Imperial Manor

In the surveyor’s words

From the most serious findings on record at Imperial Manor, in the surveyor’s own words.

• Actual harm, isolatedF692Apr 10, 2025

  2. Resident 2 was admitted to the facility was readmitted on [DATE] with diagnoses to include paranoid schizophrenia (subtype of schizophrenia, a mental illness with persistent paranoid delusions), muscle spasm and dementia (memory loss) per the undated facility admission Record. A review of Resident 2's swallow evaluation dated 9/14/23 indicated Resident 2 had history of dysphagia (difficulty in swallowing) and examination performed was modified swallow impression positive laryngeal penetration. A review of Resident 2's weight records was conducted. […]

• Actual harm, isolatedF684Nov 22, 2021

  Based on observation, interview and record review, the facility failed to follow the prescribed diet orders and ensure 1 of 3 sampled residents (1) received a chopped diet (cut ,d+[DATE] inch or smaller). As a result, Resident 1 choked and died after consuming a sandwich that was not cut as ordered. Findings: According to the facility's Admission Record, Resident 1 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Intake Information sheet dated [DATE], Resident 1 was given a sandwich to eat by staff at the facility. While eating the sandwich, Resident 1 choked and died . […]

• No harm, potential for more than minimal, widespreadF727Apr 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure a registered nurse (RN) was on duty for 8 consecutive hours per day, for three months, October 1 to December 31, 2024. This failure had the potential for advanced care activities, that needed an RN, to not be provided to the residents due to the unavailable RN. Findings: During the initial tour of the facility on 4/07/2025 at 9 A.M., the only RN at the facility was the Director of Nursing (DON). […]

• No harm, potential for more than minimal, widespreadF908Apr 10, 2025

  Based on observation, interview, and record review the facility failed to ensure scales were calibrated per manufacturer's instructions. This failure had the potential for inaccurate weights to be obtained. Findings: During an observation and interview on 4/9/25 at 9:22 A.M., the Maintenance Worker (MW) stated the maintenance department was responsible for calibrating (the process of checking a measuring instrument to see if it is accurate) scales used to weigh residents. The MW stated the facility used two different scales: a standing scale for residents who were able to stand, and a scale to weigh residents while they are sitting in the wheelchair. The MW stated to calibrate the standing scale, he will press the tare button to zero out the scale. […]

• No harm, potential for more than minimal, widespreadF851Apr 18, 2024

  Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to Centers for Medicare & Medicaid Services (CMS) for one of four fiscal quarters (1st quarter of 2023 [10/01/23 to 12/31/23]). This failure resulted in lack of reporting of facility's direct care staffing as required by CMS. Findings: During a concurrent interview on 4/15/24 at 10:40 A.M. and 4/17/24 at 9:47 A.M. with the Director of Nursing (DON) and Facility Manager (FM), the Payroll -Based Journal Staffing Data Report (PBJ) for 1st quarter of 2023 (10/1/23 to 12/31/23) was reviewed.The DON and FM verified by stating the report indicated the 1st quarter was triggered because the facility did not submit the direct care staffing information… […]