Imperial Healthcare Center: Confusion Left Unmonitored - CA
That is what inspectors found at Imperial Healthcare Center following a complaint investigation completed December 31, 2025.
The resident, identified in inspection records only as Resident 1, had been admitted to the facility on August 11, 2025, alert and oriented. Nine days later, on August 20 at 9:42 p.m., a nursing progress note recorded that she had returned from dialysis alert but confused. The nurse who wrote that note, identified as RN 1, confirmed to inspectors that the confusion was new. It represented a change of condition. She knew what that meant.
RN 1 told inspectors that when a resident experiences a change of condition, a nursing assessment should be completed, the physician should be notified, and 72-hour monitoring should begin. She said none of that happened. There was no documented assessment. No physician notification. No SBAR, the structured communication tool nurses use to relay urgent clinical information. No monitoring. The record was silent after that single 9:42 p.m. note.
The resident's attending physician, identified as AP 1, learned about the confusion not from his nursing staff that night, but from inspectors during an interview on December 30, 2025, more than four months later.
His response was unambiguous. AP 1 told inspectors he was already aware that the resident's baseline laboratory values had been abnormal since August 19, the day before the confusion appeared. He said abnormal baselines were common among his patients. What was not common, he said, was a resident who was alert and oriented at baseline suddenly becoming confused. That was a change. And when something changed, he expected a call.
"If he had been notified of Resident 1's confusion," inspectors wrote, summarizing AP 1's statement, "he would have sent Resident 1 to the emergency room for evaluation immediately."
He was not notified. She was not sent.
RN 1 told inspectors that the resident was becoming less alert and less oriented in the period after the confusion first appeared. That progression, she acknowledged, was not addressed with any intervention. She said that failure could lead to deterioration of the resident's condition.
The facility's own policy, last revised in December 2016, required nurses to notify the attending physician of a significant change in a resident's physical, emotional, or mental condition, complete a comprehensive assessment, document the change, and implement continuous monitoring for at least 72 hours. The policy existed. The training presumably existed. On the night of August 20, none of it was applied.
Inspectors classified the violation as causing minimal harm or the potential for actual harm, and noted that only a few residents were affected. That classification reflects the regulatory scoring system's lower end of the harm scale. It does not mean nothing happened to the resident. It means inspectors could not document, from the records available, the full extent of what followed.
What the records did document was a woman growing less alert, less oriented, and less herself, while the people responsible for her care wrote one note and moved on.
Her doctor, had he known, would have put her in an ambulance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Imperial Healthcare Center from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
IMPERIAL HEALTHCARE CENTER in LA MIRADA, CA was cited for violations during a health inspection on December 31, 2025.
That is what inspectors found at Imperial Healthcare Center following a complaint investigation completed December 31, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.