Imperial Care Center

F-F604

A review of Resident 4 ' s Admission Record indicated the facility admitted Resident 4 on 1/15/2015, and readmitted the resident on 3/6/2024, with diagnoses that included major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the right hand.

A review of Resident 4 ' s Side Rail/Entrapment Assessment/Care Plan, dated 3/6/2024, indicated a recommendation of side rail was not indicated.

A review of Resident 4 ' s History and Physical (H&P), dated 3/12/2024, indicated Resident 4 did not have

the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 A review of Resident 4 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/3/2024, indicated the resident sometimes had the ability to make self-understood and understand Level of Harm - Minimal harm or others. The MDS indicated the resident had impaired upper and lower extremities and was mostly dependent potential for actual harm on mobility and activities of daily living (ADLs).

Residents Affected - Some A review of Resident 4 ' s Fall Risk Assessment, dated 6/8/2024, indicated Resident 4 was high risk for falls and injuries.

During an observation on 7/9/2024, at 8:58 a.m., during resident screening, inside Resident 4 ' s room, Resident 4 was observed lying down in bed with both upper side rails up.

During an observation and interview on 7/10/2024, at 5:45 p.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 4 ' s room, Resident 4 was observed lying down in bed with both upper side rails up. CNA 3 stated she places both upper side rails up during evening shift to prevent the resident from falls and injuries. CNA 3 stated she knows that there was no order for both upper side rails to be on.

During a concurrent interview and record review on 7/10/2024, at 6:21 p.m., with Registered Nurse 4 (RN 4), Resident 4 ' s Order Summary Report, Physical Restraint Assessment Form, and Informed Consent were reviewed. RN 4 stated there was no physician order for both upper side rails to be on the resident, no Physical Restraint Assessment Form, and no Informed Consent from the resident or resident representative prior to the application of restraint both upper side rails use on the resident ' s medical chart. RN 4 stated it was important to obtain a physician ' s order, do a physical restraint assessment, and obtain an informed consent on the use of the restraint both upper side rails up to ensure appropriate use of the restraint to prevent injuries and physical decline to residents. RN 4 stated obtaining an informed consent from the resident or resident representative on the use of the restraint side rails honors the right of the resident to decide after being explained the risked and benefits of side rails if they want to use them.

During an interview on 7/12/2024, at 6:15 p.m., with the Director of Nursing (DON), the DON stated it was important to obtain a physician ' s order on the use of both upper side rails as a restraint, complete a Physical Restraint Assessment, and obtain an informed consent from the resident or resident representative prior to application of the restraint both upper side rails to ensure the safety and appropriate use of the restraint side rails and to prevent the resident from potential injuries such as entrapment.

A review of the facility's recent policy and procedure titled, Side Rail Use when Not a Restraint, last reviewed

on 7/2023, indicated use of both side-rails in up position is not considered a restraint when resident is immobile and cannot voluntarily get out of bed due to a physical limitation. Complete a Physical restraint Assessment Form. Complete Informed Consent. If the Physical Restraint Assessment Form demonstrates that the resident is immobile and cannot voluntarily get out of bed due to a physical limitation, then proceed with the accompanying IDT for Use of both Side rails as non-Restraint. The license nurse should obtain an order from the attending physician that may include the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 -Resident may have both side rails up when in bed, resident does not have voluntary or involuntary movement and resident is immobile and cannot voluntarily get out of bed due to physical limitation. This use Level of Harm - Minimal harm or of both Side Rails for this resident is not considered a restraint. Complete Care Plan entry for both side rails potential for actual harm up.

Residents Affected - Some A review of the facility's recent policy and procedure titled, Physical Restraints, last reviewed on 7/2023, indicated physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one's body. The IDT shall evaluate the outcome of all measures attempted and make recommendations accordingly. The licensed nurse shall be responsible for obtaining an order from the attending physician, which include:

a. Specific type of restraint.

b. Purpose of the restraint.

c. Time and place of application.

d. Approaches to prevent decreased functioning when applicable.

e. Informed consent obtained from resident or from surrogate decision-maker.

The Plan of Care shall specify the reason for the use of the restraint, the type, when and where it is to be used.

A review of the facility's recent policy and procedure titled, Informed Consent, last reviewed on 7/2023, indicated this facility will verify that the patient's health record contains documentation that the patient has given informed consent before initiating the administration of psychotherapeutic drugs or physical restraints.

Before initiating the administration of psychotherapeutic drugs or physical restraints, facility staff shall verify that the patient's health record contains documentation that the patient has given informed consent to the proposed treatment or procedure.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 44244

Residents Affected - Some Based on interview and record review, the facility failed to:

1.Ensure Licensed Vocational Nurse 2 (LVN 2) completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, administered, and wasted) for Resident 83 ' s clonazepam (a controlled substance [medications that are considered to have a strong potential for abuse and may also lead to physical or psychological dependence] to treat anxiety [feeling of worry, nervousness, or restlessness) on the Antibiotic or Controlled Drug Record form (a document used to track the administration of controlled substances) in one of two observed medication carts (Medication Cart 3) observed during the Medication Storage and Labeling task.

2.Ensure licensed nursing staff completed documentation indicating reconciliation of controlled medications at every change of shift on the Narcotic Count Sheet form in one of two medication carts (Medication Cart 3) observed during the Medication Storage and Labeling task.

These deficient practices had the potential for inaccurate reconciliation of controlled medication and placed

the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of prescription drugs for their use for unintended purposes) of controlled medications.

Findings:

a. A review of Resident 83 ' s Admission Record indicated the facility admitted the resident on 9/16/2021 and readmitted the resident on 10/30/2023 with diagnoses that included unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), anxiety disorder (persistent and excessive worry that interferes with daily activities), schizophrenia (mental disorder in which people interpret reality abnormally), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).

A review of Resident 83 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 5/17/2024, indicated the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS further indicated the resident was dependent on staff for eating, oral hygiene, toileting, bathing, personal hygiene, and dressing. The MDS indicated the resident was taking antianxiety medication.

A review of Resident 83 ' s physician orders indicated orders for the following:

-Clonazepam oral tablet 0.5 milligrams (mg, a unit of measurement), give 0.5 mg by mouth three times a day for anxiety manifested by inability to cope with daily living activities causing stress, dated 10/30/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a concurrent Medication Storage observation and interview on 7/10/2024 at 2:38 p.m., Licensed Vocational Nurse 1 (LVN 1) reviewed Medication Cart 3 and Resident 83 ' s Antibiotic or Controlled Drug Level of Harm - Minimal harm or Record form for clonazepam 0.5 mg tab and Medication Administration Record (MAR) for 7/2024. LVN 1 potential for actual harm stated in order to ensure the controlled medication count is accurate, controlled medications are kept in a locked drawer and the licensed nurse documents on the Controlled Drug Record the date, time, and the Residents Affected - Some administering nurse ' s initials for every dose removed from the bubble pack (packaging that have a preformed plastic pocket or shell where a product sits securely in place). LVN 1 stated the MAR is used to document the date, time, and nurse ' s initials when the controlled substance is administered to the resident. LVN 1 reviewed Resident 83 ' s Antibiotic or Controlled Drug Record form for Clonazepam and MAR for July and noted the following:

-On 7/8/2024 at 5 p.m., clonazepam tablet number 16 was removed from the bubble pack by LVN 4 and LVN 4 administered the medication.

-On 7/8/2024 at 5 p.m., clonazepam tablet number 15 was removed from the bubble pack by LVN 2 and there was no documented evidence that the dose was administered or wasted.

LVN 1 further stated the 7/8/2024 8 p.m. dose of clonazepam was removed by two different nurses, but only documented as administered by one of them. LVN 1 stated maybe LVN 2 wasted the medication. LVN 1 stated when a controlled drug is wasted there must be a licensed nurse that witnesses the wasting of the medication and documents on the Controlled Drug Record, but there was no documentation indicating the clonazepam was wasted.

During an interview and record review on 7/11/2024 at 8:04 a.m., the Director of Nursing (DON) reviewed Resident 83 ' s Antibiotic or Controlled Drug Record form for clonazepam 0.5 mg tab. The DON stated controlled drugs need to be reconciled and accounted for because there is a potential for addiction to these medications and a risk that someone besides the resident would take the drug and then the medication would not be available for the resident. The DON stated there was a dose of clonazepam that was unaccounted for because it was removed from the bubble pack by LVN 2 and not documented as administered to Resident 83.

During an interview and record review on 7/11/2024 at 5:48 p.m., LVN 2 reviewed Resident 83 ' s Antibiotic or Controlled Drug Record form for clonazepam 0.5 mg tab and stated he removed Resident 83 ' s clonazepam from the bubble pack on 7/8/2024 to administer to Resident 83. LVN 2 stated he wasted the medication because he found it was already administered, but there was no documented evidence that the medication was wasted. LVN 2 stated there was no licensed nurse around to witness the wasting of clonazepam on 7/8/2024 and he wasted the medication by himself. LVN 2 stated it was important to have a witness because it could potentially look like he took the medication home and didn ' t give it to the resident, or it could look like he double dosed the resident. LVN 2 stated he knew it was very serious that he did not have a witness to the wasting of Resident 83 ' s clonazepam. LVN 2 stated he was overwhelmed that day and he slipped up.

During a concurrent interview and record review on 7/12/2024, the DON reviewed the facility policies on controlled substances. The DON stated the facility policy was not followed because LVN 2 did not document

the waste of a controlled medication with a witness present.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 A review of the facility policy and procedure titled, Controlled Substances, last reviewed 7/2023, indicated the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and Level of Harm - Minimal harm or documentation of controlled medications. Only authorized licensed nursing and/or pharmacy personnel have potential for actual harm access to controlled drugs maintained on premises. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. Medications that are opened and subsequently not Residents Affected - Some given (refused or only partly administered) are destroyed. Waste and/or disposal of controlled medications are done in the presence of the nurse and witness who also signs the disposition sheet.

A review of the facility policy and procedure titled, Controlled Substances Wasting, last reviewed 7/2023, indicated medication is included in Drug Enforcement Administration (DEA) classification as controlled Substances are subject to special handling, storage, disposal, and record keeping in the facility according with federal and state laws and regulations. When a dose of medication is removed from container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability

record on the line representing that dose.

b. During a concurrent Medication Storage observation and interview on 7/11/2024 at 7:41 p.m., Licensed Vocational Nurse 5 (LVN 5) reviewed Medication Cart 3 and the Narcotic Count Sheet for 7/2024. LVN 5 stated at the beginning and end of each shift the oncoming and outgoing licensed nurses count the narcotics together and sign the Narcotic Count Sheet. LVN 5 stated narcotics must be counted by two nurses because

they are controlled substances and must be accounted for because there is a higher likelihood of theft and abuse and it was important to ensure the medications were available for the residents they belonged to. LVN 5 reviewed the Narcotic Count Sheet for 7/2024 and noted the following:

-On 7/10/2024 the outgoing nurse ' s signature was missing at 7 a.m.

During a concurrent interview and record review on 7/12/2024 at 10:30 a.m., the ADON reviewed the Medication Cart 3 Narcotic Count Sheet for 7/2024. The ADON stated narcotics are medications that are high risk for causing impaired mobility and thinking and are at higher risk for addiction by patients and other people that use them. The ADON stated narcotics must be locked because people may steal them. The ADON stated the Narcotic Count Sheet is used at the beginning and end of each shift by the oncoming and outgoing nurse to document the count of narcotics. The ADON stated there must be two nurses because

they are controlled medications and staff must make sure there is nothing missing. The ADON reviewed the Medication Cart 3 Narcotic Count Sheet for 7/2024 and noted the following:

-On 7/10/2024 the outgoing nurse ' s signature was missing at 7 a.m.

-On the space intended for 7/11/2024, there was no date indicated and the oncoming nurse ' s signature was missing at 11 p.m.

- On the space intended for 7/11/2024, there was no date indicated and the outgoing nurse ' s signature was missing for 7 a.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a concurrent interview and record review on 7/12/2024 at 6:12 p.m., the DON reviewed the facility policy and procedure regarding controlled substances. The DON stated the controlled drug reconciliation Level of Harm - Minimal harm or process occurs at the change of every shift by two nurses acknowledging that the oncoming nurse received potential for actual harm the correct count. The DON stated it was important to document the reconciliation of controlled substances to identify any missing doses and proceed with an investigation to know why they have a missing dose Residents Affected - Some because controlled substances have a tendency for dependence and diversion.

A review of the facility policy and procedure titled, Controlled Substances, last reviewed 7/2023, indicated the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately. The director of nursing services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties and reports the findings to the administrator. The director of nursing services consults with the provider pharmacy and the administrator to determine whether further legal action is indicated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 44376 potential for actual harm Based on interview and record review the facility failed to ensure residents were free of any significant Residents Affected - Some medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber ' s order, manufacturer ' s specifications, and accepted professional standards) for one out of two sampled residents (Resident 20) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and one out of five sampled residents (Resident 74) reviewed under unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.

The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Findings:

A review of Resident 20 ' s Admission Record indicated the facility admitted Resident 20 on 8/10/2021, and readmitted the resident on 4/2/2023, with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called the optic nerve), and chronic kidney disease (the kidneys are damaged and cannot filter blood the way it should).

A review of Resident 20 ' s Order Summary Report, dated 9/19/2022, indicated an order for Humulin R Solution (Insulin Regular Human). Inject as per sliding scale (varies the dose of insulin based on blood glucose level) subcutaneously before meals and at bedtime for diabetes type 2 (DM II) as follows:

1. If 70-180= 0; 181-200= 2 units (the amount of insulin required to lower the fasting blood sugar).

2. 201-250= 3 units; 251-300= 4 units.

3. 301-350= 6 units.

4. 351-400= 8 units.

5. Greater than (>) 400 or less than (<) 70 call MD.

6. May give orange juice 8 ounces (oz., a unit of weight that is equal to one-sixteenth of a pound) or glucose gel orally (PO) if blood sugar (BS) is below 60.

A review of Resident 20 ' s History and Physical (H&P), dated 9/7/2023, indicated the resident had decision-making capacity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 A review of Resident 20 ' s Location of Administration Report for insulin from 4/2024 to 7/12/2024, indicated insulin was administered on the following dates: Level of Harm - Minimal harm or potential for actual harm -Humulin R Solution

Residents Affected - Some 4/6/2024 at 9:51 p.m. on the Abdomen- Right Upper Quadrant (RUQ)

4/6/2024 at 9:52 p.m. on the Abdomen-RUQ

4/7/2024 at 8:52 p.m. on the Abdomen-RUQ

4/10/2024 at 5:29 p.m. on the Abdomen- Left Upper Quadrant (LUQ)

4/10/2024 at 9:09 p.m. on the Abdomen-LUQ

4/14/2024 at 12:08 p.m. on the Abdomen RUQ

4/14/2024 at 8 p.m. on the Abdomen-RUQ

4/18/2024 at 6:52 p.m. on the Abdomen-RUQ

4/19/2024 at 7:56 p.m. on the Abdomen-RUQ

4/30/2024 at 11:42 a.m. on the Abdomen-RUQ

4/30/2024 at 6:23 p.m. on the Abdomen-RUQ

5/1/2024 at 12:27 p.m. on the Abdomen-RUQ

5/2/2024 at 5:52 p.m. on the Abdomen- Left Lower Quadrant (LLQ)

5/3/2024 at 6:35 a.m. on the Abdomen-LLQ

5/14/2024 at 6:40 p.m. on the Abdomen-LLQ

5/15/2024 at 4:27 p.m. on the Abdomen-LLQ

5/18/2024 at 6:12 p.m. on the Abdomen- Right Lower Quadrant (RLQ)

5/20/2024 at 10:29 p.m. on the Abdomen-RLQ

5/24/2024 at 11:18 a.m. on the Abdomen-RUQ

5/25/2024 at 4:40 p.m. on the Abdomen-RUQ

6/1/2024 at 8:36 p.m. on the Abdomen-LLQ

6/2/2024 at 8:11 p.m. on the Abdomen-LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 6/8/2024 at 6:10 p.m. on the Abdomen-RLQ

Level of Harm - Minimal harm or 6/10/2024 at 7:59 a.m. on the Abdomen-RLQ potential for actual harm 6/13/2024 at 10:04 p.m. on the Abdomen-RLQ Residents Affected - Some 6/14/2024 at 4:03 p.m. on the Abdomen-RLQ

6/16/2024 at 8:51 p.m. on the Abdomen-LUQ

6/17/2024 at 9:19 p.m. on the Abdomen-LUQ

6/19/2024 at 10:32 p.m. on the Abdomen-LLQ

6/20/2024 at 11:47 a.m. on the Abdomen-LLQ

6/27/2024 at 3:43 p.m. on the Abdomen-LLQ

6/28/2024 at 4:48 p.m. on the Abdomen-LLQ

During a concurrent interview and record review on 7/11/2024, at 11:45 a.m., with Registered Nurse 3 (RN 3), Resident 20 ' s Order Summary Report, Medication Administration Record (MAR), and Location of Administration of insulin for 4/2024 to 7/12/2024 was reviewed. RN 3 stated there were multiple instances that the insulin was administered on the same site from 4/2024 to 7/12/2024. RN 3 stated it was important to rotate insulin administration sites to prevent bruising and lipodystrophy to residents. RN 3 stated it was nursing professional practice to rotate insulin administration sites, and she has read the insulin manufacturer's guideline and it indicated to rotate insulin administration sites. RN 3 stated not rotating insulin administration sites was a medication error.

During an interview on 7/12/2024, at 6:17 p.m., with the Director of Nursing DON, the (DON) stated it was basic nursing knowledge to rotate insulin administration sites. The DON stated if we do not rotate the administration sites, the patient will develop skin damage and absorption will be compromised. The DON stated the best area to administer was the abdominal area. The DON stated the failure to rotate the insulin administration sites was considered a medication error because the staff did not follow nursing professional practice and the manufacturer ' s guideline on the use of subcutaneous insulin injection.

43988

2. A review of Resident 74 ' s Admission Record indicated the facility admitted Resident 74 on 12/6/2023 and readmitted in the facility on 5/27/2024 with diagnoses that included abnormalities of gait and mobility, osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), and type two diabetes mellitus (DM 2 - a long-term medical condition in which the body does not use insulin properly, resulting in unusual blood sugar levels) with foot ulcer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 A review of Resident 74 ' s Order Summary Report indicated the following physician ' s order dated 5/27/2024: insulin glargine solution-yfgn (a form of hormone insulin made in the laboratory used to control Level of Harm - Minimal harm or the amount of sugar in the blood of patients with diabetes) subcutaneous (SQ - administered under the skin) potential for actual harm solution (insulin glargine-yfgn) 100 unit/ml inject 15 units SQ every 12 hours for DM 2. Rotate injection sites.

Residents Affected - Some A review of Resident 74 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/3/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and oral hygiene and partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident received insulin injections.

A review of Resident 74 ' s History and Physical, dated 6/12/2024, indicated Resident 74 did not have the capacity to understand and make decisions.

A review of Resident 74 ' s Location of Administration Report for insulin from 4/2024 to 7/2024 indicated insulin glargine solution 100 UNIT/ML was administered as follows:

04/01/24 21:00 04/01/24 20:57 subcutaneously Abdomen - RUQ

04/02/24 09:00 04/02/24 16:44 subcutaneously Abdomen - RUQ

04/06/24 21:00 04/06/24 23:05 subcutaneously Abdomen - RUQ

04/07/24 09:00 04/07/24 14:53 subcutaneously Abdomen - RUQ

04/12/24 09:00 04/12/24 09:15 subcutaneously Abdomen - RLQ

04/12/24 21:00 04/12/24 21:27 subcutaneously Abdomen - RLQ

04/18/24 21:00 04/18/24 20:41 subcutaneously Abdomen - RLQ

04/19/24 09:00 04/19/24 13:47 subcutaneously Abdomen - RLQ

04/26/24 09:00 04/26/24 09:20 subcutaneously Abdomen - RLQ

04/26/24 21:00 04/26/24 20:07 subcutaneously Abdomen - RLQ

05/07/24 21:00 05/07/24 21:22 subcutaneously Abdomen - RUQ

05/08/24 09:00 05/08/24 09:55 subcutaneously Abdomen - RUQ

06/20/24 21:00 06/20/24 20:16 subcutaneously Abdomen - LUQ

06/21/24 09:00 06/21/24 09:43 subcutaneously Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a concurrent interview and record review on 7/12/24 at 11:15 a.m., Resident 74 ' s insulin glargine Location of Administration Sites in the Medication Administration Record (MAR) from 4/2024 to 7/2024 and Level of Harm - Minimal harm or physician ' s order were reviewed with Registered Nurse 2 (RN 2). RN 2 verified the physician ' s order for potential for actual harm the insulin glargine indicated to rotate injections site. RN 2 stated there were multiple repeated insulin administration on the same sites to Resident 74 between 4/2024 to 7/2024. RN 2 stated the site of insulin Residents Affected - Some administration should be rotated to prevent bruising, bleeding, and irritation on the site which may lead to poor absorption of the medication and the resident not getting the required amount of insulin. RN 2stated it was a professional practice as a nurse to rotate insulin administration sites and not rotating administration sites is a medication error due to not following physician ' s order.

A review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed 7/2023, indicated its purpose is to provide guidelines for the safe administration of insulin to residents with diabetes.

The policy indicated the following:

- Select an injection site.

- Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately two inches around the navel.

- Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

A review of the insulin glargine patient information provided by the facility, dated 2022, indicated to rotate the injection sites with each dose to reduce the risk of getting lipodystrophy and localized cutaneous amyloidosis at the injection sites. The package insert indicated to not use the same spot for each injection, or inject

where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, scarred, or damaged.

A review of the facility provided Information for the Physician Humulin-R Regular Insulin Human Injection, USP, (rDNA Origin) 100 units per ml (U-100), issued 3/2011, indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region or in the upper arm. Subcutaneous injection into the abdominal wall ensures a faster absorption than from other injection sites. Injection into a lifted skin fold minimizes the risk of intramuscular injection. Injection sites should be rotated within the same region.

A review of the facility's policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed 7/2023, indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for one of two medication carts (Medication Cart 3) reviewed during the Medication Storage and Labeling task and for one of eight sample residents (Resident 48) reviewed during the Medication Administration task by failing to:

1.Ensure residents ' insulin pens were labeled with the open date in Medication Cart 3 for four randomly sampled residents (Residents 49, 101, 21, and 33).

2.Ensure the licensed nurse labeled the Artificial Tears (an eye drop medication administered in the eye to provide moisture) in Medication Cart 1 with the resident ' s name for one of eight sample residents (Resident 48).

These failures increased the potential for residents in the facility to receive medications that were ineffective or contaminated due to the inadequate storage, and potentially experience medication adverse consequences resulting in the negative impact to residents ' health and well-being.

Findings:

1.a. A review of Resident 49 ' s Admission Record indicated the facility admitted the resident on [DATE REDACTED] and readmitted the resident on [DATE REDACTED] with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) without complications.

A review of Resident 49 ' s physician orders indicated an order for insulin glargine (basalglar) solution, inject ten units (a measurement) subcutaneously (under the skin) at bedtime for diabetes, hold (do not give) if blood sugar is less than 60, dated [DATE REDACTED].

1.b. A review of Resident 101 ' s Admission Record indicated the facility admitted the resident on [DATE REDACTED] and readmitted the resident on [DATE REDACTED] with diagnoses

that included Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), and type two diabetes mellitus with diabetic polyneuropathy (a disorder of the peripheral nervous system that may result in pain, discomfort, and mobility issues) and hypoglycemia (low blood sugar) with coma (in a state of deep sleep and cannot be awakened).

A review of Resident 101 ' s physician orders indicated the following order:

- Humulin N (Insulin NPH) subcutaneous solution, inject 31 units subcutaneously in the morning for diabetes, hold if blood sugar is less than 60, dated [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 - Humulin N subcutaneous solution, inject 6 units subcutaneously in the evening for diabetes, hold if blood sugar is less than 60 at dinner, dated [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm 1.c. A review of Resident 21 ' s Admission Record indicated the facility admitted the resident on [DATE REDACTED] and readmitted the resident on [DATE REDACTED] with diagnoses that included unspecified dementia and type 2 diabetes Residents Affected - Some mellites.

A review of Resident 21 ' s physician orders indicated the following order:

- Lantus subcutaneous solution (Insulin glargine), inject 20 units subcutaneously at bedtime for diabetes, hold if blood sugar is less than 100, dated [DATE REDACTED].

1.d. A review of Resident 33 ' s Admission Record indicated the facility admitted the resident on [DATE REDACTED] and readmitted the resident on [DATE REDACTED] with diagnoses that included Alzheimer ' s disease, and type two diabetes mellitus without complications, and hyperglycemia (high blood sugar).

A review of Resident 33 ' s physician orders indicated the following order:

- Insulin Glargine Solution, inject 20 units subcutaneously at bedtime for diabetes mellites type 2, hold for blood sugar less than 100 and rotate injection site, dated [DATE REDACTED].

During a concurrent Medication Storage and Labeling observation and interview on [DATE REDACTED] at 2:38 p.m., reviewed Medication Cart 3 with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated Insulin Pens expired 28 days after opening them. LVN 1 noted the following:

-Resident 49 ' s Basalglar Insulin pen was open, and the pen was not labeled with the open date.

-Resident 101 ' s Humulin insulin pen was open, and the pen was not labeled with the open date.

LVN 1 further stated the licensed nurses do not always label the pen with the date opened, but sometimes

they do. LVN 1 stated the bags that hold the pens are labeled with the open date. LVN 1 stated it was important to label the insulin pen because the labeled bag may be lost, and the expiration date would not be known. LVN 1 stated it puts the resident at risk if expired insulin is used.

During a follow up Medication Storage and Labeling observation on [DATE REDACTED] at 07:41 p.m., reviewed Medication Cart 3 with Licensed Vocational Nurse 5 (LVN 5). LVN 5 noted the following:

-Resident 21 ' s Insulin Lantus pen was open, and the pen was not labeled with the open date.

-Resident 33 ' s Insulin Lantus pen was open, and the pen was not labeled with the open date.

LVN 2 further stated the bags that contained the pens were labeled with the open date. LVN 2 stated the insulin pens should be labeled with the date opened because the bag for the insulin pens could be lost resulting in the administration of expired insulin to the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During a concurrent interview and record review on [DATE REDACTED] at 10:30 a.m. the Assistant Director of Nursing (ADON) reviewed the facility policy and procedure regarding insulin and medication administration. The Level of Harm - Minimal harm or ADON stated insulin pens expire 28 days after opening and are labeled with the date opened on the sticker potential for actual harm placed on the pen itself. The ADON stated the facility policy indicates vials (small containers usually made of glass) should be labeled and an insulin pen should be labeled with the date opened. The ADON stated Residents Affected - Some insulin pens should be labeled in the same manner as an insulin vial. The ADON stated it was important to label the pen because more than one pen may be delivered at the same time or the bag may be lost. The ADON stated the facility policy was not followed for multidose container labeling.

During an interview on [DATE REDACTED] at 6:12 p.m., the Director of Nursing (DON) reviewed the facility policy regarding insulin and medication storage. The DON stated the open date should be labeled on the actual medication and the plastic bag containing the medication. The DON stated the importance of labeling the actual medication is to know when to discard the pen. The DON stated expired insulin loses its effectiveness and potentially may not control the resident ' s blood sugar resulting in hyperglycemia with further complications like kidney failure.

A review of the facility policy and procedure titled, Administering Medications, last reviewed ,d+[DATE REDACTED], indicated medications are administered in a safe manner. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded

on the container.

A review of the facility policy and procedure titled, Insulin Delivery, last reviewed ,d+[DATE REDACTED], indicated the purpose of the policy and procedure was to provide guidelines for the safe administration of insulin to residents with diabetes. Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacture recommendations for expiration after opening).

A review of the facility provided manufacture instructions for Humulin N KwikPen, last revised ,d+[DATE REDACTED], indicated store the pen currently in use at room temperature and throw away the pen after using for 14 days, even if insulin is still left in it.

A review of the facility provided manufacture instructions for Basalglar KwikPen, dated 2022, indicated do not use the pen for more than 28 days after you first start using the pen.

A review of the facility provided manufacture instructions for Lantus Insulin Glargine Injection, dated 2022, indicated once open, store the pen currently in use at room temperature and throw opened pen away after using for 28 days, even if insulin is still left in it.

2. A review of Resident 48 ' s Admission Record indicated the facility admitted the resident on [DATE REDACTED] and readmitted the resident on [DATE REDACTED] with diagnoses that included major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy), and type two diabetes mellitus without complications.

A review of Resident 48 ' s MDS, dated [DATE REDACTED], indicated the resident was usually able to understand others and was usually able to make herself understood.

A review of Resident 48 ' s physician orders indicated the following order:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 - Artificial Tears Solution instill 1 drop in both eyes three times a day for dry eye syndrome, dated [DATE REDACTED].

Level of Harm - Minimal harm or During a concurrent medication pass observation on [DATE REDACTED] at 5:18 p.m., Licensed Vocational Nurse 2 (LVN potential for actual harm 2) administered Resident 48 ' s medication from Medication Cart 1. LVN 2 stated the resident ' s Artificial Tears were not in the medication cart. LVN 2 retrieved a new box of Artificial Tears and used a pen to write Residents Affected - Some the date opened and the resident ' s room number. Observed LVN 2 did not write the resident ' s name on

the Artificial Tears Solution. LVN 2 administered the Artificial Tears to Resident 48 and returned the Artificial Tears to Medication Cart #1.

During a follow up interview on [DATE REDACTED] at 5:48 p.m., LVN 2 stated he wrote Resident 48 ' s room number and

the date opened on the Artificial Tears. LVN 2 stated he does not write resident ' s names on the Artificial Tears. LVN 2 opened the drawer of Medication Cart 1 to observe other Artificial Tears containers stored in

the cart. LVN 2 stated based on the other Artificial Tears containers he should write the resident ' s name. LVN 2 Stated it was important to write the resident ' s name because they were resident specific and the room number only indicates the resident room and residents can move rooms and the eye drops could be given to the wrong resident. LVN 2 stated when eye drops are given to the wrong resident it could affect their wellbeing because they may be allergic to the medication.

During a concurrent observation and interview on [DATE REDACTED] at 6:12 p.m. the DON reviewed the facility policy and procedure regarding medication storage. The DON stated when a new box of Artificial Tears is opened,

the licensed nurse writes the resident ' s room number and the date opened on the box. The DON stated nurses are supposed to also label the resident name because a resident can move rooms and there is a potential that the medication would be used on the wrong resident resulting in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another).

A review of the facility policy and procedure titled, Medication Storage, last reviewed ,d+[DATE REDACTED], indicated medications and biologicals are stored safely, securely, and properly, following manufacture ' s recommendations or those of the supplier.

A review of the facility policy and procedure titled, Administering Medications, last reviewed ,d+[DATE REDACTED], indicated medications are administered in a safe manner. Staff follows established facility infection control procedures. Medications ordered for a particular resident may not be administered to another resident.

A review of the facility policy and procedure titled, Medication Ordering and Receiving From Pharmacy, last reviewed ,d+[DATE REDACTED], indicated nonprescription medications not labeled by the pharmacy are kept in the manufacturer ' s original container and identified with the resident ' s name. Facility personnel may write the resident ' s name on the container or label as long as the required information is not covered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Provide routine and 24-hour emergency dental care for each resident.

Level of Harm - Minimal harm or 43988 potential for actual harm Based on interview and record review, the facility failed to follow up on the recommendation by the dentist for Residents Affected - Few one (1) out of one sampled resident (Resident 9) during an interview by failing to schedule a full mouth x-ray (FMX - a safe and painless test that uses a small amount of radiation to make an image of bones, organs, and other parts of the body) for a new full upper denture (FUD).

This deficient practice had the potential to result in the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass of the residents.

Findings:

A review of Resident 9 ' s Admission Record indicated the facility admitted Resident 9 on 4/14/2017 and readmitted the resident on 12/8/2022 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and osteoarthritis (a type of arthritis that only affects the joints, usually in the hands, knees, hips, neck, and lower back. It's the most common type of arthritis).

A review of Resident 9 ' s Order Summary Report indicated a physician ' s order for dental consult and treatment as needed for dental problems dated 12/8/2022.

A review of Resident 9 ' s History and Physical (H&P) dated 12/22/2023, indicated Resident 9 did not have

the capacity to understand and make decisions.

A review of Resident 9 ' s Social Services notes dated 3/14/2024 indicated the Social Services Assistant (SSA) called Dental Provider 1 (DP 1) to schedule the resident due to the dentures hurting her gums.

A review of Resident 9 ' s Dental Notes forms by Dental Provider 1 (DP 1) dated 4/23/2024, indicated Resident 9 required a FMX (Full Mouth Series) and new FUD (Full Upper Dentures).

A review of Resident 9 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/15/2024 indicated Resident 9 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for

an individual to thrive).

During an interview on 7/9/2024 at 11:15 a.m. in the downstairs dining room, Resident 9 stated her gums hurt and she needed to be seen by a dentist. Resident 9 stated she mentioned it to the facility staff and was still waiting to be seen by the dentist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 During a concurrent interview and record review on 7/11/2024 at 6:05 p.m., Resident 9 ' s Dental Notes were reviewed with the SSA. The SSA verified Resident 91 had a dental consultation on 4/23/2024 with Level of Harm - Minimal harm or recommendations for a FMX and new FUD as the current FUD was too high and the resident was unable to potential for actual harm eat and talk well. The SSA stated she was not aware of the dentist recommendation as DP 1 does not notify social services department or nursing prior to leaving the facility. The SSA sated DP 1 ' s recommendations Residents Affected - Few should have been followed up as it had the potential for the resident to feel uncomfortable when talking and eating.

During a concurrent interview and record review on 7/12/2024 at 9 a.m., Resident 9 ' s Dental Notes and DP 1 ' s Dental Visit Summary for 4/2024 were reviewed with the Social Services Director (SSD). The SSD stated when ancillary services such as DP 1 come and provide services to the residents, they provide a list of the residents they have seen and attach their notes and recommendations to the social services department then the note will be filed in the resident ' s medical record. The SSD verified DP 1 recommendations should have been followed up on by the SSA as it had the potential to affect the way Resident 9 talks and eat.

A review of the facility ' s policy and procedure titled, Dental Consultation, last reviewed 7/2023 indicated the following:

1. The social services and/or designee will coordinate with the dental consultant for their needed visit and follow up on their recommendations as indicated.

2. The consultant dentist is responsible for providing necessary information concerning residents to appropriate staff, care planning conferences, and/or committees.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to:

1. Ensure open bags of flour tortilla, frozen chocolate chip cookies, and a box of lentils were labelled with open date.

2. Indicate the received or delivery date on a bag of fresh cilantro and a bag of fresh parsley.

3. Ensure a bottle of chocolate syrup with an open date of [DATE REDACTED] had a cap on it and covered tightly with plastic wrap.

4. Ensure a can of applesauce with dent was placed in the shelf for dented cans.

These deficient practices had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 117 out of 121 medically compromised residents who receive food from the kitchen.

Findings:

During a brief tour of the kitchen on [DATE REDACTED] at 7:46 a.m., with the Dietary Supervisor (DS), the following was observed in the walk-in refrigerator and freezer:

1. A bag of flour tortilla with no open date in the walk-in refrigerator.

2. A bag of fresh cilantro and a bag of fresh parsley in the walk-in refrigerator that did not indicate the date

they were received.

3. A bag of opened frozen chocolate chip cookies in the freezer that did not indicate the date it was opened.

The DS verified the opened bag of flour tortilla and frozen chocolate chip cookies did not indicate the date of when they were opened. The DS stated the bags of flour tortilla and frozen chocolate chip cookies should have been labeled with the date they were opened so the staff would know when to discard unused or leftover tortillas and cookies from the bags. The DS stated the bags of fresh cilantro and parsley should have been labeled with the date they were delivered or received so the staff would know which food item should be used first.

During a follow up tour of the dry storage room on [DATE REDACTED] at 10:30 a.m., with the DS, the following was observed in the dry storage room:

4. A bottle of chocolate syrup with an open date of [DATE REDACTED] had a cap on and was covered with plastic wrap.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 5. A can of applesauce with dent remained in the shelf for cans without dent.

Level of Harm - Minimal harm or 6. An opened box of lentils which did not indicate the date it was opened. potential for actual harm

The DS verified the box of lentils did not indicate the date it was opened, a can of applesauce with dent Residents Affected - Some remained in the shelf for cans without dent, and the bottle of chocolate syrup did not have a cap on and was only covered with a plastic wrap. The DS stated the can of applesauce with dent should have been removed

in the shelf and placed in the corner for cans with dents as the dent already compromised the seal of the can. The DS stated the box of lentils should have been labeled with the date it was opened so the staff would know if it was already past the date it can remain open in the storage room. The DS stated the bottle of syrup should have been covered tightly after opening as it had the potential to get contaminated if not covered tightly. The DS stated the deficient practices can compromise resident safety and can place the residents at risk of getting sick.

During an interview on [DATE REDACTED] at 2:38 p.m., the Registered Dietitian (RD) stated safe and proper food storage should be observed at all times to ensure resident safety and prevent them from getting sick.

A review of the facility ' s policy and procedure titled, Refrigerator/Freezer Storage, last reviewed ,d+[DATE REDACTED], indicated the following:

1. All items should be properly covered, dated, and labeled. Food items should have the following dates:

1. Delivery date - upon receipt

2. Open date - opened containers

3. Thaw date - any frozen items

2. Older food items should be rotated using the FIFO method (First-in First-out).

3. No food item that is expired or beyond the best by date are in stock.

A review of the facility ' s policy and procedure titled, Storage of Canned and Dry Goods, last reviewed , d+[DATE REDACTED], indicated that food and supplies will be stored in a safe manner. The policy indicated the following:

1. Canned items should be inspected for damage such as dented, leaking, or building cans and will be stored separately in the designated area - DENTED CNAS for return to the vendor or disposed of properly.

2. All food products will be used according to the specified Food Storage Guidelines.

3. Open food items will be tightly closed to prevent exposure to pests.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 A review of the facility provided undated Dry Good Storage Guidelines, indicated items with asterisk are to be refrigerated after opening and to keep them dry and tightly covered. The guideline indicated the following: Level of Harm - Minimal harm or potential for actual harm 1. Dry beans including lentils can be stored open in the shelf for one (1) year.

Residents Affected - Some 2. *Syrups can be stored opened on a shelf for up to six (6) months.

3. Tortillas, corn and flour can be stored opened on a shelf or refrigerated for up to 1 week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 potential for actual harm Based on observation, interview, and record review the facility failed to maintain an infection prevention and Residents Affected - Some control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections by failing to:

1. Ensure Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) were implemented for one of eight sampled residents (Resident 67) observed during the Medication Administration task.

2. Ensure a potentially contaminated box of tissues and an eye drop container were not placed in Medication Cart 1 for two of eight sampled residents (Residents 95 and 221) observed during the Medication Administration task.

3. The facility offered hand hygiene to the resident prior to serving the lunch tray on 7/9/2024, at noon inside

the Dining Room to one of eleven sampled residents observed during dining observation (Resident 98).

4. The linen covers in the nursing stations were protected from external contaminants such as dust, viruses, and bacteria by using a permeable (having pores or openings that permit liquids or gasses to pass through)/ loosely woven material to cover the mobile linen carts to two out of two linen carts (Carts A and B) observed

during infection control facility task.

These deficient practices had the potential to spread infections and illnesses among residents.

Findings:

1. A review of Resident 67 ' s Admission Record indicated the facility admitted the resident on 2/13/2024 and readmitted the resident on 4/12/2024 with diagnoses that included metabolic encephalopathy (an alteration

in consciousness due to brain dysfunction), dysphagia (a condition that makes it difficult to swallow), gastrostomy (also called as gastric tube [GT], a tube inserted through the abdomen that delivers nutrition or medication directly to the stomach), and paraplegia (the inability to voluntarily move the lower parts of the body).

A review of Resident 67 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 5/30/2024, indicated the resident was sometimes able to understand others and was sometimes able to make herself understood. The MDS further indicated the resident was dependent on staff for oral hygiene, toileting, dressing, and mobility. The MDS indicated the resident had a GT.

A review of Resident 67 ' s physician orders indicated an order to crush all crushable medications and administer via GT, dated 5/23/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A review of Resident 67 ' s Care Plan titled, Risk for infection. Resident is at high risk of infection secondary to . indwelling medical device, initiated 4/16/2024, indicated a goal to reduce the risk of MDRO transmission Level of Harm - Minimal harm or daily by performing hand hygiene, wearing gowns and gloves while performing high contact activities. potential for actual harm

A review of Resident 67 ' s Care Plan titled, Enhanced Standard Precautions, high risk for infection .feeding Residents Affected - Some tubes, ostomy, initiated 5/24/2024, indicated to reduce the risk of infection.

During a medication pass observation on 7/11/2024 at 9:13 a.m., Licensed Vocational Nurse 1 (LVN 1) gathered Resident 67 ' s medications from Medication Cart 3, entered Resident 67 ' s room, performed hand hygiene, and placed gloves on his hands. LVN 1 assessed the resident ' s GT and then administered medications via the GT. Observed a sign on the wall above the head of Resident 67 ' s bed indicating EBP. Observed LVN 1 did not don (put on) a gown prior to or during administering the resident ' s medication.

During a follow up interview on 7/11/2024 at 10:09 a.m., immediately upon exiting Resident 67 ' s room after

the completion of the medication pass, LVN 1 stated he wore gloves during Resident 67 ' s GT medication pass. LVN 1 stated he was not sure what EBP was. Observed LVN 1 enter the resident ' s room to read the EBP sign on the wall. LVN 1 stated EBP included wearing a gown, but it slipped his mind. LVN 1 stated he was not sure why Resident 67 was on EBP, but he should have worn a gown during the medication pass. LVN 1 stated EBPs protect the resident from exposure to germs and bacteria that could cause infection.

During an interview on 7/12/2024 at 10:30 a.m., the Assistant Director of Nursing (ADON) stated EBPs are used to prevent residents from getting an infection from staff. The ADON stated staff wear gowns and gloves when providing hands on patient care. The ADON stated EBPs are implemented for residents with GTs because it is an indwelling device.

During a concurrent interview and record review on 7/12/2024 at 6:12 p.m., the Director of Nursing (DON) reviewed the facility policy regarding EBP. The DON stated EBP are a precaution taken to prevent transmission of bacteria for residents that have some type of indwelling device. The DON stated the facility policy was not followed because the LVN did not wear a gown during a GT medication pass.

A review of the facility policy and procedure titled, Enhanced Barrier Precautions, last reviewed 7/2023, indicated EBP are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs emply targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Device care or use is an example of high-contact resident care requiring the use of gown and gloves for EBP. EBP are indicated for residents with indwelling medical devices. EBPs remain in place for the duration of the resident ' s stay or discontinuation of the indwelling medical device that places them at increased risk.

2.a. A review of Resident 95 ' s Admission Record indicated the facility admitted the resident on 11/3/2022 and readmitted on [DATE REDACTED] with diagnoses that included unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and shortness of breath.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A review of Resident 95 ' s MDS dated [DATE REDACTED], indicated the resident was rarely/never able to understand others and was rarely/never able to make herself understood. Level of Harm - Minimal harm or potential for actual harm A review of Resident 95 ' s physician orders indicated an order for carboxymethylcellusose sodium ophthalmic eye solution (a medication to relieve dry, irritated eyes), instill one drop in both eyes two times a Residents Affected - Some day for lubrication, dated 2/22/2023.

2.b. A review of Resident 221 ' s Admission Record indicated the facility admitted the resident on 6/27/2024 with diagnoses that included psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and eosinophilia (the presence of too many white blood cells [responsible for protecting your body from infection] in the body).

A review of Resident 221 ' s MDS dated [DATE REDACTED], indicated the resident was usually able to understand others and was usually able to make herself understood. The MDS further indicated the resident required partial assistance from staff for oral hygiene, toileting, dressing, personal hygiene, and mobility.

A review of Resident 221 ' s Care Plan titled, Risk for infection. Resident is at high risk for infection ., initiated 6/29/2024, indicated to clean and disinfect high touch surface areas, and to notify the physician of any sign or symptom of infection.

During a medication pass observation on 7/11/2024 at 8:40 a.m., Licensed Vocational Nurse 3 (LVN 3) gathered Resident 95 ' s medications from Medication Cart 1 including a box of tissues and a small container holding carboxymethylcellusose sodium ophthalmic eye drops. Observed LVN3 enter Resident 95 ' s room and placed the tissue box and container on Resident 95 ' s plastic nightstand. Observed LVN 3 did not clean Resident 95 ' s nightstand prior to placing the tissue box and container. LVN 3 administered the eye drops, used a tissue on Resident 95 ' s eyes, then exited the room and returned the box of tissues and container to Medication Cart 1. LVN 3 did not disinfect the box of tissue or container prior to placing the tissue box and container in the medication cart. LVN 3 then entered Resident 221 ' s room and administered medication to

the resident from Medication Cart 1.

During a follow up interview on 7/11/2024 at 9:07 a.m., immediately after the medication pass observation, LVN 3 stated she removed the tissue box and Resident 95 ' s eye drop container from Medication Cart 1, set them down on the resident ' s nightstand without cleaning the nightstand, and then placed the tissue box and eye drop container back in Medication Cart 1. LVN 3 stated it looked like the nightstand surface was clean and she didn ' t see any dirt. LVN 3 stated she should have cleaned the surface before placing the tissue box and container and then disinfected them prior to placing them back in the medication cart. LVN 3 stated it was possible the tissue box and eye drop container could become contaminated with germs and bacteria and then cause infection of other residents whose medication is stored in the medication cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a concurrent interview and record review on 7/12/2024 at 6:12 p.m., the DON reviewed the facility policy regarding infection control. The DON stated the facility policy was not followed when the LVN did not Level of Harm - Minimal harm or disinfect the surface prior to placing the tissue box and eye drop container on the nightstand and prior to potential for actual harm placing them back in the medication cart. The DON Stated there was a potential for cross contamination from bacteria on one surface moving to another surface which increased the risk of infections in residents. Residents Affected - Some

A review of the facility policy and procedure titled, Medication Storage, last reviewed 7/2023, indicated medications and biologicals are stored safely, securely, and properly, following manufacture ' s recommendations or those of the supplier. Medication storage areas are kept clean.

44376

3.A review of Resident 98 ' s Admission Record indicated the facility admitted the resident on 12/21/2022, and readmitted the resident on 2/4/2024, with diagnoses including urinary tract infection (UTI, a condition in which bacteria invade and grow in the urinary tract), systemic inflammatory response syndrome (SIRS, an exaggerated defense response from the body to a harmful stressor), and Coronavirus Disease 2019 (COVID-19, a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks).

A review of Resident 98 ' s History and Physical (H&P), dated 2/7/2024, indicated the resident did not have

the capacity to understand and make decisions.

A review of Resident 98 ' s MDS, dated [DATE REDACTED], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident needed supervision or touching assistance on eating, oral hygiene, personal hygiene, and always had urine and bowel incontinence (unable to control excretions, to hold urine in the bladder, or to keep feces in the rectum.)

A review of Resident 98 ' s Care Plan titled, COVID-19. Resident is at risk for (shortness of breath, irregular respiration, cough, rhonchi (are continuous gurgling or bubbling sounds typically heard during both inhalation and exhalation), activity intolerance, fever of greater than (>) 99.6, nausea & vomiting, sore throat, runny nose) related to COVID-19 pandemic, last revised on 2/7/2024, indicated an intervention to practice hand hygiene technique.

During an observation and interview on 7/9/2024, at 12:33 p.m., with the Activity Assistant (AA), inside the Dining Room Area, observed staff serving the tray of Resident 98 without offering hand hygiene. The AA stated the staff should offer the resident a hand sanitizer or bring the resident to their rooms to wash their hands before eating to prevent infection.

During an interview on 7/12/2024, at 2:12 p.m., with the Infection Preventionist (IP), the IP stated it was important that the staff offered the residents hand hygiene prior to eating and after eating to stop the spread of germs and bacteria among residents.

During an interview on 7/12/2024, at 6:33 p.m., with the DON, the DON stated the staff should have offered hand hygiene to the resident because hands can transmit bacterial infection. The DON also stated hand washing stops transmission of infection to residents that can cause gastrointestinal (GI, of, relating to, affecting, or including both stomach and intestines) issues.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A review of the facility's recent policy and procedure titled, Hand Washing, last reviewed on 7/2023, indicated hand washing must also be performed as follows: Level of Harm - Minimal harm or potential for actual harm - Before and after eating.

Residents Affected - Some 4.During a concurrent observation and interview on 7/12/2024, at 9:42 a.m., with Certified Nursing Assistant 6 (CNA 6), observed Linen Cart A covered with loosely woven/permeable material to protect the clean linens of the residents. CNA 6 stated she preferred the cover used by Laundry Department in distributing supplies

in the mobile cart that was made of plastic without pores that prevents bacteria or viruses from entering the cart.

During a concurrent observation and interview on 7/12/2024, at 9:52 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Linen Cart B covered with loosely woven/permeable material to protect the clean linens of

the residents. LVN 1 stated he preferred the cover used by Laundry Department in distributing supplies in the mobile cart that was made of plastic without pores that prevents bacteria or viruses from entering the cart.

During an interview on 7/12/2024, at 2:04 p.m., with the IP, the IP stated the linen carts should be covered with a non-permeable (do not allow water-vapor and air pass through below an agreed upon threshold) material that inhibits the bacteria or viruses from permeating (to spread or diffuse) inside the clean linens.

The IP stated using permeable or loosely woven material for covering the clean linens predisposes the clean linens to be contaminated with bacteria, viruses, and external contaminants such as splashes of liquid and sprays that can cause illness to spread to the residents.

During an interview on 7/12/2024, at 6:37 p.m., with the DON, the DON stated they should use a non-permeable cover on their mobile linen carts to prevent contamination of the linen that can transmit infection to the resident. The DON stated the permeable cover can let viruses and bacteria inside the cart.

A review of the facility's recent policy and procedure titled, Health Services Operations Manual, last revised

on 7/2023, indicated all clean linen must be covered during delivery to prevent potential contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 43988 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and Residents Affected - Few patient care equipment in safe operating condition for one (1) of 1 sampled resident (Resident 91) investigated during a random observation when Resident 91 ' s bed controller (device used to change the height and angle of the bed) cable was observed with frayed and exposed wires.

This deficient practice had the potential to place Resident 91 at risk for injury.

Findings:

A review of Resident 91 ' s Admission Record indicated the facility admitted the resident on 5/8/2024 with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination, and muscle weakness.

A review of Resident 91 ' s History and Physical (H&P) dated 5/10/2024, did not indicate the resident had the capacity to understand and make decisions.

A review of Resident 91 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/15/2024 indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating; partial/moderate assistance with oral and personal hygiene; substantial/maximal assistance with mobility and dressing; total assistance with all other ADLs.

During an observation on 7/9/2024 at 9:20 a.m., inside Resident 91 ' s room, Resident 91 was observed lying

in bed with the bed controller placed on top of the resident ' s overbed table and within reach. Observed the base of the bed controller cable with the white, red, brown, and yellow wires were exposed and the brown wire frayed and sticking out (exposed).

During a concurrent observation and interview, with the Director of Nursing (DON), on 7/9/2024, at 9:35 a.m.,

the DON verified the cable to Resident 91 ' s bed controller had exposed wires and stated it is not safe for

the resident to have exposed wires next to them. The DON stated she will notify the Maintenance Supervisor (MS) to change the bed controller.

During an interview on 7/12/2024 at 10:00 a.m., the Administrator (Adm) stated the MS makes rounds every month to ensure the building and all resident care equipment are in good working condition. The Adm stated

the exposed wire could potentially result in accident and injure the resident.

During a follow up interview on 7/12/2024 at 7:30 p.m., the DON stated the bed controller wires should not be exposed for resident safety as it can cause injury to the resident.

A review of the facility ' s policy and procedure titled, Maintenance Service, last reviewed 7/2023, indicated

the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 - Maintenance of a safe and sanitary environment ensures safety, affords protection, and enhances the well-being of the residents, public, and staff. maintenance activities include ensuring that all equipment, Level of Harm - Minimal harm or buildings, spaces, and fixtures are kept in operable condition. potential for actual harm - The facility shall employ safe and proper methods in maintaining the facility to protect against injury to the Residents Affected - Few residents, staff, or visitors. facility shall hold weekly maintenance inspections as part of a general facility safety inspection.

- Inspect all electric beds at least quarterly and after a resident is discharged . check controls, cords, and plugs for damage and replace cords as necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0911 Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376

Residents Affected - Some Based on observation, interview, and record review the facility failed to meet the requirement for no more than four residents per room for two of 45 resident rooms (rooms [ROOM NUMBERS]).

This deficient practice had the potential to result in inadequate space to provide sufficient nursing care and privacy for the residents.

Findings:

A review of the Client Accommodation Analysis form completed by the facility indicated rooms [ROOM NUMBERS] housed five beds per room.

During the Resident Council Meeting on 7/10/2024, at 2:08 p.m., when the residents were asked about their room space, there were no concerns or issues brought up.

During the recertification survey from 7/9/2024 to 7/12/2024, it was observed that the residents residing in

the rooms with an application for variance had sufficient amount of space for residents to move freely inside

the rooms. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff for the residents.

On 7/10/2024, the Administrator submitted a letter requesting for a waiver for room with more than four residents per room for the following rooms:

- room [ROOM NUMBER]- with five residents = 394.28 square feet per room

- room [ROOM NUMBER]- with five residents = 398.94 square feet per room

A review of the waiver letter, undated, indicated, There is enough space to provide for each resident care, dignity, and privacy. The rooms are in accordance with the special needs of the resident and would not have

an adverse effect on the resident ' s health and safety or impede the ability of any resident in the rooms to attain his or her highest practicable well-being.

A review of the facility's recent policy and procedure titled, Bedrooms, last reviewed on 7/2023, indicated all residents are provided with clean, comfortable, and safe bedrooms that meet federal and state requirements. Bedrooms accommodate no more than two residents at a time. Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. (Note: Individual variations on this may be permitted by federal authorities if it is demonstrated that the variation is in accordance with special needs of the resident and will not adversely affect the resident's health and safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376

Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure that 2 of 45 resident rooms (rooms [ROOM NUMBERS]) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms.

The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Findings:

During the Resident Council Meeting 7/10/2024, at 2:08 p.m., when the residents were asked about their room space, there were no concerns or issues brought up.

During the recertification survey from 7/9/2024 to 7/12/2024, it was observed that the residents residing in

the rooms with an application for variance had sufficient amount of space for residents to move freely inside

the rooms. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff for the residents.

On 7/10/2024, the Administrator submitted the application for the Room Variance Waiver for 16 resident rooms. The room variance letter indicated that these rooms did not meet the 80 square feet per resident requirement per federal regulation. The room waiver request showed the following:

Room # Square Footage Number of Beds

16 394.28 5

45 398.94 5

The minimum requirement for a 2 bedroom should be at least 160 sq. ft.

The minimum requirement for a 3 bedroom should be at least 240 sq. ft.

The minimum requirement for a 4 bedroom should be at least 320 sq. ft.

A review of the room waiver letter, undated, indicated, There is enough space to provide for each resident care, dignity, and privacy. The rooms are in accordance with the special needs of the resident and would not have an adverse effect on the resident ' s health and safety or impede the ability of any resident in the rooms to attain his or her highest practicable well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 A review of the facility's recent policy and procedure titled, Bedrooms, last reviewed on 7/2023, indicated all residents are provided with clean, comfortable, and safe bedrooms that meet federal and state requirements. Level of Harm - Minimal harm or Bedrooms accommodate no more than two residents at a time. Bedrooms measure at least 80 square feet of potential for actual harm space per resident in double rooms, and at least 100 square feet of space in single rooms. (Note: Individual variations on this may be permitted by federal authorities if it is demonstrated that the variation is in Residents Affected - Some accordance with special needs of the resident and will not adversely affect the resident's health and safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 71 555707

F-F700

A review of Resident 4 ' s Admission Record indicated the facility admitted the resident on 1/15/2015, and readmitted the resident on 3/6/2024, with diagnoses that included major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the right hand.

A review of Resident 4 ' s Side Rail/Entrapment Assessment/Care Plan, dated 3/6/2024, indicated a recommendation for side rails was not indicated.

A review of Resident 4 ' s History and Physical (H&P), dated 3/12/2024, indicated Resident 4 did not have

the capacity to understand and make decisions.

A review of Resident 4 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/3/2024, indicated Resident 19 sometimes had the ability to make self-understood and to understand others. The MDS indicated Resident 19 had impaired upper and lower extremities and was mostly dependent on mobility and activities of daily living (ADLs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 A review of Resident 4 ' s Fall Risk Assessment, dated 6/8/2024, indicated Resident 19 was a high risk for falls and injuries. Level of Harm - Minimal harm or potential for actual harm During an observation on 7/9/2024, at 8:58 a.m., during resident screening, inside Resident 4 ' s room, Resident 4 was lying down in bed with both upper side rails up. Residents Affected - Some

During an observation and interview on 7/10/2024, at 5:45 p.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 4 ' s room, Resident 4 was observed lying down in bed with both upper side rails up. CNA 3 stated she places both upper side rails up during the evening shift to prevent the resident from falls and injuries. CNA 3 stated she knows there was no order for both upper side rails to be up.

During a concurrent interview and record review on 7/10/2024, at 6:21 p.m., with Registered Nurse 4 (RN 4), Resident 4 ' s Order Summary Report, Physical Restraint Assessment Form, and Informed Consent was reviewed. RN 4 stated there was no physician order for both upper side rails to be on the resident, no physical restraint assessment form, and no informed consent from the resident or resident representative prior to the application of restraint-both upper side rails use in the resident ' s medical chart. RN 4 stated it was important to obtain a physician ' s order, perform a physical restraint assessment, and obtain an informed consent for the use of the restraint-both upper side rails up, to ensure appropriate use of the restraint, to prevent injuries and physical decline to residents. RN 4 stated obtaining an informed consent from the resident or resident representative for the use of the restraint side rails honors the right of the resident to decide after being explained the risks and benefits of side rails if they want to use them.

During an interview on 7/12/2024, at 6:15 p.m., with the Director of Nursing (DON), the DON stated it was important to obtain a physician ' s order for the use of both upper side rails as a restraint, complete a Physical Restraint Assessment, and obtain an informed consent from the resident or resident representative prior to application of the restraint both upper side rails, to ensure the safety and appropriate use of the restraint side rails and to prevent the resident from potential injuries such as entrapment.

A review of the facility's recent policy and procedure titled, Physical Restraints, last reviewed on 7/2023, indicated physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one's body. The IDT shall evaluate the outcome of all measures attempted and make recommendations accordingly. The licensed nurse shall be responsible for obtaining an order from the attending physician, which include:

a. Specific type of restraint.

b. Purpose of the restraint.

c. Time and place of application.

d. Approaches to prevent decreased functioning when applicable.

e. Informed consent obtained from resident or from surrogate decision-maker.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 The Plan of Care shall specify the reason for the use of the restraint, the type, when and where it is to be used. Level of Harm - Minimal harm or potential for actual harm A review of the facility's most recent policy and procedure titled, Informed Consent, last reviewed on 7/2023, indicated this facility will verify that the patient's health record contains documentation that the patient has Residents Affected - Some given informed consent before initiating the administration of psychotherapeutic drugs or physical restraints.

Before initiating the administration of psychotherapeutic drugs or physical restraints, facility staff shall verify that the patient's health record contains documentation that the patient has given informed consent to the proposed treatment or procedure.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244

Residents Affected - Some Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (CP, a written course of action that helps a patient achieve outcomes that improve their quality of life) for residents by failing to:

1. Develop and implement a person-centered care plan regarding Post Traumatic Stress Disorder (PTSD, a mental health condition caused by very stressful, frightening, or distressing events) for one of five residents (Resident 39) reviewed under the Behavioral-Emotional care area.

2. Develop and implement a comprehensive person-centered care plan for the use of insulin glargine-yfgn (a form of hormone insulin made in the laboratory used to control the amount of sugar in the blood of patients with diabetes) for one (1) out of five (5) sampled residents (Resident 74).

3. Develop and implement a comprehensive person-centered care plan for one of four sampled residents (Resident 4) reviewed under physical restraints (devices that limit a patient ' s movement) and side rails (metal rails that normally hang on the side of the patient ' s bed) care areas.

These deficient practices had the potential to result in a delay in the provision of necessary care and services for Residents 39, 74, and 4.

Findings:

1. A review of Resident 39 ' s Admission Record indicated the facility admitted the resident on 10/3/2023 and readmitted the resident on 10/27/2023 with diagnoses that included bipolar disorder (a mental health disorder that causes extreme mood swings), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one ' s daily functioning), Alzheimer ' s disease (a type of dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]) ), suicidal ideations (the act of thinking about or a state of preoccupation with taking one's own life), and PTSD.

A review of Resident 39 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 4/11/2024, indicated Resident 39 was sometimes able to understand others and sometimes was able to make herself understood. The MDS further indicated Resident 39 had feelings of feeling down, depressed, or hopeless two to six days a week. The MDS indicated Resident 39 was dependent on staff for bathing, required substantial assistance for dressing, and required partial assistance for personal hygiene, toileting, and oral hygiene.

A review of Resident 39 ' s Trauma Care Evaluation (a tool used to recognize trauma symptoms and acknowledge the role that trauma plays in a person ' s life), dated 4/11/2024, indicated Resident 39 stated that she was A survivor of Hitler ' s time when Jewish people were in concentration [NAME].

During an observation on 7/9/2024 at 9 a.m., Resident 39 was observed lying in bed awake and did not respond to the surveyor ' s questions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview and record review on 7/12/2024 at 8:18 a.m. the Assistant Director of Nursing (ADON) reviewed Resident 39 ' s Trauma Care Evaluation dated 4/11/2024 and Care Plans. The ADON stated PTSD Level of Harm - Minimal harm or occurs after a traumatic event and a resident may have episodes of stress from the trauma. The ADON potential for actual harm stated Resident 39 had a diagnosis of PTSD when admitted to the facility. The ADON stated the interdisciplinary team (IDT) has a care plan meeting to identify resident problems, establish goals, and Residents Affected - Some interventions to meet the goals. The ADON stated Resident 39 had an evaluation that indicated the resident had PTSD and a care plan should have been developed, but it was not. The ADON stated without a PTSD CP it could potentially lead to undiscovered or a delay in discovering episodes of PTSD in a timely manner.

The ADON stated without a CP there were no interventions to prevent or properly care for episodes of PTSD with the potential for not meeting the resident ' s psychological care needs.

During a concurrent interview and record review on 7/12/2024 at 6:12 p.m. the Director of Nursing (DON) reviewed the facility policy and procedure regarding comprehensive care plans. The DON stated CPs are based on the resident ' s diagnoses, general condition, and physician ' s order. The DON stated CPs are used to properly care for residents and to show what is being implemented and whether or not it is effective.

The DON stated for Resident 39, the facility policy regarding CPs was not followed because a CP was not provided at admission to identify the

triggers of Resident 39 ' s PTSD and they did not have the proper goals to provide services or identify a significant change in the resident ' s condition. The DON stated without the PTSD CP, it could potentially result in increased anxiety and depression due to trauma and triggering factors for the resident.

43988

2. A review of Resident 74 ' s Admission Record indicated the facility admitted the resident on 12/6/2023 and readmitted to the facility on [DATE REDACTED] with diagnoses that included abnormalities of gait and mobility, osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), and type two diabetes mellitus (DM 2 - a long-term medical condition in which the body does not use insulin properly, resulting in unusual blood sugar levels) with foot ulcer.

A review of Resident 74 ' s MDS dated [DATE REDACTED], indicated Resident 74 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and oral hygiene and partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 74 received insulin injections.

A review of Resident 74 ' s History and Physical, dated 6/12/2024, indicated Resident 74 did not have the capacity to understand and make decisions.

A review of Resident 74 ' s Order Summary Report indicated the following physician ' s order dated 5/27/2024 to administer insulin glargine solution-yfgn (a form of hormone insulin made in the laboratory used to control the amount of sugar in the blood of patients with diabetes) subcutaneous (SQ - administered under

the skin) solution (insulin glargine-yfgn)100 unit/ml inject 15 units SQ every 12 hours for DM 2 and rotate injection sites.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a concurrent interview and record review on 7/12/2024 at 11 a.m., Resident 74 ' s physician ' s orders and care plans were reviewed with Registered Nurse 2 (RN 2). RN 2 verified Resident 74 was currently Level of Harm - Minimal harm or receiving insulin and there was no documented evidence that a care plan was developed and implemented potential for actual harm for the use of insulin glargine. RN 2 stated care plans should have been developed within seven (7) days of

the date of the MDS assessment so the staff would be aware the resident is on insulin to prevent delay in the Residents Affected - Some delivery of necessary care and services Resident 74 needs.

44376

3. A rereview of Resident 4 ' s Admission Record indicated the facility admitted the resident on 1/15/2015, and readmitted on [DATE REDACTED], with diagnoses that included major depressive disorder, anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the right hand.

A review of Resident 4 ' s History and Physical (H&P), dated 3/12/2024, indicated Resident 4 did not have

the capacity to understand and make decisions.

A review of Resident 4 ' s MDS, dated [DATE REDACTED], indicated Resident 4 sometimes had the ability to make self-understood and to understand others. The MDS indicated the resident had impaired upper and lower extremities and was mostly dependent on mobility and activities of daily living (ADLs).

A review of Resident 4 ' s Side Rail/Entrapment Assessment/Care Plan, dated 3/6/2024, indicated a recommendation for side rails was not indicated.

A review of Resident 4 ' s Fall Risk Assessment, dated 6/8/2024, indicated the resident was high risk for falls and injuries.

During an observation on 7/9/2024, at 8:58 a.m., during resident screening, inside Resident 4 ' s room, observed the resident lying down in bed with both upper side rails up.

During a concurrent interview and record review on 7/10/2024, at 6:21 p.m., with Registered Nurse 4 (RN 4), Resident 4 ' s Order Summary Report, Physical Restraint Assessment Form, Informed Consent, and Care Plans was reviewed. RN 4 stated there was no physician order for both upper side rails to be used for the resident, no Physical Restraint Assessment Form, and no Informed Consent from the resident or resident representative prior to the application of restraint both upper side rails use in the resident ' s medical chart, and Care Plan on the use of restraint side rails. RN 4 stated it was important to obtain a physician ' s order, do a physical restraint assessment, obtain an informed consent, and care plan on the use of the restraint both upper side rails up to ensure appropriate use of the restraint to prevent injuries and physical decline to residents. RN 4 stated obtaining an informed consent from the resident or resident representative on the use of the restraint side rails honors the right of the resident to decide after being explained the risks and benefits of side rails if they want to use them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview on 7/12/2024, at 6:15 p.m., with the Director of Nursing (DON), the DON stated it was important to obtain a physician ' s order on the use of both upper side rails as a restraint, complete a Level of Harm - Minimal harm or Physical Restraint Assessment, obtain an informed consent from the resident or resident representative, and potential for actual harm develop a care plan on the use of the restraint side rails to ensure the safety and appropriate use of the restraint side rails and to prevent the resident from potential injuries such as entrapment. Residents Affected - Some

A review of the facility ' s policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed 7/2023, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The CP includes measurable objectives and timeframes, describes services that are to be furnished, the resident ' s stated goals and desired outcomes, builds on the resident ' s strengths, and reflects currently recognized standards of practice for problem areas and conditions. Services provided for or arranged by the facility and outlined in the CP are culturally competent and trauma informed.

A review of the facility's recent policy and procedure titled, Physical Restraints, last reviewed on 7/2023, indicated physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one's body. The IDT shall evaluate the outcome of all measures attempted and make recommendations accordingly. The licensed nurse shall be responsible for obtaining an order from the attending physician, which include:

a. Specific type of restraint.

b. Purpose of the restraint.

c. Time and place of application.

d. Approaches to prevent decreased functioning when applicable.

e. Informed consent obtained from resident or from surrogate decision-maker.

The Plan of Care shall specify the reason for the use of the restraint, the type, when and where it is to be used.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 potential for actual harm Based on interview and record review, the facility ' s licensed nursing staff failed to provide care in Residents Affected - Some accordance with professional standards for two of two sampled residents (Residents 20 and 74) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.

This deficient practice had the potential to result in adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Findings:

1. A review of Resident 20 ' s Admission Record indicated the facility admitted theresident on 8/10/2021, and readmitted the resident on 4/2/2023, with diagnosesthat included type 2 diabetes mellitus (a disease that occurs when the bloodglucose, also called blood sugar, is too high), glaucoma (a group of eye diseasesthat can cause vision loss and blindness by damaging a nerve in the back of theeye called the optic nerve), and chronic kidney disease (the kidneys are damagedand cannot filter blood the way it should).

A review of Resident 20 ' s Order Summary Report, dated 9/19/2022, indicated anorder for Humulin R Solution (Insulin Regular Human). Inject as per sliding scale(varies the dose of insulin based on blood glucose level): if 70-180= 0; 181-200= 2units (the amount of insulin required to lower the fasting blood sugar); 201-250= 3units; 251-300= 4 units; 301-350= 6 units; 351-400= 8 units greater than (>) 400or less than (<) 70 call MD, subcutaneously before meals and at bedtime fordiabetes type 2 (DM II). May give orange juice 8 ounces (oz., a unit of weight thatis equal to one-sixteenth of a pound) or glucose gel orally (PO) if blood sugar (BS)is below 60.

A review of Resident 20 ' s History and Physical (H&P), dated 9/7/2023, indicatedResident 20 had decision-making capacity.

A review of Resident 20 ' s Location of Administration Report for insulin from4/2024 to 7/12/2024, indicated insulin was administered on the following dates:

-Humulin R Solution

4/6/2024 at 9:51 p.m. on the Abdomen-Right Upper Quadrant (RUQ)

4/6/2024 at 9:52 p.m. on the Abdomen-RUQ

4/7/2024 at 8:52 p.m. on the Abdomen-RUQ

4/10/2024 at 5:29 p.m. on the Abdomen-Left Upper Quadrant (LUQ)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 4/10/2024 at 9:09 p.m. on the Abdomen-LUQ

Level of Harm - Minimal harm or 4/14/2024 at 12:08 p.m. on the Abdomen RUQ potential for actual harm 4/14/2024 at 8 p.m. on the Abdomen-RUQ Residents Affected - Some 4/18/2024 at 6:52 p.m. on the Abdomen-RUQ

4/19/2024 at 7:56 p.m. on the Abdomen-RUQ

4/30/2024 at 11:42 a.m. on the Abdomen-RUQ

4/30/2024 at 6:23 p.m. on the Abdomen-RUQ

5/1/2024 at 12:27 p.m. on the Abdomen-RUQ

5/2/2024 at 5:52 p.m. on the Abdomen-Left Lower Quadrant (LLQ)

5/3/2024 at 6:35 a.m. on the Abdomen-LLQ

5/14/2024 at 6:40 p.m. on the Abdomen-LLQ

5/15/2024 at 4:27 p.m. on the Abdomen-LLQ

5/18/2024 at 6:12 p.m. on the Abdomen-Right Lower Quadrant (RLQ)

5/20/2024 at 10:29 p.m. on the Abdomen-RLQ

5/24/2024 at 11:18 a.m. on the Abdomen-RUQ

5/25/2024 at 4:40 p.m. on the Abdomen-RUQ

6/1/2024 at 8:36 p.m. on the Abdomen-LLQ

6/2/2024 at 8:11 p.m. on the Abdomen-LLQ

6/8/2024 at 6:10 p.m. on the Abdomen-RLQ

6/10/2024 at 7:59 a.m. on the Abdomen-RLQ

6/13/2024 at 10:04 p.m. on the Abdomen-RLQ

6/14/2024 at 4:03 p.m. on the Abdomen-RLQ

6/16/2024 at 8:51 p.m. on the Abdomen-LUQ

6/17/2024 at 9:19 p.m. on the Abdomen-LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 6/19/2024 at 10:32 p.m. on the Abdomen-LLQ

Level of Harm - Minimal harm or 6/20/2024 at 11:47 a.m. on the Abdomen-LLQ potential for actual harm 6/27/2024 at 3:43 p.m. on the Abdomen-LLQ Residents Affected - Some 6/28/2024 at 4:48 p.m. on the Abdomen-LLQ

During a concurrent interview and record review on 7/11/2024, at 11:45 a.m., with Registered Nurse 3 (RN 3), Resident 20 ' s Order Summary Report, Medication Administration Record (MAR), and the Location of Administration of insulin for 4/2024 to 7/12/2024 was reviewed. RN 3 stated there were multiple instances that the insulin was administered on the same site from 4/2024 to 7/12/2024. RN 3 stated it was important to rotate insulin administration sites of insulin to prevent bruising and lipodystrophy to residents.

During an interview on 7/12/2024, at 6:17 p.m., with the Director of Nursing (DON), the DON stated it was basic nursing knowledge to rotate insulin administration sites. The DON stated if we do not rotate the administration sites of the insulin, the resident will develop skin damage and absorption will be compromised.

The DON stated the best area to administer was the abdominal area.

A review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 7/2023, indicated Select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

A review of the facility provided Information for the Physician Humulin-R Regular Insulin Human Injection, USP, (rDNA Origin) 100 units per ml (U-100), issued 3/2011, indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region or in the upper arm. Subcutaneous injection into the abdominal wall ensures a faster absorption than from other injection sites. Injection into a lifted skin fold minimizes the risk of intramuscular injection. Injection sites should be rotated within the same region.

43988

2. A review of Resident 74 ' s Admission Record indicated the facility admitted the resident on 12/6/2023 and was readmitted on [DATE REDACTED] with diagnoses that included abnormalities of gait and mobility, osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), and type two diabetes mellitus (DM 2 - a long-term medical condition in which the body does not use insulin properly, resulting in unusual blood sugar levels) with foot ulcer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 A review of Resident 74 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/3/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring Level of Harm - Minimal harm or knowledge and understanding) and required supervision with eating and oral hygiene and partial/moderate potential for actual harm assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident received insulin injections. Residents Affected - Some

A review of Resident 74 ' s History and Physical, dated 6/12/2024, indicated the resident did not have the capacity to understand and make decisions.

A review of Resident 74 ' s Order Summary Report indicated the following physician ' s order dated 5/27/2024 to administer insulin glargine solution-yfgn (a form of hormone insulin made in the laboratory used to control the amount of sugar in the blood of patients with diabetes) subcutaneous (SQ - administered under

the skin) solution (insulin glargine-yfgn) 100 unit/ml inject 15 units SQ every 12 hours for DM 2 and rotate injection sites.

A review of Resident 74 ' s Location of Administration Report for insulin from 4/2024 to 7/2024 indicated insulin glargine solution 100 UNIT/ML was administered as follows:

4/01/24 21:00 4/01/24 20:57 subcutaneously Abdomen - RUQ

4/02/24 09:00 4/02/24 16:44 subcutaneously Abdomen - RUQ

4/06/24 21:00 4/06/24 23:05 subcutaneously Abdomen - RUQ

4/07/24 09:00 4/07/24 14:53 subcutaneously Abdomen - RUQ

4/12/24 09:00 4/12/24 09:15 subcutaneously Abdomen - RLQ

4/12/24 21:00 4/12/24 21:27 subcutaneously Abdomen - RLQ

4/18/24 21:00 4/18/24 20:41 subcutaneously Abdomen - RLQ

4/19/24 09:00 4/19/24 13:47 subcutaneously Abdomen - RLQ

4/26/24 09:00 4/26/24 09:20 subcutaneously Abdomen - RLQ

4/26/24 21:00 4/26/24 20:07 subcutaneously Abdomen - RLQ

5/07/24 21:00 5/07/24 21:22 subcutaneously Abdomen - RUQ

5/08/24 09:00 5/08/24 09:55 subcutaneously Abdomen - RUQ

6/20/24 21:00 6/20/24 20:16 subcutaneously Abdomen - LUQ

6/21/24 09:00 6/21/24 09:43 subcutaneously Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During a concurrent interview and record review on 7/12/24 at 11:15 a.m., Resident 74 ' s insulin glargine Location of Administration Sites in the Medication Administration Record (MAR) for the month of 4/2024, Level of Harm - Minimal harm or 5/2024, 6/2024, and 7/2024 and physician ' s order were reviewed with Registered Nurse 2 (RN 2). RN 2 potential for actual harm verified the physician ' s order for the insulin glargine indicated to rotate injections site. RN 2 verified the administration sites for the insulin glargine were not rotated. RN 2 stated the administration sites should have Residents Affected - Some been rotated to prevent bruising, bleeding, and irritation on the site which may lead to poor absorption of the medication and the resident not receiving the required amount of insulin.

A review of the facility's most recent policy and procedure titled, Insulin Administration, last reviewed 7/2023, indicated the purpose is to provide guidelines for the safe administration of insulin to residents with diabetes.

The policy indicated the following:

- Select an injection site.

- Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

- Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

A review of the insulin glargine patient information provided by the facility, dated 2022, indicated to rotate the injection sites with each dose to reduce the risk of getting lipodystrophy and localized cutaneous amyloidosis at the injection sites. The package insert indicated to not use the same spot for each injection, or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, scarred, or damaged.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or 44244 potential for actual harm Based on observation, interview, and record review the facility failed to provide care consistent with Residents Affected - Some professional standards of practice to prevent pressure ulcers (PU, also called pressure injuries, pressure sores, and decubitus ulcers - injuries to skin and underlying tissue resulting from prolonged pressure) for two of two sampled residents (Resident 21 and Resident 93) reviewed under the care area Pressure Ulcer/Injury by failing to:

1. Ensure Resident 93 ' s low air loss mattress (LALM- a support surface composed of inflatable air cushions used to relieve pressure on body parts and help prevent skin breakdown) was set to the correct weight.

2. Turn Resident 93, who had a stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle) in the coccyx (the small bone at the bottom of the spine) every two hours in bed and follow the facility ' s policy on repositioning residents to indicate the position the resident was placed during repositioning.

3. Ensure Resident 93 ' s Pressure Injury Weekly Wound Assessment and Measurement was done per facility protocol. The wound was not assessed the week of 4/28/2024 to 5/4/2024.

These deficient practices had the potential to result in the development and/or worsening of resident pressure ulcers.

Findings:

1. A review of Resident 21 ' s Admission Record indicated the facility admitted Resident 21 on 11/11/2020, and readmitted Resident 21 on 4/11/2020, with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), pressure ulcer stage four (full thickness tissue loss with exposed bone, tendon or muscle) of sacral region (region at the bottom of the spine lying between the lumbar spine [L5] and the coccyx [tailbone]), type 2 diabetes mellites (a chronic condition that affects the way the body processes blood sugar [glucose]), and non-pressure chronic ulcer of right heel and midfoot with unspecified severity.

A review of Resident 21 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 4/9/2024, indicated Resident 21 sometimes was able to understand others and sometimes was able to make himself understood. The MDS further indicated the resident was dependent on staff for eating, oral hygiene, toileting, bathing, personal hygiene, dressing, and mobility. The MDS indicated the resident had a stage 4 PU with a pressure reducing device for the bed as treatment.

A review of Resident 21 ' s physician orders indicated an order for a LALM for prevention/management for pressure sores, dated 4/11/2022.

A review of Resident 21 ' s Care Plan titled, Actual Pressure Sore, Resident noted with stage 4 pressure ulcer, site: Sacro coccyx, initiated 4/11/2022, indicated to administer treatment as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During an observation on 7/9/2024 at 9:25 a.m., Resident 21 was lying in bed on a LALM, the resident did not respond to the surveyor. The LALM pump (device that adds and removes air from the mattress) set to a Level of Harm - Minimal harm or resident weight of 120 pounds (lbs). potential for actual harm

During an observation on 7/10/2024 at 7:15 a.m., Resident 21 was lying in bed on a LALM. The LALM pump Residents Affected - Some was set to 280 lbs.

During a concurrent observation and interview on 7/10/2024 at 7:20 a.m., Certified Nursing Assistant 3 (CNA 3) entered Resident 21 ' s room and stated the LALM was set to 280 lbs. CNA 3 stated she did not think the resident weighed 280 lbs. CNA 3 stated the LALM was set to 280lbs when she arrived that morning.

During a concurrent observation, interview, and record review on 7/10/2024 at 7:35 a.m. Licensed Vocational Nurse 4 (LVN 4) reviewed Resident 21 ' s weights and stated the resident weighed 110 lbs. LVN 4 entered Resident 21 ' s room and stated the LALM was not set to the correct weight because it was set to 280lbs, but

it should be set to 120lbs the setting nearest the resident ' s weight. LVN 4 stated the LALM is for safety, comfort and pressure injuries. LVN 4 stated when the LALM is set to a higher weight it makes the mattress harder and could disrupt the pressure injury healing process.

During a concurrent interview and record review on 7/10/2024 at 7:40 a.m., Registered Nurse 2 (RN 2) reviewed Resident 21 ' s weight. RN 2 stated LALM mattresses are calibrated by weight and set to a setting nearest to the resident ' s weight. RN 2 stated Resident 21 weighed 110lbs and the LALM should be set to 120lbs to promote pressure injury healing.

During an interview and record review on 7/12/2024 at 10:30 a.m. with the Assistant Director of Nursing (ADON) reviewed Low Air Los Mattress 1 ' s (LALM 1) Operation Manual. The ADON stated the Operation Manual indicated to select the resident ' s correct weight on the pump device. The ADON stated setting the LALM to the wrong weight will make the mattress firmer and the wound could become worse, or a new pressure injury may develop.

During a concurrent interview and record review on 7/12/2024 at 6:12 p.m., the Director of Nursing (DON) reviewed LALM 1 ' s Operation Manual and the facility policy regarding pressure ulcer prevention. The DON stated the LALM is set to the resident ' s weight. The DON stated if the LALM is set to a weight that is too low or high then it could potentially be a contributing factor to delayed wound healing. The DON stated if the LALM is too firm then the surface is hard, and the mattress is not functioning properly. The DON stated the facility policy and LALM 1 Operation Manual was not followed which had a potential for delayed wound healing, an increase in the size of the pressure injury, and hospitalization from infection.

A review of the facility policy and procedure titled, Pressure-Reducing Mattresses, last reviewed 7/2023, indicated the objective of the policy was to provide mattresses that will prevent and/or minimize pressure on

the skin.

A review of the facility policy and procedure titled, Prevention of Pressure Injuries, last reviewed 7/2023, indicated the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Prevention includes selecting appropriate support surfaces based on the resident ' s risk factors, in accordance with current clinical practice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 A review of the facility ' s undated Operation Manual for LALM 1, indicated LALM 1 is designed for prevention, treatment, and management of pressure ulcers. The Level of Harm - Minimal harm or potential for actual harm manual indicated to select the up or down buttons on the pump unit to select the correct patient weight. Users can adjust the mattress to a desired firmness according to the patient ' s weight or the suggestion from Residents Affected - Some a health care professional.

44376

2. A review of Resident 93 ' s Admission Record indicated the facility admitted the resident on 4/1/2024, with diagnoses that included lack of coordination, muscle weakness, and a Stage 4 pressure ulcer of the sacral region.

A review of Resident 93 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/12/2024, indicated Resident 93 sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired upper and lower extremities and was dependent on mobility and activities of daily living (ADLs). The MDS indicated the resident was at risk for further developing pressure ulcer/injuries and had an unhealed Stage 4. The MDS did not indicate that Resident 93 was on a turning/repositioning program.

A review of Resident 93 ' s History and Physical (H&P), dated 6/3/2024, indicated Resident 93 did not have

the capacity to understand and make decisions.

A review of Resident 93 ' s Order Summary Report, dated 7/2/2024, indicated an order Irrigate the Sacro coccyx Stage 4 Pressure Ulcer- with normal saline (a mixture of salt and water), pat dry, apply Santyl ointment (to help the healing of burns and skin ulcers), pack with calcium alginate (super absorbent dressings that absorb excess wound drainage), cover with super absorbative foam dressing daily. Every day shift for 30 days and monitor for pain during treatment through pain ad 0-10).

A review of Resident 98 ' s Care Plan titled, Actual pressure sore: Resident is noted with: Stage 4 pressure ulcer, site: Sacro coccyx, last revised on 5/27/2024, indicated an intervention to encourage Resident 93 to assist with turning and positioning changes as tolerated, turn and position as needed when in bed or wheelchair, and weekly body checks per facility protocol.

A review of Resident 98 ' s Monitoring Sheet for Turning and Repositioning on 7/10/2024, indicated Resident 93 was turned at 4:30 a.m. and 1:43 p.m. The entries on the flow sheet were entered before the end of the CNA 1 shift.

During an observation on 7/10/2024, Resident 93 was positioned in bed at the following times:

8:53 a.m. Resident was facing the window or the left side.

11:43 a.m. Resident was facing the door or the right side.

1:53 p.m. Resident was facing the door or the right side.

2:44 p.m. Resident was facing the door or the right side.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During a concurrent observation and interview on 7/10/2024, at 2:50 p.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 93 ' s room, Resident 93 was facing the door or the right side. CNA 1 stated the Level of Harm - Minimal harm or last time she turned the resident was 1:43 p.m. on the right side. CNA 1 stated that she was not the only one potential for actual harm turning the resident but other staff as well. CNA 1 stated she cannot remember what the position of the resident was before she turned the resident to the right. CNA 1 stated they only document the Residents Affected - Some turning/repositioning of the resident once a shift as done, and they do not indicate position of the resident. CNA 1 stated the resident needed to be turned every 2 hours to prevent worsening of pressure injury.

During an observation on 7/11/2024, Resident 93 was positioned in bed at the following times:

8:10 a.m. Resident was facing the door or to the right side.

9:54 a.m. Resident was facing the window or to the left side.

11:53 a.m. Resident was facing the door or to the right side.

3:31 p.m. Resident was facing the door or to the right side.

During a concurrent observation and interview on 7/11/2024, at 3:32 p.m., with Certified Nursing Assistant 2 (CNA 2), inside Resident 93 ' s room, Resident 93 was facing the door or to the right side. CNA 2 stated he just got there, and the resident was facing the door or to the right side when he came in. CNA 2 stated he has not repositioned the resident yet.

During an interview on 7/11/2024, at 5:35 p.m., with Treatment Nurse 1 (TN 1), TN 1 stated the staff need to turn the resident every 2 hours to relieve pressure to the bony prominences of the body and it should be documented in a timely manner and make sure that the position was indicated to prevent confusion on which side the resident will be facing next to prevent further skin breakdown. TN 1 stated the wound was not assessed on the week of 4/28/2024 to 5/4/2024. TN 1 stated it was important to consistently perform the weekly assessment and measurement of the pressure ulcer to ensure the wound was responding well to the treatment.

During an interview on 7/12/2024, at 6:21 p.m., with the Director of Nursing (DON), the DON stated it was important to reposition the resident every two hours to promote circulation to the skin, if there was decreased circulation, there will be an increased risk for skin damage. The DON stated that turning the resident every two hours was important for skin maintenance and to prevent other skin complications. The DON stated TN 1 should do weekly wound assessment and measurement to keep track if the wound was responding to the current treatment, to evaluate the interventions being provided if it needed to continue or not. The DON stated the importance of placing the position of the resident when repositioning was to keep track of where

the resident was turned to prevent turning on the same side for continuity of care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 A review of the facility's recent policy and procedure titled, Repositioning, last reviewed on 7/2023, indicated

the purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to Level of Harm - Minimal harm or aid in the development of an individualized care plan for repositioning, to promote comfort for all potential for actual harm bed-or-chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning is a common, effective intervention for preventing skin breakdown, promoting Residents Affected - Some circulation, and providing pressure relief. Residents who are in bed should be repositioned frequently and as needed. The following information should be recorded in the resident's medical record:

1. The position in which the resident was placed. This may be on a flow sheet.

7. The signature and title of the person recording the data.

A review of the facility's recent policy and procedure titled, Prevention of Pressure Injuries, last reviewed on 7/2023, indicated to assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm 44376

Residents Affected - Few Based on interview and record review the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion (ROM, how far and in what direction

the joint or muscle can move) and/or prevent further decrease in range of motion for one of two sampled residents (Resident 4) by failing to conduct a consistent restorative nursing weekly summary for the month of April 2024.

This deficient practice had the potential to place the resident at increased risk of ROM decline.

Findings:

A review of Resident 4 ' s Admission Record indicated the facility admitted the resident on 1/15/2015, and readmitted the resident on 3/6/2024, with diagnoses that included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), obesity (having too much fat), and contracture (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the right hand.

A review of Resident 4 ' s History and Physical (H&P), dated 3/12/2024, indicated Resident 4 did not have

the capacity to understand and make decisions.

A review of Resident 4 ' s Order Summary Report, dated 4/4/2024, indicated an order for Restorative Nursing Aide (RNA) to provide passive range of motion exercises (PROME, joint movement caused by another person or a specialized device) on both lower extremities (LE) as tolerated. Everyday (Qd) 5 times per week (x/wk).

A review of Resident 4 ' s Care Plan titled, Limitation(s) in range of motion/contractures related to muscle weakness, general dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person ' s daily life and activities), last revised on 4/4/2024, indicated an intervention of restorative nursing treatment as ordered and RNA to provide PROME on both LE as tolerated. Qd (Every day) 5x/wk.

A review of Resident 4 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/3/2024, indicated Resident 4 sometimes had the ability to make self-understood and understand others. The MDS indicated Resident 4 had impaired upper and lower extremities and was mostly dependent

in mobility and activities of daily living (ADLs).

During a concurrent interview and record review on 7/11/2024, at 11:30 a.m., with Restorative Nursing Aide 1 (RNA 1), Resident 4 ' s Restorative Nursing Weekly Summary for Range of Motion was reviewed. RNA 1 stated there was only one Restorative Nursing Weekly Summary for range of motion that was done for the resident for the month of April 2024. RNA 1 stated there should be at least four per month. RNA 1 stated it was important to perform a Restorative Nursing Weekly Summary range of motion for the resident to check if

the resident was responding well to the therapy and to assess if the resident was having a decline in function to intervene as soon as possible by reporting to the Director of Rehabilitation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 During an interview on 7/12/2024, at 6:28 p.m., with the Director of Nursing (DON), the DON stated it was important for the RNA to do a weekly RNA summary to prevent a decline in range of motion. Level of Harm - Minimal harm or potential for actual harm A review of the facility's most recent policy and procedure titled, Restorative Nursing Program, last reviewed

on 7/2023, indicated the purpose of the policy is to maintain resident's functional ability, and to reduce further Residents Affected - Few decline. Weekly assessment is to be made of the resident's progress in the Restorative Nursing Program by

the restorative nurse and documented in the resident's medical record. Any change in resident's condition or response to treatment is reported to nursing and documented in the medical record. The Director of Nursing, or designee, shall design a schedule for the facility's staff to ensure the residents receive appropriate restorative programs. Residents who are completely incapacitated are to be scheduled for a range of motion exercise when turned or repositioned, or during dressing and bathing. The restorative nurse assistant shall be scheduled for specific restorative and rehabilitative duties by the Director of Nursing, or designee, in regular consolation with the physical therapist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988

Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards, ensure residents received adequate supervision, and implement interventions to prevent accidents for five (5) of 5 sampled residents (Resident 54, 58, 27, 77, and 60) investigated under the Accidents care area by failing to:

1. Ensure Resident 58 ' s left side floor mat was not overlapping with Resident 54 ' s right side floor mat

during a random observation.

This deficient practice placed Resident 54 and 58 at risk for fall incidents which may lead to injuries.

2. Ensure Resident 27 ' s sensor pad alarm (a device consisting of a pressure-sensing pad that sends a signal to a nearby receiver to sound when the resident rises and their weight shifts) was functioning properly when the resident tried to get out of bed unassisted during a random observation.

This deficient practice placed Resident 27 at risk for exiting the bed without staff knowledge and sustaining injuries from falls.

3. Ensure the sensor pad alarms (a device consisting of a pressure-sensing pad that sends a signal to a nearby receiver to sound when the resident rises and their weight shifts) were connected and functioning for Resident 77 and Resident 60.

This deficient practice had the potential to place Resident 60 and 77 at risk for falls and injuries.

Findings:

a. A review of Resident 58 ' s Admission Record indicated the facility admitted Resident 58 on 8/14/2020 and readmitted to the facility on [DATE REDACTED] with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and traumatic subdural hemorrhage (a type of bleeding near your brain that can happen after a head injury due to trauma).

A review of Resident 58 ' s History and Physical (H&P) dated 2/12/2024, indicated Resident 58 did not have

the capacity to understand and make decisions.

A review of Resident 58 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/15/2024 indicated Resident 58 had a severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating; partial/moderate assistance with mobility, walking, oral, toileting, and personal hygiene; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 58 ' s Fall Risk Assessments indicated the following:

Level of Harm - Minimal harm or 1. 2/9/2024 was assessed as high risk for falls with a score of 26 due to a fall incident. potential for actual harm 2. 2/14/2024 was assessed as high risk for falls with a score of 26 during readmission. Residents Affected - Some 3. 5/25/2024 was reassessed as high risk for falls with a score of 28 during a quarterly assessment.

A review of Resident 58 ' s care plans indicated the following:

1. Resident is at risk for falls/injury related to generalized weakness, history of falls, and impaired cognition initiated 2/15/2024 indicated to provide low bed with floor mat as ordered as one of the interventions.

2. Actual fall related to balance deficit, cognitive impairment, and history of falls initiated 2/9/2024 indicated to provide low bed with floor mat as ordered, administer pain medications as ordered, apply cold compress as ordered as some of the interventions.

During a concurrent observation and interview on 7/9/2024 at 10:05 a.m. inside Resident 58 ' s room with Certified Nursing Assistant 7 (CNA 7), observed Resident 58 ' s left lower side floor mat was on top of Resident 54 ' s right lower side floor mat. CNA 7 verified Resident 58 ' s floormat was overlapping with Resident 54 ' s floor mat and stated it was not supposed to be overlapping as it had the potential for both residents to trip and fall causing injury. CNA 7 stated the floor mats were supposed to be properly placed and not overlapping.

During a concurrent observation and interview on 7/9/2024 at 10:07 a.m. inside Resident 58 ' s room with Registered Nurse 2 (RN 2), Resident 58 ' s left lower side floor mat was on top of Resident 54 ' s right lower side floor mat. RN 2 verified Resident 58 ' s floormat was overlapping with Resident 54 ' s floor mat and stated it was supposed to be properly placed on the floor and not overlapping as it had the potential for both residents to trip and fall causing injury.

A review of the facility ' s policy and procedure titled, Accident reduction: Useful Interventions, last reviewed 7/2023, indicated useful interventions will be utilized to reduce accidents and injuries. The policy indicated padding on the floor and low bed as some of the interventions.

A review of the facility ' s policy and procedure titled, Falling Star Program, last reviewed 7/2023, indicated recommendations to ensure successful program would be to include evaluation for appropriate useful interventions for fall reduction.

b. A review of Resident 54 ' s Admission Record indicated the facility admitted Resident 54 on 8/2/2023 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), generalized weakness, restlessness and agitation, and delirium (a mental state in which a person is confused and has reduced awareness of their surroundings).

A review of Resident 54 ' s History and Physical (H&P) dated 8/8/2023, indicated Resident 54 did not have

the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 54 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/15/2024 indicated Resident 54 had severely impaired cognition (mental action or process of Level of Harm - Minimal harm or acquiring knowledge and understanding) and required total assistance with showers, supervision with eating, potential for actual harm partial/moderate assistance with mobility, walking, oral and personal hygiene, and transfers, and substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be Residents Affected - Some accomplished every day for an individual to thrive).

A review of Resident 54 ' s Order Summary Report indicated a physician ' s order dated 9/16/2023 for low bed with floor mat to decrease potential injury every shift.

A review of Resident 54 ' s Fall Risk Assessments indicated the resident was assessed as a high risk for falls with a score of 24 on 2/11/2024 and 5/19/2024 during quarterly assessments.

A review of Resident 54 ' s care plans indicated the following:

- Actual fall related to auditory deficits, balance deficit, cognitive impairment, decreased strength/endurance, history of falls, non-compliant with requests

for assistance/non-use of call light, poor safety awareness/judgment, unsteady gait initiated 11/27/2023 target date 8/9/2024 indicated to provide a low bed with floor mat as ordered as one of the interventions.

During a concurrent observation and interview on 7/9/2024 at 10:05 a.m. inside resident 58 ' s room with Certified Nursing Assistant 7 (CNA 7), Resident 58 ' s left lower side floor mat was on top of Resident 54 ' s right lower side floor mat. CNA 7 verified Resident 58 ' s floormat was overlapping with Resident 54 ' s floor mat and stated it was not supposed to be overlapping as it had the potential for both residents to trip and fall causing injury. CNA 7 stated the floor mats were supposed to be properly placed and not overlapping.

During a concurrent observation and interview on 7/9/2024 at 10:07 a.m. inside Resident 58 ' s room with Registered Nurse 2 (RN 2), Resident 58 ' s left lower side floor mat was on top of Resident 54 ' s right lower side floor mat. RN 2 verified Resident 58 ' s floormat was overlapping with Resident 54 ' s floor mat and stated it was supposed to be properly placed on the floor and not overlapping as it had the potential for both residents to trip and fall causing injury.

A review of the facility ' s policy and procedure titled, Accident reduction: Useful Interventions, last reviewed 7/2023, indicated useful interventions will be utilized to reduce accidents and injuries. The policy indicated padding on floor and low bed as some of the interventions.

44376

c. A review of Resident 27 ' s Admission Record indicated the facility admitted Resident 27 on 2/23/2021 with diagnoses that included Alzheimer ' s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and congestive heart failure (a condition that develops when the heart does not pump enough blood for

the body's needs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 27 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/23/2024 indicated Resident 27 had severely impaired cognition (mental action or process of Level of Harm - Minimal harm or acquiring knowledge and understanding) and required supervision with eating and bed mobility; potential for actual harm substantial/maximal assistance walking, shower transfer, and lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for Residents Affected - Some an individual to thrive).

A review of Resident 27s History and Physical (H&P) dated 7/10/2024, indicated Resident 27 did not have

the capacity to understand and make decisions.

A review of Resident 27 ' s Order Summary Report indicated the following physician ' s orders:

1. 7/14/2024: Bed pad alarm to alert staff when resident attempts to stand up from bed unassisted every shift.

2. 7/14/2024: Monitor for function and placement of bed pad alarm every shift.

3. 7/17/2023: Monitor episodes of resident attempting to stand up from bed unassisted every shift.

A review of Resident 27 ' Fall Risk Assessments indicated the following:

1. 11/18/2023: Resident was assessed as a high risk for falls with a score of 20 during a quarterly assessment.

2. 2/18/2023: Resident was assessed as a high risk for falls with a score of 16 during an annual assessment.

3. 5/25/2024: Resident was assessed as a high risk for falls with a score of 16 during a quarterly assessment.

A review of Resident 27 ' s care plans indicated the following:

1. Actual fall related to cognitive impairment, decreased strength/endurance, poor gait and balance initiated 7/14/2023 with target date 8/21/2024 indicated to apply bed alarm to alert staff that resident is attempting to get up from the bed unattended as one of the interventions.

2. Resident is at risk for falls/injury related to dementia, impaired cognition, poor safety awareness/judgment initiated 2/24/2021 target date 8/21/2024 indicated to apply a bed alarm to alert staff that resident is attempting to get up from the bed unattended and ensure bed pad alarm is in place and monitor for function and placement as some of the interventions.

During an observation on 7/9/2024 at 9:51 a.m., inside Resident 27 ' s room, observed Resident lying in bed

in a supine position then got up in a sitting position at the edge of the bed. Observed a bed pad alarm hanging on the right side of the bed with a red blinking light and the pad alarm did not function.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a concurrent observation and interview on 7/9/2024 at 9:53 a.m. inside Resident 27 ' s room, Certified Nursing Assistant 8 (CNA 8) assisted Resident 27 to the restroom and the bed alarm did not function. CNA 8 Level of Harm - Minimal harm or verified the bed alarm did not make a sound when she assisted the resident to the restroom. CNA 8 stated potential for actual harm the bed alarm should have made a sound when the Resident 27 moved in the bed as it placed the resident at risk for falls and injuries. Residents Affected - Some

During a concurrent observation and interview on 7/9/2024 at 9:55 a.m. inside Resident 27 ' s room, Certified Nursing Assistant 7 (CNA 7) stated they checked the bed pad alarm for functionality by pressing on the pad and letting go for the alarm to make a sound. CNA 7 checked Resident 27 ' s bed pad alarm for functionality and the alarm did not make a sound. CNA 7 stated the bed pad alarm should have made a sound when pressed and let go for the staff to be aware that the resident got up unassisted and placed Resident 27 at risk for falls.

During a concurrent observation and interview on 7/9/2024 at 10 a.m. inside Resident 27 ' s room, Registered Nurse 2 (RN 2) verified Resident 27 ' s bed pad alarm did not make a sound when she checked

the functionality. RN 2 stated the bed pad alarm should have made a sound when pressed and let go to alert staff that the resident was trying to get up unassisted as it placed Resident 27 at risk for falls and injuries.

A review of the facility ' s policy and procedure titled, Personal Alarm, last reviewed 7/2023, indicated the facility will use a sensor pad that conveniently sounds an audible alarm when the sensor detects a patient rising out of the bed/wheelchair reminding the resident to return to a safe position while alerting staff to a potential fall. The policy indicated the following:

- Check the alarm system every day for proper functioning.

- Nursing will monitor proper functioning and positioning of personal alarm.

d. A review of Resident 77 ' s Admission Record indicated the facility admitted Resident 77 on 6/22/2021 and readmitted on [DATE REDACTED] with diagnoses that included a fracture (a break) of unspecified part of neck of right femur (the region just below the ball of the hip joint), difficulty walking, osteoarthritis (condition that causes

the joints to become very painful and stiff) of right hip, pathological fracture (broken bone caused by disease) of hip, and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).

A review of Resident 77 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 4/26/2024, indicated Resident 77 was able to understand others and was able to make herself understood.

The MDS further indicated Resident 77 was dependent on staff for toileting, dressing, and mobility, and required partial assistance from staff for eating and personal hygiene.

A review of Resident 77 ' s Care Plan titled, Resident is at risk for falls/injury related to dementia, generalized weakness, history of falls, and impaired cognition, initiated 5/31/2024 indicated a goal that the resident would have reduced risk of falls and injury through appropriate interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 77 ' s Care Plan titled, Sensor Pad Alarm. Resident requires sensor pad alarm when in bed due to spontaneous act/behavior of trying to get up unassisted. Alarm used to alert staff from any unsafe Level of Harm - Minimal harm or mobility initiated 4/19/2024, indicated to apply the sensor pad alarm as ordered, monitor the alarm for good potential for actual harm working condition and proper placement as needed.

Residents Affected - Some During an observation on 7/9/2024 at 8:30 a.m., Resident 77 lay in bed with her eyes closed. Observed a sensor pad alarm at the foot of the resident ' s bed with the alarm connection cord disconnected from the sensor pad.

During a concurrent observation and interview on 7/9/2024 at 8:50 a.m., Certified Nursing Assistant 4 (CNA 4) entered Resident 77 ' s room and stated the bed alarm was disconnected. CNA 4 reconnected the alarm and stated maybe the resident disconnected it. CNA 4 stated she was not caring for Resident 77.

During an interview on 7/9/2024 at 8:55 a.m., Certified Nursing Assistant 5 (CNA 5) entered Resident 77 ' s room and stated she was caring for the resident. CNA 5 stated she made rounds when she delivered the breakfast trays and did not notice the alarm disconnected. CNA 5 stated she had never seen the resident disconnect her alarm and maybe the nightshift disconnected it. CNA 5 stated it was important to make sure

the alarm was functioning for safety and to know if there were any emergencies, like a fall.

During a concurrent interview and record review on 7/12/2024 at 10:18 a.m., the Assistant Director of Nursing (ADON) reviewed the facility policy on personal

alarms. The ADON stated Resident 77 needs the sensor pad alarm because she is a fall risk and had a history of a fractured hip. The ADON stated staff must make sure alarms are connected and functioning well because staff need to timely assist the residents. The ADON stated if the alarm was not connected there was

a potential for injury from a fall including bruising, pain, and fractures. The ADON stated the facility policy was not followed because the alarm was disconnected.

During a concurrent interview and record review on 7/12/2024 at 6:12 p.m., the Director of Nursing (DON) reviewed the facility policy on personal alarms. The DON stated Resident 77 had a physician ' s order for a pad alarm so staff would be alerted that the resident was trying to get up unassisted. The DON stated the resident was a high risk for falls and the pad alarm is an intervention for fall prevention. The DON stated when the alarm was disconnected, the resident could sustain a fall with the potential for injury including fractures and head trauma. The DON stated the facility policy was not followed.

A review of the facility policy and procedure titled, Accident Reduction: useful Interventions, last reviewed 7/2023, indicated useful interventions will be utilized to reduce accidents and injuries. The following useful interventions should help reduce accidents and injuries: bed alarms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of the facility policy and procedure titled, Falls and Fall Risk, Managing, last reviewed 7/2023, indicated based on previous evaluations and current data, the staff will identify interventions related to the Level of Harm - Minimal harm or resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize potential for actual harm complications from falling. Resident conditions that may contribute to risk for falls includes cognitive and functional impairments. The staff with the input from the attending physician, will implement a Residents Affected - Some resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. A systemic evaluation of a resident ' s fall risk identifies several possible interventions. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

A review of the facility policy and procedure titled, Personal Alarm, last reviewed 7/2023, indicated the facility will use, as indicated, a sensor pad that conveniently sounds an audible alarm when the sensor detects a patient rising out of the bed reminding the resident to return to a safe position while alerting staff to a potential fall. Nursing will monitor proper functioning and positioning of personal alarm.

e. A review of Resident 60 ' s Admission Record indicated the facility admitted Resident 60 on 12/1/2021 and readmitted the resident on 10/24/2022 with diagnoses that included unspecified dementia, age-related osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue), restlessness and agitation, pathological fracture right femur, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one ' s daily functioning).

A review of Resident 60 ' s Care Plan titled, Resident is at risk for falls/injury related to dementia, cognitive impairment, and poor safety awareness, initiated 10/25/2022 indicated a goal that the resident would have reduced risk of falls and injury through appropriate interventions.

A review of Resident 60 ' s Care Plan titled, Actual Fall, related to .balance deficit, cognitive impairment, history of falls, poor safety awareness, initiated 3/1/2024 indicated interventions including the bed pad alarm.

A review of Resident 60 ' s physician orders indicated an order for a bed pad alarm secondary to unassisted transfer for safety awareness, dated 3/4/2024.

A review of Resident 60 ' s Care Plan titled, Sensor Pad Alarm. Resident requires sensor pad alarm when in bed due to spontaneous act/behavior of trying to get up unassisted. Alarm used to alert staff from any unsafe mobility initiated 3/4/2024 indicated to apply the sensor pad alarm as ordered, monitor the alarm for good working condition and proper placement as needed.

A review of Resident 60 ' s MDS dated [DATE REDACTED], indicated Resident 60 was rarely/never able to understand others and was rarely/never able to make herself understood. The MDS further indicated Resident 60 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an observation on 7/9/2024 at 8:32 a.m., Resident 60 lay in bed with the bed in the lowest position, Resident 60 did not respond to the surveyor. A sensor pad alarm was observed on the floor with the alarm Level of Harm - Minimal harm or connection cord disconnected from the sensor pad. potential for actual harm

During a concurrent observation and interview on 7/9/2024 at 8:50 a.m., Certified Nursing Assistant 4 (CNA Residents Affected - Some 4) entered Resident 60 ' s room and stated the bed alarm was disconnected and on the floor. CNA 4 stated Resident 60 moves around a lot. CNA 4 reconnected the alarm and the alarm sounded. CNA 4 stated she was not caring for Resident 60, but maybe when the assigned CNA was feeding the resident the alarm fell and became disconnected.

During an interview on 7/9/2024 at 8:55 a.m., Certified Nursing Assistant 5 (CNA 5) entered Resident 60 ' s room and stated she was caring for the resident. CNA 5 stated she made rounds when she delivered the breakfast trays and did not notice the alarm was disconnected. CNA 5 stated she had never seen the resident disconnect her alarm and maybe the nightshift disconnected it. CNA 5 stated it was important to make sure the alarm was functioning for safety and to know if there were any emergencies, like a fall.

During a concurrent interview and record review on 7/12/2024 at 10:18 a.m., the Assistant Director of Nursing (ADON) reviewed the facility policy on personal alarms. The ADON stated Resident 60 needs the sensor pad alarm because she had spontaneous movements. The ADON stated Resident 60 does not have

the ability to disconnect the alarm. The ADON stated staff must make sure alarms are connected and functioning well because staff need to timely assist the residents. The ADON stated if the alarm was not connected there was a potential for injury from a fall including bruising, pain, and fractures. The ADON stated

the facility policy was not followed because the alarm was disconnected.

During a concurrent interview and record review on 7/12/2024 at 6:12 p.m., the Director of Nursing (DON) reviewed the facility policy on personal alarms. The DON stated the resident had a physician ' s order for a bed alarm so staff would be alerted that the resident was trying to get up unassisted. The DON stated the resident was a high risk for falls and the bed alarm is an intervention for fall prevention. The DON stated when the alarm was disconnected, the resident could sustain a fall with the potential for injury including fractures and head trauma. The DON stated the facility policy was not followed.

A review of the facility policy and procedure titled, Accident Reduction: useful Interventions, last reviewed 7/2023, indicated useful interventions will be utilized to reduce accidents and injuries. The following useful intervention should help reduce accidents and injuries: bed alarms.

A review of the facility policy and procedure titled, Falls and Fall Risk, Managing, last reviewed 7/2023, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to risk for falls includes cognitive and functional impairments. The staff with the input from the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. A systemic evaluation of a resident ' s fall risk identifies several possible interventions. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of the facility policy and procedure titled, Personal Alarm, last reviewed 7/2023, indicated the facility will use, as indicated, a sensor pad that conveniently sounds an audible alarm when the sensor detects a Level of Harm - Minimal harm or patient rising out of the bed reminding the resident to return to a safe position while alerting staff to a potential for actual harm potential fall. Nursing will monitor proper functioning and positioning of personal alarm.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm 44376

Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure a resident receiving enteral feeding (any method of feeding that uses the gastrointestinal tract to deliver nutrition and calories) received appropriate care and services to prevent complications of enteral feeding for one out of one sampled resident (Resident 93) being investigated under enteral nutrition by failing to label the irrigation syringe (a specialized medical instrument designed for the irrigation or cleansing of wounds, cavities, or body orifices) pouch with the name of the resident and the date it was last changed.

The deficient practice had the potential for complications associated with enteral feeding such as peritonitis (a redness and swelling [inflammation] of the lining on the abdomen).

Findings:

A review of Resident 93 ' s Admission Record indicated the facility admitted Resident 93 on 4/1/2024, with diagnoses that included gastrostomy (a surgical procedure used to insert a tube, often referred to as a g-tube, through the abdomen and into the stomach), enterocolitis (an inflammation of the intestines) due to clostridium difficile (a bacterium that causes an infection of the colon, the longest part of the large intestine), and sepsis (a serious condition in which the body responds improperly to an infection).

A review of Resident 93 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/12/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had a feeding tube while a resident in the facility.

A review of Resident 93 ' s History and Physical (H&P), dated 6/3/2024, indicated Resident 93 did not have

the capacity to understand and make decisions.

A review of Resident 93 ' s Care Plan titled, Risk for infection. Resident at moderate risk for infection secondary to history of colonization (infection that is present in the body but cannot cause illness) with Multi-resistant Organisms (MDRO, bacteria that have become resistant to certain antibiotics), and indwelling medical devices (relating to device that is left inside the body), was initiated on 7/2/2024, indicated an intervention of indwelling device care if indicated.

A review of Resident 93 ' s Order Summary Report, dated 7/9/2024, indicated an order for enteral feeding.

The order indicated to hang Jevity 1.2 (provides complete, balanced nutrition for long- or short-term tube feeding) alternatives until Fiber source (a nutritionally complete tube feeding formula with fiber) feeding is available at 70 cubic centimeters (cc, a unit of volume) per hour for 20 hours via pump to provide 1400 cc/1680 kilocalories (kcal, a unit of energy) per day. Every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 During a concurrent observation and interview on 7/10/2024, at 8:50 a.m., with Registered Nurse 1 (RN 1), inside Resident 93 ' s room, Resident 93 ' s irrigation syringe was observed inside a plastic pouch hanging Level of Harm - Minimal harm or on a feeding pole pump with a date of 7/9/2024. RN 1 stated the irrigation syringe should be changed every potential for actual harm 24 hours or daily to prevent growth of germs on the barrel of the irrigation syringe that can cause illness to

the resident. RN 1 stated it was the responsibility of the night shift licensed staff to ensure the irrigation Residents Affected - Few syringes were replaced daily. RN 1 stated the plastic pouch of the irrigation syringe should be dated when it was last changed.

During an interview on 7/12/2024, at 2:13 p.m., with the Infection Preventionist (IP), the IP stated the irrigation syringe should be dated and replaced every 24 hours to ensure there was no growth of bacteria on

the irrigation syringe that can cause infection to residents. The IP stated further that residents with g-tube are susceptible to infection because bacteria can grow on the irrigation syringe that can be flushed in the resident's system causing gastrointestinal (GI, relating to, affecting, or including both stomach and intestine) infections.

During an interview on 7/12/2024, at 6:31 p.m., with the Director of Nursing (DON), the DON stated the staff needed to change the irrigation syringe daily and should date them when it was last change to ensure there was no bacterial growth on the syringe that can cause potential GI infection.

A review of the facility's recent policy and procedure titled, Enteral Feedings, last reviewed on 7/2023, indicated to ensure the safe administration of enteral nutrition. Feeding syringe shall be changed every 24 hours or whenever if there is a damage or is contaminated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 71 555707 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555707 B. Wing 07/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm 44376 Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (adjustable rigid plastic bars attached to the bed that may be positioned in various locations on

the bed; upper or lower, either or both sides) to one of four sampled residents (Resident 4) investigated

during review of physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) by failing to:

1. Complete a Physical Restraint Assessment Form prior to the application of both upper side rails as a restraint.

2. Obtain an informed consent from the resident or resident representative prior to the application of both upper side rails as a restraint.

3. Obtain an order from the attending physician prior to the application of both upper side rails as a restraint.

These deficient practices had the potential to result in the restriction of residents ' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents.

Findings:

Cross Reference