Health inspection·April 1, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm impaired with cognitive skills for daily decision making and required maximum assistance with toileting and bathing. During a review of Resident 7's COVID-19 Point of Care Test Result Report Form, dated 3/29/2024, the COVID-19 test result report indicated Resident 7 tested negative for COVID -19. Residents Affected - Many c. During a review of Resident 8's admission Record, dated 4/2/2024, the admission record indicated Resident 8 was initially admitted to the facility on [DATE] with the following diagnoses which included COVID-19, Parkinson's disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), pulmonary edema (excess fluid in the lungs), hyperlipidemia (an abnormally high concentration of fat particles in the blood), hypertension (high blood pressure), and acute kidney failure. During a review of Resident 8's H&P, dated 3/14/2024, the H&P indicated that Resident 8 had the capacity to understand and make decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 was moderately impaired with cognitive skills for daily decision making and required supervision for eating and oral hygiene and maximal assistance, toileting, and bathing. During a review of Resident 8's COVID-19 Point of Care Test Result Report Form, dated 3/29/2024, the COVID-19 test result report indicated Resident 8 tested positive for COVID -19. d. During a review of Resident 9's admission Record, dated 4/2/2024, the admission record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included epilepsy, pneumonia (an infection that affects one or both lungs), type 2 diabetes, asthma (chronic disease in which the airways in the lungs become narrowed and swollen, making it difficult to breathe), chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), and hyperlipidemia (an abnormally high concentration of fat particles in the blood). During a review of Resident 9's H&P, dated 3/5/2024, the H&P indicated that Resident 9 had the capacity to understand and make decisions. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 was moderately impaired with cognitive skills for daily decision making and was independent with eating, and required maximal assistance with toileting and personal hygiene. During a review of Resident 9's COVID-19 Point of Care Test Result Report Form, dated 3/29/2024, the COVID-19 test result report indicated Resident 9 tested negative for COVID-19. e. During a review of Resident 10's admission Record, dated 4/2/2024, the admission record indicated Resident 10 was initially admitted to the facility on [DATE] with the following diagnoses which included COVID-19, acute respiratory failure with hypoxia, type 2 diabetes, pleural effusion (when fluid builds up in the space between the lung and the chest wall), hypertension, hyperlipidemia, atrial fibrillation (a rapid, irregular heartbeat). During a review of Resident 10's H&P, dated 3/5/2024, the H&P indicated that Resident 10 had the capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056115 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Healthcare Center 11926 LA Mirada Blvd LA Mirada, CA 90638 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was moderately impaired with cognitive skills for daily decision making and required maximal assistance with toileting and bathing. During a review of Resident 10's COVID-19 Point of Care Test Result Report Form, dated 3/29/2024, the COVID-19 test result report indicated Resident 10 tested positive for COVID-19. During an observation on 4/1/2024 at 12:20 p.m., observed staff walking in the hallways in patient care areas wearing N95 masks (a disposable mask that forms a tight seal around the nose and mouth and is used as a respiratory protective device to filtrate particles in the air). Also observed residents in the hallways, some of the residents were wearing masks and others were not wearing masks. During an observation on 4/1/2024 at 3:02 p.m., in Nursing Station 1, observed doors opened to COVID-19 positive rooms. (Rooms 3, 5, 12, 10. 15 and 16). During an interview on 4/1/2024 at 3:46 p.m., with the Infection Preventionist Nurse (IPN), the IPN was asked how many residents were positive for COVID-19 and what the facility's process was once a resident tested positive for COVID-19 in the facility. The IPN stated that there were currently eight residents (Residents 5, 6, 8, 10, 11, 12, 13 and 14) in the facility who were positive for COVID-19 and two residents (Residents 7 and 9) who were exposed but had not converted to a positive COVID-19 status. The IPN stated that Resident 7 currently had developed symptoms of a cough but continued to test negative for COVID19. The IPN also stated that on 3/29/2024, Resident 5 presented with symptoms of fever and chills and was then tested for COVID-19, which came back with a positive result. The IPN then stated that COVID-19 rapid response testing (a rapid test to detect COVID-19) was performed on Resident 5's roommate (Resident 9) and all staff that were exposed to Resident 5 for the last 5 days were also given a COVID-19 test. The IPN stated that COVID-19 testing was then started for all staff and residents on 3/29/2024 with a plan to continue testing twice per week, every 2 weeks. The IPN stated that contact tracing (used to identify and notify people who have been exposed to someone with an infectious disease) was also initiated, starting with Resident 5. The IPN stated that contract tracing revealed that Resident 5 had gone out on a pass to visit family and that the facility initially thought Resident 5 was exposed while visiting outside of the facility. Resident 5's family was notified of the Resident 5's positive COVID-19 status. The IPN stated that Resident 5's family members who were in contact with Resident 5 were all tested for COVID-19. The IPN stated that no family members reported a positive COVID test or having any signs of illness. The IPN also stated that Resident 5 had previously resided in another room in the facility but was transferred to her current room on 3/27/2024. The IPN stated that she tested Resident 5's former roommate (Resident 11) who also tested positive for COVID-19 on 3/29/2023. The IPN stated that Resident 11's new roommate (Resident 12) was also exposed, tested, and converted to a positive COVID-19 status on 3/31/2024. The IPN stated that residents with a positive COVID-19 status were not cohorting (grouping residents together based on their risk of infection or whether they have tested positive for COVID-19 during an outbreak) but were to isolate (in place in their current rooms. The IPN stated that this was done because the facility was full and changing rooms to move COVID-19 positive residents to other rooms could have potentially cause cross contamination and exposed more residents to COVID-19. The IPN stated that she was waiting on further recommendations from the public health outbreak nurse (OBN). The IPN stated that residents that are isolating in place should have a filtration system in the room along with curtains drawn to separate and cause a barrier between each resident in the COVID-19 positive rooms. The IPN stated that doors should be kept closed at all times to prevent airborne (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056115 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Healthcare Center 11926 LA Mirada Blvd LA Mirada, CA 90638 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many particles from emitting into the hallways. The IPN stated that the doors should not have been open. The IPN also stated that there are residents in the hallway and not all residents wear masks. The IPN stated that residents are notified that there is a COVID-19 outbreak and the residents were encouraged to wear masks while in the hallways and public area, but resident have a choice not to wear the masks. The IPN stated that the staff should have made sure that the doors were closed to all COVID-19 positive residents and residents that were exposed to COVID 19. The IPN stated that there was an in-service regarding COVID-19 on 3/28/2024 during the all-staff meeting, so the staff should know to close the doors of COVID-19 residents' rooms. The IPN stated that there was no designated staff to care for COVID-19 residents only. The IPN stated that staff are told to do the positive resident firsts and do the negative resident last so that they do not cross contaminate. The IPN stated that staff will also change N95 masks when leaving COVID-19 positive rooms and put on a fresh one. The IPN stated that nurses that work in the front are not rotated. The IPN stated that certified nursing assistants (CNAs) were seeing both positive and negative residents. The IPN stated that if the facility gets more than seven COVID-19 positive residents, she would then assign one nurse to the COVID-19 area. The IPN stated that there were currently three staff members that tested positive for COVID-19 (CNA 4, CNA 5, and the Activities Director (AD). The IPN stated that CNA 4 tested positive for COVID-19 on 3/31/2029 and her last day at work was 3/29/2024. The IPN stated that on CNA 4's last workday, CNA 4 worked the 3 p.m. to 11 p.m. shift and was assigned to care for COVID-19 positive residents, Resident 5, Resident 10, Resident 11, Resident 12, and Resident 14 and Resident 9 who was exposed to Five of which tested positive to COVID-19 and one exposed. The IPN stated that staff CNA 5 and AD both tested positive on the morning of 4/1/2024 when they arrived to work and were both sent home the same day. IPN stated that staff can return to work after 5 days if they have a negative COVID-19 test and asymptomatic (have no symptoms). During an observation on 4/1/2024 at 6:05 p.m., at Station 1, with the Physical Therapy Assistant (PTA) and the Occupational Therapy Assistant (OTA), in Resident 11's room, observed both the PTA and the OTA providing therapy for Resident 11 with the door open for approximately 15 minutes. Observed Licensed Vocational Nurse (LVN) 2 standing outside of the room tending to a resident in a wheelchair who refused to put her mask over her nose and mouth. The resident rolled down the hallway with the mask on her chin. The PTA and OTA came out of Resident 11's room but did not close the door when they both left the room. During a concurrent observation and interview on 4/1/2024 at 6:30 p.m., with the PTA and OTA, at Station 1, outside of Resident 11's room, PTA and OTA was asked if the door to Resident 11's room should remain open if the residents in the room are COVID-19 positive. PTA stated that he was about to close the door to Resident 11's room and stated that he is aware that it is unsafe to keep the doors open when residents are COVID-19 positive. The PTA stated that COVID-19 could possibly spread further. The OTA also acknowledged that the door should have been closed while they were providing therapy and the door should have been closed as soon as they both left the room and of the resident. During an interview on 4/1/2024 at 6:35 p.m., with LVN 2, LVN 2 stated that she was just recently trained on the COVID protocol and that the doors were not to be kept open when a resident was COVID-19 positive. LVN 2 stated, If the infection (COVID-19) is in the air, it can come out of the room and infect other residents. LVN 2 stated that the goal is to contain COVID-19 and not spread it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056115 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Healthcare Center 11926 LA Mirada Blvd LA Mirada, CA 90638 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many further. LVN 2 stated that the resident that was in the hallway across from Resident 11's room with not mask could have been exposed to COVID-19 because the doors were open. During an interview on 4/1/2024 at 6:50 p.m., with CNA 3, CNA 3 stated that when a resident becomes COVID-19 positive, it was her responsibility as a CNA to ensure the doors were closed. CNA 3 stated that some residents would open the door and get agitated if the doors were closed. CNA 3 stated that if this happens, the CNA staff should report it to the charge nurse so that they can intervene. CNA 3 stated that leaving the doors open could spread COVID-19 to other residents. During an interview on 4/1/2024 at 7:00 p.m., with the Administrator (ADM), the ADM stated that the doors should be closed on rooms with COVID-19 positive residents. During a telephone interview on 4/2/2024 at 2:02 p.m., with the Outbreak Nurse (OBN), the OBN stated that she spoke with the IPN on 4/1/2024 to inform her of the COVID-19 recommendations. The OBN stated that she was there in January 2024 for another COVID-19 outbreak in the facility. The OBN stated that she did not think that the facility was following some of the recommendations provided. The OBN stated that she gave the same recommendation for this COVID-19 outbreak as she did for the outbreak in January 2024. The OBN stated that the doors should be closed to the COVID-19 positive residents and there should be dedicated CNAs to work only with COVID-19 positive residents or the CNAs and staff would be at a higher risk of cross contamination. During a review of the facility's Policy and Procedure (P&P) titled, COVID-19, Prevention and Control, revised 9/29 2023, the P&P indicated Residents suspected or confirmed COVID-19 infection will be placed on transmission-based precautions (contact and droplet precautions). The P&P also indicated, Dedicated, consistent staffing teams who directly interact with residents that are COVID-19 positive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056115 If continuation sheet Page 5 of 5