Imperial Care Center: Inaccurate Fall Risk Assessments - CA
The nurses missed that the resident had fallen just three weeks earlier. They documented incorrect medication information. One nurse failed to note the resident's history of behavioral issues that had led to a previous discharge from the facility.
The errors came to light during a federal inspection in August, after the resident fell again on August 3.
Resident 1 had returned to Imperial Care Center on July 21 following a discharge for behavioral problems. The next day, two different nurses — one from the morning shift, another from the evening shift — each completed separate fall risk evaluations without communicating with each other.
The morning nurse, identified as RN 2, scored the resident's fall risk at 16 points. The evening nurse, RN 3, scored it at 18 points. But both assessments contained the same critical error: they indicated the resident had experienced no falls in the previous three months.
The resident had fallen in their room on July 3, just 19 days earlier.
"RN 2 and RN 3's fall risk evaluation was inaccurate because RN 2 and RN 3 indicated Resident 1 had no falls in the past three months and that is inaccurate because Resident 1 had a fall on 7/3/2025," the Director of Nursing told inspectors.
The medication documentation was equally flawed. RN 2 recorded that the resident took "one to two" of certain medications, when the actual number was "three to four," according to the Director of Nursing.
RN 2 also failed to document the resident's history of behavioral issues — the very problems that had led to their earlier discharge and recent readmission to the facility.
The documentation problems extended beyond July. When nurses completed another fall risk evaluation for the same resident on August 7, they indicated the resident had "none of the listed predisposing diseases" that could contribute to falls.
The Director of Nursing acknowledged this assessment was also inaccurate.
During the inspection, the MDS coordinator expressed uncertainty about which fall risk evaluations were reliable. "The MDS stated was unsure which fall risk evaluations were accurate," inspectors noted.
The Director of Nursing explained that all residents at Imperial Care Center are considered fall risks "due to poor cognitive awareness and safety issues." Before the August 3 fall, she said, this particular resident was not classified as high risk for falls and could walk without assistance devices.
The facility's own policies require documentation to be "objective, complete, and accurate." The fall risk policy specifically states that staff must identify factors "related to the resident's specific risk and cause to try to prevent the resident from falling and to try to minimize complications from falling."
The Director of Nursing told inspectors that accurate assessments are essential for resident safety. "Assessment must be accurate because if assessments are not accurate there is a potential to not have the appropriate intervention for the residents," she said.
The facility had implemented a new system for fall risk evaluations, but the Director of Nursing acknowledged being unsure which of the conflicting July 22 assessments was correct. The communication breakdown between nursing shifts meant the resident received multiple evaluations on the same day, each containing different errors.
Federal inspectors found the documentation failures represented a violation of requirements for accurate resident assessments. The inspection was conducted in response to a complaint about the facility.
The resident's case illustrates how documentation errors can cascade through a facility's care system. The missed fall history, incorrect medication records, and overlooked behavioral issues all represented pieces of information that could have influenced fall prevention strategies.
Two weeks after the flawed assessments, on August 3, the resident fell again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Imperial Care Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
IMPERIAL CARE CENTER in STUDIO CITY, CA was cited for violations during a health inspection on August 14, 2025.
The nurses missed that the resident had fallen just three weeks earlier.
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.