Health inspection·December 31, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure timely physician notification for a significant change in condition for one of three sampled residents (Resident 1). This deficient practice had the potential to delay physician evaluation, timely medical intervention, and result in the deterioration of Resident 1's condition.Findings: During a review of Resident 1's admission Record, dated 12/19/2025, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included acute and chronic respiratory failure (a condition in which the lungs are unable to provide enough oxygen to the body or remove carbon dioxide, occurring suddenly and/or over a long period of time), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), congestive heart failure (CHF- a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), acute pulmonary edema (a sudden buildup of fluid in the lungs that makes breathing difficult), pleural effusion (a buildup of fluid between the lungs and the chest wall that can interfere with breathing), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), end stage renal disease (ESRD- a condition in which the kidneys no longer function well enough to remove waste and excess fluid from the body), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed), and history of renal transplant (a past medical history of receiving a donor kidney to replace failed kidneys). During a review of Resident 1's Admission/readmission Initial Assessment, dated 8/11/2025 at 7:25 p.m., the admission assessment indicated Resident 1 was readmitted to the facility from the general acute care hospital (GACH). The admission assessment indicated Resident 1 had a normal thought process and was oriented to person, place, and time, was able to follow simple commands, had clear speech, understood verbal content, and was understood upon admission. During a review of Resident 1's History and Physical (H&P), dated 8/12/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 8/15/2025, the MDS indicated Resident 1's cognition (ability to think, remember, and reason) was intact. The MDS indicated Resident 1 could eat independently and required moderate assistance (helper does less than half the effort) for toileting, bathing, and personal hygiene. During a review of Resident 1's care plan titled, Resident at risk for cardiac distress related to A-fib, congestive heart failure, hypercholesterolemia, hypertension, and renal failure/end-stage renal disease, initiated on 8/14/2025, the care plan indicated interventions included to monitor Resident 1 for headache, chest pain, irregular pulse, edema, shortness of breath, elevated blood pressure, dizziness, hypotension (low blood pressure), altered level of mentation and to report findings to the physician promptly. During a review of Resident 1's Nursing Progress Note dated 8/20/2025 at 9:42 p.m., the progress note indicated Resident Page 1 of 2 056115 056115 12/31/2025 Imperial Healthcare Center 11926 LA Mirada Blvd LA Mirada, CA 90638

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 returned from dialysis alert with confusion. During a review of Resident 1's Nursing Progress Note dated 8/24/2025 at 11:57 p.m., the progress note indicated Resident 1 was alert with episodes of confusion. During a review of Resident 1's nursing progress notes from 8/20/2025 through 10/25/2025, the progress notes indicated there was no documented entries Resident 1's physician was notified of the resident's new onset of confusion. The progress notes indicated there was no documented entries a nursing assessment or monitoring was done addressing Resident 1's new onset of confusion. During an interview on 12/30/2025 at 4:39 p.m., with Resident 1's Attending Physician (AP 1), AP 1 stated he was aware Resident 1's baseline laboratory values were abnormal on 8/19/2025. AP 1 stated it was common for residents to have abnormal laboratory values at baseline. AP 1 stated when laboratory values or a resident's condition changed from baseline, the facility was expected to notify the physician. AP 1 stated Resident 1 was alert and oriented at baseline and new onset confusion represented a change of condition. AP 1 stated on 8/20/2025, he would have wanted to be notified of Resident 1's confusion. AP 1 stated if he had been notified of Resident 1's confusion he would have sent Resident 1 to the emergency room for evaluation immediately. During a concurrent interview and record review on 12/31/2025 at 10:00 a.m., with Registered Nurse (RN) 1, Resident 1's nursing progress notes dated 8/11/2025 and 8/20/2025, were reviewed. Resident 1's nursing progress note dated 8/11/2025, indicated Resident 1 was alert and oriented upon admission to the facility. Resident 1's nursing progress note dated 8/20/2025 at 9:42 p.m., indicated Resident 1 was alert with confusion upon her return from dialysis. RN 1 stated this was a new onset of confusion for Resident 1 and represented a change of condition. RN 1 stated when a resident experienced a change of condition, the resident should have been assessed, the physician should have been notified, and appropriate follow-up initiated in accordance with the facility's policy and procedure (P&P). RN 1 stated Resident 1's medical records did not indicate there was a documented nursing assessment, physician notification, a SBAR (Situation, Background, Assessment, and Recommendation), or 72-hour monitoring related to Resident 1's new onset of confusion. RN 1 stated Resident 1 was becoming less alert and less oriented, and this change of condition was not addressed with appropriate interventions which could lead to the deterioration of Resident 1's condition. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 12/2016, the P&P indicated the nurse was required to notify the resident's attending physician of a significant change in the resident's physical, emotional, or mental condition, complete a comprehensive assessment, document the change in condition, and implement continuous monitoring for 72 hours or longer as indicated. 056115 Page 2 of 2