Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Imperial Manor during CMS and state inspections, most recent first.
Two residents experienced unplanned and significant weight loss that was not promptly identified or addressed by staff. Despite observations of decreased intake and physical signs of weight loss, there was a lack of timely communication, assessment, and intervention by the IDT, DON, and RD. Facility policies requiring monitoring and comprehensive nutritional assessments were not followed, resulting in a deficiency related to maintaining adequate nutrition and hydration.
The facility did not ensure an RN was on duty for at least eight consecutive hours per day over a three-month period. Staffing records and staff interviews confirmed that the DON was the only RN and was not scheduled regularly, resulting in multiple days with no RN coverage as required by facility policy.
Maintenance staff did not calibrate resident weighing scales according to manufacturer instructions, instead using hand weights or placing a person on the scale rather than certified weights. The DON expected calibration to follow manufacturer guidelines, and facility policy required the use of calibrated scales for accurate resident weights.
Two residents received incorrect medication dosages when a nurse administered Benztropine mesylate without clarifying an unclear order and gave Olanzapine 20 mg in the morning instead of the prescribed 10 mg. The pharmacy dispensed incorrect tablet strengths, and the nurse did not verify or clarify orders as required, resulting in a medication error rate of 6.45%.
Two residents requiring pureed diets due to medical conditions received food that was not properly prepared, as pureed brussel sprouts were served with visible chunks instead of a smooth, lump-free consistency. Staff acknowledged the food did not meet recipe and policy standards, which require pureed foods to be smooth and eliminate the need for chewing.
The facility did not identify or address weight loss trends among two residents in its QAPI meetings, focusing instead on other issues. The DON acknowledged that weight loss should have been monitored and discussed as part of patient care, but it was not included in the QAPI agenda, resulting in a lack of systemic action to address the issue.
Two residents were affected when staff failed to follow infection control protocols: one resident's uncovered urinary drainage bag repeatedly touched the floor, and Enhanced Barrier Precautions were not implemented for another resident with indwelling medical devices. Staff interviews confirmed a lack of knowledge and adherence to required infection prevention practices.
The facility's Infection Preventionist did not complete the required annual specialized infection control training and held a Licensed Vocational Nurse license instead of the Registered Nurse license specified in the job description. Training records showed only a single 4-hour course and two online courses without CEUs, and the IP dedicated limited weekly hours to infection prevention duties.
A resident with severe cognitive impairment and a urinary catheter was repeatedly observed in the dining room with an uncovered urinary bag, visible to others. Staff interviews confirmed a lack of awareness and adherence to facility policy requiring catheter bags to be covered to maintain resident dignity.
Surveyors found that a resident room was housing six individuals, surpassing the allowed maximum of four per room. Facility records confirmed the over-occupancy, though no quality of care or quality of life issues were identified for those residing in the room.
Six resident rooms were found to provide less than the required 80 square feet per resident, with measurements ranging from 70 to 74 square feet per person in rooms housing three or four residents. Despite this deficiency, there was no indication that residents' health, safety, or quality of care was negatively impacted during the survey.
The facility failed to report an allegation of genital exposure between two residents to the State Agency, as required by its abuse reporting policy. This oversight allowed the alleged victim to remain in proximity to the alleged aggressor, preventing an investigation. The DON was unaware of the alleged aggressor's documented history of hypersexual behavior, and the Social Worker did not report the incident due to not being present. The facility's policies on reporting and protecting residents were not followed.
The facility failed to submit staffing information based on payroll data to CMS for the first quarter of 2023. The DON and FM mistakenly believed the submission was only required for Medicare residents, leading to non-submission. This resulted in a triggered status for the quarter, indicating no data was submitted.
The facility failed to ensure safe and sanitary kitchen practices, including improper labeling of food items, unclean oven exhaust fan and air vent, and incorrect calibration of the food thermometer. These deficiencies were confirmed by the cook, CDM, and DON, and were not in accordance with the facility's policies.
The facility failed to follow infection control practices by not conducting water testing for germs, including Legionella. The Maintenance Personnel confirmed that no water testing was performed, and the Director of Nursing stated there were no related illnesses among residents. However, there was no documented evidence to ensure water testing was being conducted.
The facility failed to ensure that two residents had their end-of-life wishes properly documented and signed in their medical records. Resident 8's POLST was missing the required signature from the legally recognized decision-maker, and Resident 24's POLST lacked the physician's signature and date, posing a risk of not honoring their end-of-life wishes.
A resident with dementia and severely impaired cognition developed a stage III pressure ulcer on her coccyx, but the facility failed to complete a significant change in status assessment (SCSA) in the minimum data set (MDS). Despite treatment and acknowledgment of the wound by staff, the necessary documentation and coding in the MDS were not performed, contrary to facility policy.
The facility failed to develop person-centered care plans for a resident at risk for pressure ulcers and another involved in a resident-to-resident altercation. Despite identifying a pressure ulcer and a behavioral incident, no care plans were created to guide treatment and monitoring, as confirmed by staff interviews and facility policy.
The facility failed to ensure that one resident room accommodated no more than four residents, as required by regulations. During a recertification survey, a room was observed to accommodate six residents. Despite this, there were no observed quality of care or quality of life concerns, and a continuance of a waiver allowing the six-bed room was recommended.
An observation during the annual recertification survey found that six resident rooms contained less than the required 80 square feet per resident. Despite this, there were no observed quality of care or quality of life concerns negatively impacting the residents. A continuance of a waiver for these rooms was recommended.
The facility failed to correlate the MDS assessment with the elopement risk assessment prior to a facility outing, resulting in a resident's elopement and attempts to walk into oncoming traffic. The resident, with a history of wandering behavior and moderate impairment, was incorrectly assessed as not at risk. During the outing, the resident ran away from the CNA and was found hours later attempting to walk into traffic again.
The facility failed to provide adequate supervision to a resident with a history of mental health disorders who eloped during an outing. The resident ran away from the CNA, attempted to run into traffic, and was later found at a local convenience store. An observation revealed that a door leading to a backyard was unlocked and unalarmed, allowing residents to access the area without staff supervision. The resident's care plan indicated an elopement risk, but a recent assessment stated otherwise.
Failure to Identify and Address Significant Unplanned Weight Loss
Penalty
Summary
The facility failed to identify and address unplanned and significant weight loss in two residents, resulting in a deficiency related to maintaining adequate nutrition and hydration. One resident with a history of paranoid schizophrenia, muscle spasm, dementia, and dysphagia experienced a progressive weight loss from July through November, which was not recognized or addressed by staff. Interviews revealed that CNAs noticed the resident's declining intake and need for assistance with eating, but this information was not consistently communicated to licensed nurses or the interdisciplinary team. The DON and RD acknowledged that the weight loss should have triggered weekly weights, IDT discussion, and physician notification, but there was no documentation of these actions being taken. Another resident with metabolic disorder, iron deficiency, paraplegia, and gastrostomy status also experienced significant unplanned weight loss over several months. Staff observed the resident refusing meals and noted physical changes such as looser-fitting briefs, indicating weight loss. Despite these observations and a documented 13.7% weight loss over six months, the RD did not perform a comprehensive nutritional assessment, citing that such assessments were only done annually regardless of significant weight changes. Progress notes indicated continued monitoring but no substantial intervention until further weight loss occurred. Facility policies required monitoring for undesirable weight changes, prompt identification of causes, and comprehensive nutritional assessments upon significant weight loss or change in condition. However, these policies were not followed, as evidenced by the lack of timely assessment, intervention, and communication among staff and the IDT. The failure to implement a comprehensive, systemic approach to monitoring and addressing nutritional status led to the deficiency cited in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, over a three-month period from October 1 to December 31, 2024. Review of the facility's payroll-based journal (PBJ) Staffing Data Report and Direct Care Service Hours Per Patient Day (DHPPD) reports confirmed that there were multiple days with no RN hours recorded, and interviews with facility staff, including the Facility Assistant (FA), a licensed nurse, and the Director of Nursing (DON), revealed that the DON was the only RN associated with the facility. The DON was not scheduled regularly and only came in on an as-needed basis, such as to cover call-offs or last-minute absences, and was not present for eight consecutive hours each day. Further review of facility policy indicated that an RN should provide services for at least eight consecutive hours every 24 hours, seven days a week. However, both staffing records and staff interviews confirmed that this requirement was not met, as there was no consistent RN coverage during the period in question. The DON acknowledged the lack of compliance with the RN coverage requirement, and the FA confirmed that from January 2025 onward, there continued to be no RN scheduled to work at the facility.
Failure to Calibrate Scales per Manufacturer Instructions
Penalty
Summary
The facility failed to ensure that resident weighing scales were calibrated according to the manufacturer's instructions. During interviews, the Maintenance Worker described calibrating the standing scale by pressing the tare button to zero it out and did not use any certified weights, instead placing a person on the scale to check accuracy. The Maintenance Supervisor reported using two five-pound hand weights to calibrate both the standing and wheelchair scales, placing the weights on the scale and confirming the reading matched the weight. However, a review of the manufacturer's instructions for both types of scales indicated that calibration should be performed using certified weights, with specific weight standards required for accuracy. The Director of Nursing confirmed that her expectation was for maintenance staff to calibrate the scales according to the manufacturer's instructions to ensure accurate resident weights. The facility's policy also required the use of calibrated and facility-approved scales for weighing residents. The failure to follow the manufacturer's calibration procedures had the potential to result in inaccurate weight measurements for residents.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two out of 31 observed medication administrations were performed incorrectly, resulting in an error rate of 6.45%. During a medication pass, a licensed nurse administered Benztropine mesylate to a resident with Parkinson's disease. The physician's order specified Benztropine mesylate 1 mg by mouth once daily, but the pharmacy dispensed a 20 mg tablet, and the order itself was unclear. The nurse did not clarify the order with the physician prior to administration, and both the nurse and the Director of Nursing acknowledged that clarification should have occurred. In a separate incident, the same nurse administered Olanzapine 20 mg to another resident with schizophrenia in the morning, despite the physician's order specifying 10 mg in the morning and 20 mg at bedtime. The pharmacy had dispensed 20 mg tablets for both morning and bedtime doses, and the medication was not administered according to the physician's order. The facility's policy required medications to be administered in accordance with prescriber orders and for the nurse to verify the correct dosage before administration, which was not followed in these cases.
Failure to Prepare Pureed Food to Required Consistency
Penalty
Summary
The facility failed to ensure that pureed food was prepared to the appropriate consistency for two residents who required a pureed diet due to medical conditions such as chewing problems and being underweight. For one resident with a history of metabolic disorder, iron deficiency, paraplegia, and gastrostomy status, the dietary services supervisor had assessed the need for a pureed diet. However, during food preparation, pureed brussel sprouts were observed to contain pea-sized chunks and were not smooth in appearance, which did not meet the required consistency for a pureed diet. Staff interviews and a review of the facility's recipe and policy confirmed that pureed foods should be smooth, lump-free, and meet the Spoon Tilt Test standard. The staff member preparing the food acknowledged that the brussel sprouts needed more broth and additional blending time to achieve the correct texture. The facility's policy and recipe both specified that pureed foods must eliminate the chewing phase and be free of lumps, but these standards were not followed during the observed preparation, resulting in food that did not meet the dietary needs of the residents.
Failure to Address Resident Weight Loss in QAPI Process
Penalty
Summary
The facility failed to identify and address weight loss trends among residents as part of its Quality Assurance Performance Improvement (QAPI) process. During interviews and record reviews, it was revealed that the QAPI meetings focused on issues such as elopement prevention and resident-to-resident altercations, but did not include discussions about resident weight loss. The Director of Nursing acknowledged that monitoring and addressing weight loss should have been part of the QAPI agenda, as it is a critical aspect of patient care. As a result, the facility did not implement a systemic approach to address the weight loss experienced by two residents, which was not recognized or acted upon prior to the recertification survey. A review of the facility's QAPI policy confirmed that its purpose is to monitor, evaluate, and improve the quality of resident care, and that staff at all levels are expected to identify and solve quality concerns. Despite this, the facility did not identify weight loss as an area requiring action, leading to the deficiency.
Failure to Follow Infection Control Program and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its own infection prevention and control program for two residents. For one resident with severe mental impairment and a diagnosis of benign prostate hyperplasia, repeated observations showed that the resident's uncovered urinary drainage bag was in contact with the floor while the resident was seated in the dining room. Interviews with CNAs and the DON confirmed that the urinary bag and tubing should not touch the floor, as per facility policy, which specifically states not to place the drainage bag on the floor. For another resident with multiple diagnoses, including paraplegia and gastrostomy status, who had indwelling medical devices, the facility did not implement Enhanced Barrier Precautions (EBP) as required by CDC guidelines. Observations revealed no signage or PPE available for EBP outside the resident's room. Interviews with the Infection Preventionist and the DON indicated a lack of knowledge about EBP and confirmed that EBP had not been implemented for residents with indwelling medical devices, despite current regulatory guidance and facility policy requiring adherence to up-to-date infection prevention standards.
Infection Preventionist Lacked Required Training and Credentials
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist Nurse (IP) completed the required annual specialized training in infection control. The IP, who had been in the role for about a year, reported spending the majority of his work hours passing medications and only dedicating a small portion of time weekly to infection prevention duties. Review of the IP's training certificates showed completion of a 4-hour infection control course and two additional online courses without listed continuing education units or credit hours. Additionally, the IP held a Licensed Vocational Nurse license rather than the Registered Nurse license specified as a requirement in the facility's job description for the Infection Preventionist. The job description also required participation in continuing education programs, which was not adequately documented.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with severe mental impairment and a diagnosis of benign prostate hyperplasia with lower urinary symptoms was observed multiple times in the dining room with an uncovered urinary catheter bag. The resident, who had a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment, was seen on several occasions with the urinary bag visible to others, while other residents were present in the dining area. Interviews with two CNAs revealed that one was unaware of the requirement to cover the urinary bag, while the other acknowledged that it should be covered to promote the resident's dignity. The Director of Nursing also confirmed that the urinary bag should have been covered in accordance with facility policy, which emphasizes treating residents with dignity and respect at all times. Facility policies reviewed supported the expectation that residents' dignity be maintained, including the covering of urinary bags.
Resident Room Exceeds Maximum Occupancy Limit
Penalty
Summary
During an initial facility tour, surveyors observed that one resident room contained six beds, exceeding the regulatory maximum of four residents per room. Review of the facility's Analysis of Accommodations confirmed that six residents were housed in this room, as documented by the facility. No quality of care or quality of life issues were identified for the six residents residing in the room at the time of the survey.
Resident Rooms Below Minimum Size Requirement
Penalty
Summary
During the annual recertification survey, observations and record reviews revealed that six out of nine resident rooms did not meet the minimum required space of 80 square feet per resident for multiple occupancy rooms. Specifically, rooms with three or four residents each provided between 70 and 74 square feet per resident, falling short of the regulatory standard. The facility's Analysis of Accommodations confirmed these measurements, with total room sizes ranging from 210 to 283 square feet for rooms housing three or four residents. Despite these deficiencies in room size, there was no evidence during the survey that the reduced space adversely affected residents' health, safety, quality of care, or quality of life.
Failure to Report Alleged Abuse and Protect Residents
Penalty
Summary
The facility failed to implement its abuse reporting policy when it did not report an allegation of genital exposure by one resident to another to the State Agency (SA). This failure resulted in the continued proximity of the alleged victim to the alleged aggressor and prevented an investigation by the SA. The incident involved two residents, one with schizoaffective disorder bipolar type and schizophrenia, and the other with paranoid schizophrenia and anxiety disorder. The alleged victim reported the incident to staff, but it was not escalated to the SA as required by the facility's policy. Interviews and record reviews revealed that the Director of Nursing (DON) was unaware of the alleged aggressor's history of hypersexual behavior, which was documented in a psychiatric note. The Social Worker did not report the incident because they were not present when it occurred. The facility's policy requires all reports of resident abuse to be reported to local, state, and federal agencies and thoroughly investigated, but this was not followed. The facility also failed to protect the residents from further harm during the investigation, as outlined in their policy.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS) for the first quarter of 2023. This failure was identified during interviews and record reviews with the Director of Nursing (DON) and Facility Manager (FM). Both the DON and FM confirmed that the Payroll-Based Journal (PBJ) Staffing Data Report for the first quarter of 2023 was not submitted. The DON and FM mistakenly believed that the PBJ submission was only required for residents with Medicare insurance, whereas their facility had residents with Medicaid insurance. This misunderstanding led to the non-submission of the required staffing data. A review of the facility's report for the first quarter of 2023 indicated that the metric for submitting data was not met, resulting in a triggered status, which means no data was submitted for the quarter. The CMS Electronic Staffing Data Submission Payroll-Based Journal; Long-Term Care Facility Policy Manual specifies that direct care staffing and census data must be collected quarterly and submitted timely and accurately. The facility failed to meet this requirement, as the submission was not received by the end of the 45th calendar day after the last day of the fiscal quarter.
Failure to Ensure Safe and Sanitary Kitchen Practices
Penalty
Summary
The facility failed to ensure safe and sanitary measures in the kitchen during dietary operations. Observations revealed that food items in the refrigerator and dry food storage room were not properly labeled with expiration or use-by dates. Items such as cilantro, cut cabbage leaves, grated parmesan cheese, tortillas, Monterey cheese, bagels, and cocoa were found without proper labeling. The cook and Certified Dietary Manager (CDM) confirmed that the policy required labeling with expiration dates, but this was not consistently followed. The Director of Nursing (DON) also emphasized the importance of labeling to prevent foodborne illnesses among residents. Additionally, the facility did not maintain cleanliness in the kitchen, as evidenced by dust and lint in the oven exhaust fan and air vent. The CDM and DON both acknowledged that these areas should be kept clean to prevent contamination of food with dust particles and microbes, which could potentially cause harm to residents. The facility's policy on sanitation and maintenance was not adhered to, as it required all kitchen and food storage areas to be maintained and sanitized according to state and federal regulations. Furthermore, the kitchen staff did not calibrate the food thermometer correctly. An observation showed that the cook placed the thermometer in a cup of ice water with the tip touching the base of the cup, which is not the correct method for accurate calibration. The CDM and DON both stated that the thermometer should be calibrated properly to ensure food safety. The facility's policy on calibrating thermometers was not followed, which could lead to inaccurate temperature readings and potential foodborne illnesses.
Failure to Conduct Water Testing for Germs
Penalty
Summary
The facility failed to follow infection control practices by not conducting water testing for germs, including Legionella. During a facility tour, the Maintenance Personnel (MP) confirmed that no water testing was performed to check for germs and elements. The Director of Nursing (DON) stated that there were no illnesses noted among residents related to water-borne infections. However, there was no documented evidence provided by the facility to ensure that water testing was being conducted.
Incomplete POLST Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had their end-of-life wishes properly documented and signed in their medical records. For Resident 8, the POLST (Physician Orders for Life-Sustaining Treatment) was not valid as it lacked the required signature and relationship information from the legally recognized decision-maker. Despite being on a public conservatorship, the POLST for Resident 8 was incomplete, which was confirmed during an interview and record review with the Director of Nursing (DON). The POLST had been signed by the physician but was missing the necessary signature from the responsible party, rendering it invalid. Similarly, Resident 24's POLST was found to be incomplete as it lacked the physician's signature and date. During an interview and record review with the DON, it was confirmed that the POLST should have been signed by the physician to be considered a valid order. The facility's policy on Palliative/End-of-Life Care-Clinical Protocol, which was revised in March 2018, mandates that the attending physician must review and sign the POLST to ensure the resident's end-of-life wishes are honored. The failure to have these documents properly signed and completed posed a risk of not honoring the residents' end-of-life wishes.
Failure to Complete Significant Change in Status Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) in the minimum data set (MDS) for a resident who developed a stage III pressure ulcer on her coccyx. The resident, who was admitted with dementia and had severely impaired cognition, was noted to have no skin conditions in her initial MDS. However, a physician's order for antibiotic ointment for a stage III pressure ulcer was issued, and the wound was treated but not documented in the MDS. Interviews with staff confirmed the presence and treatment of the pressure ulcer, but the necessary SCSA was not completed, and the change in the resident's condition was not coded in the MDS tool as required by facility policy and regulations. The Director of Staff Development (DSD) and the Director of Nursing (DON) acknowledged that the pressure ulcer was not coded in the MDS and that the licensed nurses should have triggered a situational alert to update the MDS. The facility's policy on comprehensive assessments mandates that significant changes in a resident's status, such as the development of a stage III pressure ulcer, should be documented in the MDS to aid in developing a person-centered care plan. The failure to complete the SCSA and update the MDS compromised the communication of the resident's status and medical history among the nursing staff.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, one at risk for pressure ulcers and another involved in a resident-to-resident altercation. Resident 5, who was admitted with dementia and had a severely impaired cognition score, developed a pressure ulcer on her tailbone. Despite the identification of the pressure ulcer and a physician's order for antibiotic ointment, no care plan was developed to address this condition. Both the Director of Staff Development and the Director of Nursing acknowledged that a care plan should have been created to guide the treatment and measure the effectiveness of the care provided. Resident 19, diagnosed with paranoid schizophrenia, was involved in an altercation with her roommate. Despite the incident, no care plan was developed to monitor or address the resident's behavioral needs. Interviews with the Certified Nursing Assistant and the Social Worker confirmed the lack of behavioral monitoring and the absence of a care plan. The Director of Nursing also confirmed that a care plan should have been developed to monitor and prevent further incidents. The facility's policy on care plans, which emphasizes the importance of goals and objectives for resident care, was not followed in these cases.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to ensure that one resident room accommodated no more than four residents, as required by regulations. During the recertification survey conducted from April 15, 2024, to April 18, 2024, room [ROOM NUMBER] was observed to accommodate six residents. Despite this non-compliance, there were no observed quality of care or quality of life concerns that negatively impacted the residents residing in that room. Consequently, a continuance of a waiver allowing the six-bed room was recommended.
Resident Room Size Deficiency
Penalty
Summary
An observation of resident rooms was conducted during the annual recertification survey from 4/15/24 through 4/18/24. It was found that six resident rooms contained less than the required 80 square feet per resident. Specifically, Room 1 housed 3 residents with 72 square feet per resident, Room 2 housed 3 residents with 74 square feet per resident, Room 3 housed 3 residents with 72 square feet per resident, Room 6 housed 3 residents with 70 square feet per resident, Room 7 housed 3 residents with 73.66 square feet per resident, and Room 8 housed 4 residents with 70.75 square feet per resident. Despite these deficiencies, there were no observed quality of care or quality of life concerns that negatively impacted the residents residing in those rooms. A continuance of a waiver allowing the six rooms that contained less than 80 square feet per resident was therefore recommended.
Failure to Correlate MDS and Elopement Risk Assessment
Penalty
Summary
The facility failed to correlate the Minimum Data Set (MDS) assessment with the elopement risk assessment prior to a facility outing that one resident attended with four other residents supervised by one Certified Nursing Assistant (CNA). This failure resulted in the resident's elopement from the outing and attempts to walk into oncoming traffic. The resident, who has been conserved and has resided in the secured behavioral health facility since 2015, was assessed to have moderate impairment and had a history of wandering behavior occurring 4 to 6 days as per the MDS section E0900 dated 2/28/24. Despite this, the facility's Risk of Elopement Assessment conducted by the Director of Nursing (DON) on 3/5/24 indicated that the resident was not at risk at that time. On 3/12/24, during a facility outing to a large store, the resident declined to return to the facility, ran away from the CNA, and attempted to run into oncoming traffic. The resident was found approximately four hours and 20 minutes later by the facility Social Worker (SW) at a local convenience store. The resident again tried to walk into oncoming traffic, entered a local motel, and locked the door. The resident was transported to the local emergency department and later to the County Mental Health Crisis Center, where they remained for two days before returning to the facility. The facility's policy on providing behavioral health services and conducting comprehensive assessments was not adhered to, leading to this incident.
Inadequate Supervision Leading to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a resident who eloped during a facility outing. The resident, who has been conserved and has resided in the secured behavioral health facility since 2015, has a history of mental health disorders including schizoaffective disorder, mood disorder, major depressive disorder, anxiety disorder, and suicidal ideations. During an outing to a large store, the resident declined to return to the facility, ran away from the CNA, and attempted to run into oncoming traffic. The resident was later found by the facility social worker at a local convenience store, tried to walk into oncoming traffic again, and eventually entered a local motel and locked the door. The resident was transported to the local emergency department and later to the County Mental Health Crisis Center before returning to the facility. The facility's Director of Nursing (DON) acknowledged that the resident had expressed a desire to leave the facility. An observation revealed that a door leading to a backyard was unlocked and unalarmed, with a gate approximately five feet high, and that residents were able to access this area without staff supervision. The facility had three prior elopements over the back gate and fence. The resident's care plan indicated an elopement risk, but a recent Risk of Elopement Assessment conducted by the DON stated that the resident was not at risk. The facility's policy on off-premises activities emphasized the need for proper supervision, which was not adequately provided in this instance.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Imperial
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| El Centro Post-acute Care | 4.3 mi | ★★★★★ | 0 | 0 |
| Pioneers Memorial Skilled Nursing Center | 9 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.