Imperial Care Center: Fall Risk Records Falsified - CA
The resident, identified in inspection records only as Resident 1, had already fallen once before, on July 3, 2025, inside their room. No injury that time. They were discharged from the facility shortly after, for behavioral issues, and returned on July 21. The next day, two nurses from different shifts each completed a fall risk evaluation. One nurse, identified as RN 2, recorded a score of 16. The other, RN 3, recorded an 18.
The Director of Nursing told inspectors she wasn't sure which one was accurate.
It turned out neither was. Both nurses had documented that Resident 1 had no falls in the past three months. The July 3 fall was in the record. The Director of Nursing confirmed to inspectors that this was a straightforward error, not a judgment call.
That wasn't the only problem with RN 2's evaluation. She had also recorded that Resident 1 had no relevant change of condition. The Director of Nursing said that was wrong too. Resident 1 had, in fact, been readmitted specifically because of a documented change of condition related to behavioral issues. The Director of Nursing said RN 2 had also gotten the medications wrong, recording that Resident 1 took one to two of the medications listed on the evaluation when the actual number was three to four.
The errors didn't stop there. A third fall risk evaluation, completed on August 7, four days after Resident 1 fell again, recorded that the resident had none of the listed predisposing diseases. The Director of Nursing reviewed that evaluation with inspectors and said it too was inaccurate.
Inspectors visited on August 14 following a complaint. The fall that triggered the visit had happened August 3.
The Director of Nursing, to her credit, did not minimize what the paperwork failures meant. "Assessment must be accurate," she told inspectors, "because if assessments are not accurate there is a potential to not have the appropriate intervention for the residents." She acknowledged the facility had recently moved to a new system for fall risk evaluations, and that the duplicate July 22 entries, one from the morning shift nurse and one from the evening shift nurse, were a known byproduct of that transition. She said she was aware of both entries. She did not say anyone had caught the errors before the August 3 fall.
Fall risk evaluations exist for a specific purpose: to tell staff what a resident's actual vulnerabilities are so that protective steps can be put in place. A score is only meaningful if the information feeding it is accurate. A resident's fall history, their medications, their diagnoses, their recent changes in condition, each of those inputs shapes what interventions get ordered, what monitoring happens, how staff approach that person during a shift. When nurses record that a resident has had no recent falls, no change of condition, fewer medications than they actually take, and none of the relevant underlying diseases, the score that results is a number built on nothing.
Resident 1 had a documented fall on July 3. They had a documented behavioral change of condition. They were taking three to four medications on a list designed to flag fall risk. All of that information existed in the record. None of it made it into the evaluations completed the day after they came back to the facility.
Eleven days later, they 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.
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 22, 2026 · Our methodology
IMPERIAL CARE CENTER in STUDIO CITY, CA was cited for violations during a health inspection on August 14, 2025.
The resident, identified in inspection records only as Resident 1, had already fallen once before, on July 3, 2025, inside their room.
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.