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-20 | 2021-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-20 | 2021-06-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-27 | 2021-06-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-05-27 | 2021-06-12 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-05-27 | 2021-06-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-27 | 2021-06-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-21 | 2019-11-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-10-21 | 2019-11-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-10-21 | 2019-11-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-21 | 2019-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-21 | 2019-11-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-10-21 | 2019-11-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-21 | 2019-11-14 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-21 | 2019-11-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-10-21 | 2019-11-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-21 | 2019-11-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-21 | 2019-11-14 | N |
| Post nurse staffing information every day. | Health | 2019-10-21 | 2019-11-14 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-10-21 | 2019-11-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-21 | 2019-11-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-10-21 | 2019-11-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-21 | 2019-11-14 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2021-05-20 | Not Fixed | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-10-21 | Not Fixed | N |
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