Health inspection·November 26, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview, on 11/25/2024, at 2:42 p.m., with Resident 2, Resident 2 stated that he had known CNA 1 to work multiple jobs, so that would cause CNA 1 to slack off and he would sleep at the nurses ' station for half of the shift. Resident 2 stated that he would recall that when Resident 2 would use the call light button, CNA 1 would reach into the room to turn off the call light system and would not address Resident 2 ' s needs. Resident 2 stated that all the staff knew of CNA 1 ' s work ethic and would recall that nurses complained about him. During an interview, on 11/26/2024, at 11:07 a.m., with Resident 3, Resident 3 stated that he had known CNA 1 to sleep at the nurses ' station and snore very loudly. Resident 3 stated, CNA 1 was going to work the way he wanted to work. Resident 3 stated CNA 1 used his cellular device excessively. Resident 3 stated that he had witnessed CNA 1 usually start his shift by sitting in the smoking area and using his cellular device. Resident 3 stated that he recalled a time that no one was answering his call light, so he went to the nurses ' station to ask for his medicine and witnessed CNA 1 sleeping and snoring like crazy at the nurses ' station. During an interview on 11/25/2024, at 4:10 p.m., with the Director of Nursing (DON), the DON stated that she expected that all staff are expected to work when he or she has clocked into work. The DON stayed that it was unacceptable and disrespectful for any staff to sleep at the nurses ' station, or use their cellular device, especially when the residents can see these actions. During a review of the facility ' s Policy and Procedure (P&P), titled, Quality of Life-Dignity, dated 2/2020, the P&P indicated that each resident was to be care for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056115 If continuation sheet Page 2 of 4 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 11/26/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to: Residents Affected - Few 1. Notify both designated emergency contacts listed on a resident ' s admission Record for one out of three sampled residents (Resident 1) when Resident 1 suffered a fall, and was sent to the General Acute Gare Hospital (GACH). These findings resulted in Responsible Party (RP) 1 becoming upset that she was not notified and was unaware that her father fell, and was transported to the hospital. Findings: During an interview, 11/21/2024, at 10:52 a.m., RP 1 stated that she was informed that her father (Resident 1) had arrived back to the facility after being transported to the GACH. RP 1 stated that she was never informed that her father had fallen around 2:00 a.m. (on 11/21/2024) and was never informed that he was sent to the GACH. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], with a diagnosis of traumatic subarachnoid hemorrhage, fracture of orbital floor, fracture of skull, traumatic hemorrhage of cerebrum, fracture of medial orbital wall, left side. During a review of Resident 1 ' s Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 8/23/2024, the MDS indicated that Resident 1 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 was dependent on staff for dressing, toileting and performing personal hygiene. During a review of Resident 1 ' s History and Physical (H&P), dated 8/22/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Situation Background Assessment Recommendation (SBAR- note indicating a resident ' s change of condition) Note, dated 11/21/2024, the note indicated Resident 1 fell at around 2:20 a.m. and was found lying at the right side of his body and sustained two skin tears on his right hand. The note indicated that Resident 1 stated that he hit his head. The note indicated that Resident 1 was sent to the GACH at 3:28 a.m. The note indicated that RP 1 was notified at 12:00 a.m. During an interview, on 11/26/2024, at 8:37 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she was assigned to care for Resident 1 on 11/21/2024 and worked the 11:00 p.m. to 7:00 a.m. shift. LVN 1 acknowledged that the SBAR Note indicated that RP 1 was notified at 12:00 am on 11/21/2024. LVN 1 stated that she did not call or attempt to call RP 1 because the fall and transfer [of Resident 1] occurred around 2:00 a.m. and did not want to wake RP 1. LVN 1 stated that it was in her practice to call or notify family of a change of condition when it was closer to the end of her shift. LVN 1 stated that she should have called closer to the end of her shift, but instead, endorsed to have RP 1 called by the incoming nurse because a lot of things were happening and that LVN 1 was busy. LVN 1 stated that it was important to promptly notify the family member or the RP whenever (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056115 If continuation sheet Page 3 of 4 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 11/26/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete there was a change of condition because it was his or her right to know the medical condition and whereabouts of his or her loved one. During a review of the facility ' s Policy and Procedure (P&P), titled, Change in a Resident ' s Condition or Status, dated 2/2021, the P&P indicated the facility was to promptly notify the resident representative of changes in the resident ' s medical condition or status. The policy indicated that a nurse will notify the resident ' s representative when the resident was involved in an accident and [or] it was necessary to transfer the resident to a hospital. Event ID: Facility ID: 056115 If continuation sheet Page 4 of 4