Imperial Care Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
concurrent interview and record review on 8/14/2025 at 9:27 a.m. with the MDS, Resident 1's Fall Risk Evaluation dated 7/22/2025 was reviewed. The MDS stated Resident 1 was discharged then returned to the facility on 7/21/2025. The MDS stated Resident 1 had multiple fall risk evaluations on 7/22/2025 because
the nursing staff did not communicate with each other. The MDS stated was unsure which fall risk evaluations were accurate.During a concurrent interview and record review on 8/14/2025 at 3 p.m. with the Director of Nursing (DON), Resident 1's Fall Risk Evaluation dated 7/22/2025 was reviewed. The DON stated Resident 1 prior to fall on 8/3/2025 was not a high risk for falls but all residents in this facility are fall risk due to poor cognitive awareness and safety issues. The DON stated Resident 1 was able to ambulate without devices and had a prior fall in Resident 1's room without injury on 7/3/2025. The DON stated Resident 1 was discharged prior due to behavioral issues and returned to the facility on 7/21/2025. The DON stated the facility has a new system for the Fall Risk Evaluation, the DON stated was aware that two entries were done on 7/22/2025 one was from the nurse from 7 a.m. to 3 p.m. shift and the other was from
the nurse from the 3 p.m. to 11 p.m. shift. The DON stated was not sure which fall risk evaluation was accurate. The DON stated the one Registered Nurse (RN) 2 did indicated Resident 1 had a fall risk score of 16 and RN 3's fall risk evaluation indicated Resident 1's fall risk score was 18. The DON stated RN 2 and RN 3's fall risk evaluation was inaccurate because RN 2 and RN 3 indicated Resident 1 had no falls in the past three (3) months and that is inaccurate because Resident 1 had a fall on 7/3/2025. The DON stated RN 2 inaccurately documented Resident 1's COC because Resident 1 did have a COC for behaviors and that is why Resident 1 was readmitted on [DATE REDACTED]. The DON stated RN 2 inaccurately documented Resident 1's medications, the record indicates Resident 1 takes one to two of the listed medications, but it should indicate Resident 1 takes three to four of the listed medications. The DON reviewed the fall risk evaluation for Resident 1 for 8/7/2025 and the DON stated the fall risk evaluation was inaccurate because it indicated Resident 1 had none of the listed predisposing diseases. The DON stated assessment must be accurate because if assessments are not accurate there is a potential to not have the appropriate intervention for the residents.During a review of the facility's Policies and Procedures (P&P) titled, Charting and Documentation, last reviewed on 7/2025, the P&P indicated, documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.During a review of the facility's P&P titled, Falls and Fall Risk, Managing, last reviewed on 7/2025, the P&P indicated, based on previous evaluations and current data, the staff will identify related to the resident's specific risk and cause to try to prevent the resident from falling and to try to minimize complications from falling.
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If continuation sheet
IMPERIAL CARE CENTER in STUDIO CITY, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in STUDIO CITY, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from IMPERIAL CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.