Health inspection·April 27, 2025

F 0684 Resident 1 was prescribed the following medications: Level of Harm - Minimal harm or potential for actual harm - Insulin Lispro (Humalog - a rapid-acting insulin used to manage high blood sugar levels) 3 units (unit of measurement) before meals for diabetes mellitus. Residents Affected - Few - Repaglinide (Prandin, a medication used to treat high blood sugar levels) 0.5 mg three times a day with meals for diabetes mellitus. During an interview on 4/27/2025 at 1:07 p.m. with Registered Nurse (RN) 1, RN 1 stated on 4/25/2025 at approximately 5 p.m. RN 1 located Resident 1 in Resident 1 ' s apartment. RN 1 stated Resident was accompanied back to the facility on 4/25/2025 at approximately 24 hours, at 6 p.m. on 4/25/2025 with the assistance of 2 local police officers. RN 1 stated Resident 1 ' s readmission assessment was completed by RN 2 after Resident 1 ate 100 percent (% - per one hundred) of her meal provided by the facility. RN 1 stated licensed staff should have measured Resident 1 ' s blood sugar level before her meal because Resident 1 was at risk of experiencing hypoglycemia (a condition in which blood sugar levels fall below normal level and can cause confusion and loss of consciousness) or hyperglycemia (a condition where the level of blood sugar in the blood is elevated above the normal range and can cause confusion, blurred vision, loss of consciousness) after being absent from the facility for approximately 24 hours. During an interview on 4/27/2025 at 5:15 p.m. with the DON, the DON stated facility should have measured Resident 1 ' s blood sugar when Resident 1 returned to the facility on 4/25/2025 since Resident 1 was at risk of experiencing hypoglycemia or hyperglycemia and might have required treatment. During a review of current facility-provided policy and procedure titled, Nursing Care of Older Adults with Diabetes Mellitus, last reviewed on 7/2024, the policy and procedure indicated, Blood Glucose Monitoring . For resident receiving insulin who is well controlled: c. monitor as indicated if the individual is fasting before a medical procedure, has returned to the facility after a significant absence, or has an acute infection or illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 2 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) to one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities) and was admitted to a secured facility (specialized healthcare setting that restricts patient movement and access to promote safety with measures such as locked doors and surveillance). On 4/24/2025 at 6:48 p.m., Restorative Nurse Aide (RNA – focuses on helping residents regain or maintain their physical abilities and independence through restorative program and activities) 1 without verifying Resident 1 ' s identity, opened the facility ' s locked gate due to RNA 1 thought Resident 1 was a visitor, and allowed Resident 1 to exit the facility ' s building. This deficient practice resulted in Resident 1 ' s elopement (the act of leaving a facility unsupervised and without prior authorization) on 4/24/2025 at 6:48 p.m., placing Resident 1 at risk for vehicular accidents since the facility is located in a busy street with many cars passing by, negative outcome from not receiving Resident 1 ' s medication, and exposure to extreme temperatures (heat during the day and cold during the night) that could lead to serious injury, serious harm, or death. On 4/26/2025 at 5:49 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ – a situation in which the facility ' s non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator and the Director of Nursing (DON) due to the facility ' s failure to provide supervision to Resident 1 and to prevent the elopement of Resident 1 on 4/24/2025 at 6:48 p.m. On 4/27/2025 at 2:34 p.m., the DON provided an acceptable IJ removal plan (a detailed plan to address the IJ findings) for the facility ' s failure to provide supervision to Resident 1 and to prevent the elopement of Resident 1 on 4/24/2025 at 6:48 p.m. On 4/27/2025 at 6:19 p.m., while onsite at the facility, the SSA verified and confirmed the facility ' s full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding elopement due to lack of supervision was no longer present. The SSA removed the IJ on 4/27/2025 at 6:48 p.m., in the presence of the Administrator and the DON. The acceptable IJ Removal Plan included the following summarized actions: 1. On 4/25/2025, the Administrator gave a disciplinary action (a reprimand or corrective action in response to employee misconduct, rule violation, or poor performance) and suspended RNA 1 pending investigation. 2. On 4/25/2025 at 5 p.m., Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 1, and 2 local police officers located Resident 1 in Resident 1 ' s apartment, approximately 7.8 miles (unit of measurement) away from the facility. 3. On 4/25/2025 at 5:56 p.m., RN 1, LVN 1, and 2 local police officers accompanied Resident 1 back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 3 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to the facility. RN 2 completed Resident 1 ' s skin assessment and noted a scab (a dry, rough protective crust that forms over a cut or wound during healing) on Resident 1 ' s left knee. 4. On 4/25/2025 at 8:30 p.m., Resident 1 was transferred to General Acute Care Hospital (GACH) 1 for further evaluation. 5. From 4/25/2025 to 4/26/2025, the DON, the Quality Assurance (QA) Nurse Consultant (a registered nurse specializing in improving resident care quality, ensuring compliance with regulations, and enhancing healthcare practices), and the Director of Staff Development (DSD), conducted a series of in-services (a planned, workplace-based training program designed to enhance staff competency, improve job performance, and keep staff up to date with current best practices and new techniques) to staff regarding Safety and Supervision of Residents, Elopement, Missing Person, and Resident Identification policies, emphasizing the following: a. The purpose and importance of identifying and confirming with the Licensed Nurses (LNs), RNs, the Administrator, or Receptionist, that the person leaving the facility is a visitor and not a resident of the facility before allowing anyone to leave the (facility ' s secured) premises. b. The purpose and importance of supervising residents while in the facility and always being mindful of their (residents) whereabouts to ensure residents ' safety. c. The purpose and importance of identifying residents by checking if they are wearing an Identification (ID) wristband [a bracelet-like band, often worn on the wrist, contain at the minimum two identifiers (name and birthday) used for identification purposes] or having another form of identification such as a photograph. d. The purpose and importance of immediate action and interventions such as initiating a code to initiate search immediately once a resident was found missing. e. The purpose and importance of seeking assistance from the Local Police Department in searching for a missing resident. 6. On 4/26/2025, LN, Medical Records Director, and Designee checked all residents to see if in-house residents were wearing ID wristbands. There were four residents (Residents 3, 6, 12, and 13) who were found not wearing ID wristbands due to refusal. An Interdisciplinary meeting (IDT meeting, involves professionals from different fields or specialties collaborating to address a shared problem or achieve a common goal) was conducted to discuss Residents 3, 6, 12, and 13 ' s noncompliance. The residents ' refusal to wear ID wristbands was addressed in the residents ' care plans. 7. On 4/26/2025, the Social Service Director (SSD) or designee and LNs evaluated all residents to see if the residents feel safe while in the facility using the safety/wellness evaluation tool. No other resident was found to be affected by the deficient finding. 8. On 4/26/2025, the IDT members comprising of the Administrator, the DON, and the DSD reviewed a new policy pertaining to secured unit/facility integrating the guidelines on admission process, environment special consideration, and visitation. a. The RN or Licensed Designee will immediately apply an ID wristband to a resident upon admission to help identify a resident while in the facility. A resident ' s photograph will also be taken, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 4 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the resident ' s picture will be uploaded in the resident ' s electronic health record (a digital version of a resident ' s medical history, stored on a computer and designed to be shared across different healthcare settings). b. A green colored ID wristbands will be provided to residents who are ambulatory without assistance for identification purposes and to alert staff about the risk for elopement especially when the residents seek exit doors. c. The Administrator will assign Department Heads or IDT members to conduct room inspections and check residents to see if they are wearing ID wristbands. The Administrator will also assign a Department Manager to be a Manager of the Day (MOD) on the weekends (Saturday to Sunday) to conduct random room inspection, including but not limited to checking Residents if they are wearing ID wristbands. d. The LNs will be conducting visual monitoring every 30 minutes for 72 hours to check newly admitted residents ' whereabouts, activities, and behaviors. e. The facility will assign a staff member to monitor the reception area daily seven days a week to monitor the front lobby as well as monitoring individuals entering and exiting the facility. The assigned receptionist will inform the SSD and/or designee five times a week (Monday to Friday) and the Manager of the Day on the weekends as coverage if the assigned receptionist will go on a break. An alarm has been installed on the main entrance door to also alert staff when there is someone coming in and out of the facility, in the absence of the receptionist in the front lobby. Findings: During a review of Resident 1 ' s History and Physical (H&P) from GACH 2, dated 3/9/2025, the H&P indicated Resident 1 was admitted to GACH 2 due to hypertensive urgency (a situation where blood pressure is significantly elevated, but there is no immediate evidence of organ damage), and had diagnoses of hypertension (high blood pressure), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s GACH 2 Progress Notes, dated 4/2/2025, the Progress Notes indicated Resident 1 had a history of involvement from Adult Protective Services (APS – program to promote the safety, independence, and quality of life for adults who are unable to protect themselves) for self-neglect. The Progress Notes indicated Resident 1 had altered mental status (any significant change in a resident ' s normal mental state, encompassing a range of conditions from mild confusion to complete unconsciousness) with episodes of agitation (a condition in which a resident is unable to relax and be still), delirium (a sudden change in a resident ' s mental state, characterized by confusion and difficulty focusing), and had high concern for falls. The Progress Notes indicated it was not safe for Resident 1 to return home. During a review of Resident 1 ' s H&P from the Center of Behavioral Health (CBH), dated 4/11/2025, the H&P indicated Resident 1 had cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and was gravely disabled (refers to a condition where a resident, because of a mental health disorder, is unable to provide for the basic personal needs for food, clothing, shelter, personal safety, or necessary medical care) with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 5 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 lost with reality). Level of Harm - Immediate jeopardy to resident health or safety During a review of Resident 1 ' s admission Assessment, dated 4/24/2025, the admission Assessment indicated Resident 1 was admitted to the facility on [DATE] at 5 p.m. The admission Assessment indicated Resident 1 was alert and oriented to time, place, with slow comprehension and required assistance with showers, bed baths, oral hygiene, grooming, and dressing. Residents Affected - Few During a review of Resident 1 ' s Change of Condition (COC – when there is a sudden significant change in a resident ' s health status) Assessment Form, dated 4/24/2025, the COC indicated on 4/24/2025 at 6:50 p.m., Resident 1 walked out of the facility after RNA 1 opened the facility ' s locked gate. The COC indicated LVN 2 noticed an unfamiliar person leaving the facility after RNA 1 used the code to open the locked gate. The COC indicated on 4/24/2025 at 7:55 p.m., the police was notified of Resident 1 ' s elopement. During a concurrent observation, interview, and record review on 4/25/2025 at 11:15 a.m., the facility ' s video surveillance footage of Station 1 and Reception area with the recording date and time of 4/24/2025 at 6:28:40 p.m. (adjusted to reflect the 12-hour clock) was observed and reviewed with the Administrator. The video footage showed RNA 1 opened the facility ' s locked gate, and a person (Resident 1) walked toward the open gate and exited the facility. The Administrator stated Resident 1 was the person in the video surveillance. The Administrator stated the following: a. On 4/24/2025 at 6:46:56 p.m., Resident 1 came out of Resident 1 ' s room and walked towards Station 1. b. On 4/24/2025 at 6:47:34 p.m., Resident 1 was ambulating (walking) near Station 1 while LVN 3 was standing in front of Station 1, in the hallway leading to the locked gate. RN 1 was inside Station 1, while RNA 1 was walking towards the locked gate. Resident 1 passed by LVN 3 who was standing near Station 1 and walked towards the locked gate, behind RNA 1. c. On 4/24/2025 at 6:47:56 p.m., LVN 3 was walking behind Resident 1 towards the locked gate. d. On 4/24/2025 at 6:47:57 p.m., Resident 1 was walking towards the locked gate and talked to RNA 1. e. On 4/24/2025 at 6:48:10 p.m., RNA 1 opened the locked gate and Resident 1 walked outside the locked gate towards the reception area. f. On 4/24/2025 at 6:48:29 p.m., Resident 1 opened the front door (in the reception area) and exited the facility building. The Administrator stated there was no facility staff present in the lobby. During a concurrent interview and record review on 4/25/2025 at 1:17 p.m. with the DON, Resident 1 ' s Discharge Reconciliation Report, from the CBH, dated 4/24/2025 was reviewed. The Discharge Reconciliation Report indicated Resident 1 was gravely disabled. The DON stated Resident 1 was admitted to the facility as gravely disabled. The DON stated the facility was in a high traffic area, with an occasionally homeless population and Resident 1 was at risk of being hit by a car and at risk of physical and sexual abuse from the homeless individuals. The DON stated Resident 1 was at risk of hypothermia (a significant and potentially dangerous drop in body temperature caused by prolonged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 6 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few exposure to cold) at night and hyperthermia (a condition characterized by abnormally high body temperatures) during the day when the temperature would go up. The DON stated Resident 1 could potentially experience any type of injury while outside of the facility including death. The DON stated the facility did not have a policy and procedure addressing supervision and access of the locked gate. The DON stated the facility was a secured facility and all the exit doors were kept locked and required a special key or code to open to prevent residents from wandering outside the building without supervision. The DON stated residents could exit the locked area only with staff supervision. The DON stated RNA 1 should not have opened the locked gate for Resident 1. The DON stated RNA 1 failed to identify Resident 1 as a resident of the facility resulting in Resident 1 ' s elopement. The DON stated the facility had not located Resident 1 (as of this time of the interview) and as a result Resident 1 was at risk to experiencing negative effects from missing her medications, including hypoglycemia (a condition in which the body ' s blood sugar level drop below the normal range) or hyperglycemia (a condition in which the there is too much sugar in the blood). A concurrent review of the Discharge Reconciliation Report with the DON indicated Resident 1 was prescribed the following medications: - Olanzapine (Zyprexa, a medication to treat several mental health conditions including psychosis) 2.5 milligram (mg - unit of measurement for weight/mass) twice daily for severe psychosis. - Divalproex Sodium (Depakote, a medication to improve mood, thoughts, and behavior) 125 mg three times daily for mood changes (sudden changes in how you feel). - Aspirin (a medication used to treat pain, fever, inflammation and blood clots) 81 mg daily for the prevention of myocardial infarction (a medical condition where blood flow to the heart muscle is suddenly blocked). - Furosemide (Lasix, a medication used to treat excessive fluid accumulation) 20 mg every Monday, Wednesday, and Friday for edema (swelling caused by the accumulation of excess fluid in the body). - Nebivolol HCL (Bystolic, a medication used to treat high Blood Pressure) 20 mg daily for hypertension. - Repaglinide (Prandin, a medication used to treat high blood sugar levels) 0.5 mg three times a day with meals for diabetes mellitus. - Insulin Lispro (Humalog - a rapid-acting insulin used to manage high blood sugar levels) 3 units (unit of measurement) before meals for diabetes mellitus. - Nifedipine (Procardia, a medication used to treat high Blood Pressure and chest pain) 90 mg daily for the prevention of anginal pain (chest pain) associated with coronary artery disease (a condition where the arteries that supply blood to the heart become narrowed or blocked). During an interview on 4/25/2025 at 2:40 p.m. with RNA 1, RNA 1 stated on 4/24/2025 at approximately 6:50 p.m. while walking towards the locked gate, Resident 1 asked RNA 1 to open the door stating, I have to leave now. I need to buy stuff. I will be back soon. RNA 1 stated she (RNA 1) did not ask Resident 1 if Resident 1 was a visitor or a resident and did not check to see if Resident 1 was wearing an ID wristband. RNA 1 stated because Resident 1 looked nice and well-dressed RNA 1 concluded Resident 1 was a visitor and opened the locked gate allowing Resident 1 to leave the facility without supervision. RNA 1 stated RNA 1 should have verified Resident 1 ' s identity prior to letting Resident 1 leave the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 7 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 4/25/2025 at 5:02 p.m. with RN 2, RN 2 stated RN 2 was the RN assigned to care for Resident 1 on 4/24/2025. RN 2 stated, on 4/24/2025 at approximately 5 p.m., RN 2 initiated Resident 1 ' s admission assessment. RN 2 stated Resident 1 was transferred from the CBH where Resident 1 was admitted due to being gravely disabled. RN 2 stated Resident 1 was cognitively impaired, required frequent reminders on Resident 1 ' s location and situation. RN 2 stated during the admission, Resident 1 was not provided with an ID wristband since the facility does not utilize ID wristbands. RN 2 stated on 4/24/2025 at approximately 7:10 p.m., she (RN 2) was informed by Certified Nursing Assistant (CNA) 1 that Resident 1 was missing after which staff (unable to identify) initiated a facility search but were not able to locate Resident 1. RN 2 stated RNA 1 should not have opened the locked gate before confirming Resident 1 ' s identity. RN 2 stated Resident 1 had diabetes and was at risk of experiencing hypoglycemia or hyperglycemia without diabetes medication and possibly without food. RN 2 stated Resident 1 could potentially experience negative effects from missing Resident 1 ' s medications and was at risk of being hit by a car. During an interview on 4/26/2025 at 10:14 a.m. with the DON, the DON stated all residents in the facility should be wearing ID wristbands for identification. The DON stated that upon admission social services staff or RNs were required to provide ID wristbands to new residents. The DON stated the facility had a policy addressing the identification of residents during medication administration but did not have a policy regarding provision of ID wristbands and verification of residents' or visitors' identity prior to allowing them (residents and visitors) to leave the facility. During an interview on 4/26/2025 at 12:20 p.m. with CNA 1, CNA 1 stated on 4/24/2025 CNA 1 was the CNA assigned to care for Resident 1. CNA 1 stated Resident 1 was admitted around 5 p.m. on 4/24/2025. CNA 1 stated when Resident 1 was admitted to the facility, CNA 1 introduced self to Resident 1 and with RN 1, they completed Resident 1 ' s inventory list after which CNA 1 left to assist with dinner. CNA 1 stated she last saw Resident 1 (on 4/24/25) between 6:30 p.m. to 7 p.m., walking in the hallway of Station 1. CNA 1 stated at approximately 7:35 p.m. CNA 1 went to check on Resident 1 but was not able to locate Resident 1. CNA 1 stated CNA 1 then notified RN 1 that Resident 1 was missing. CNA 1 stated facility staff (unable to identify) searched for Resident 1 inside and outside of the facility building but were not able to locate Resident 1. During an observation on 4/26/2025 at 3:19 p.m. in front of the facility entrance, the facility was located on a busy street in a commercial area (designated location used for business, retail, and offices) and a large number of cars are moving along the road. During an interview on 4/27/2025 at 1:07 p.m. with RN 1, RN 1 stated on 4/25/2025 at approximately 5 p.m. RN 1 located Resident 1 in Resident 1 ' s apartment. RN 1 stated Resident 1 was accompanied back to the facility after approximately 24 hours, at 6 p.m. on 4/25/2025 with the assistance of 2 local police officers. RN 1 stated Resident 1 ' s elopement incident could have been prevented if the facility had a system in place for the identification of residents and monitoring of the locked gate. RN 1 stated Resident 1 could have potentially experience physical harm, abuse, and negative effects from missing Resident 1 ' s medications such as low or high blood sugar levels, and behavioral issues from missing Resident 1 ' s psychotropic medications (used to treat mental health disorders). During an interview on 4/27/2025 at 5:15 p.m. with the DON, the DON stated the facility did not have a system in place for the monitoring of the locked gate and identification of the residents and visitors. The DON stated Resident 1 ' s elopement incident could have been prevented if the facility had a system in place for the monitoring of the locked gate and identification of the residents and visitors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 8 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During a review of the current facility-provided policy and procedure titled, Wandering and Elopement, last reviewed on 7/2024, the policy and procedure indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. During a review of the current facility-provided policy and procedure titled, Safety and Supervision of Residents, last reviewed on 7/2024, the policy and procedure indicated, Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risk for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes . and a facility-wide commitment to safety at all levels of the organization Individualized, Resident-Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individuals together to implement a systems approach to safety, which considers the hazards identified in the environment and individual risk factors and then adjust interventions accordingly. 2. Resident supervision is a core component of the system ' s approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and overtime for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 9 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a licensed Administrator (ADM) held a current and active license from the State to serve in the capacity of a nursing home administrator (NHA). This deficient practice resulted in the facility operating without a licensed ADM that had the potential to negatively affect the facility's functions. Findings: During an observation on 4/272025 at 9:05 a.m. in the hallway, ADM' s license was posted at the facility's lobby. The ADM ' s license indicated the license expired on [DATE]. During an interview on [DATE] at 3:07 p.m. with the ADM, the ADM stated the ADM ' S license had expired on [DATE] and the application for the renewal of the license had not been submitted yet. The ADM stated the application for the renewal of license should have been submitted 60 days prior to the expiration of the license. During a review of the current facility-provided policy and procedure titled, Administrator, last reviewed on 7/2024, the policy and procedure indicated, A licensed administrator is responsible for the day-to-day functions of the facility 1. The governing board of this facility has appointed an administrator who is dully licensed in accordance with current federal and state requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 10 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical records of two of four sampled residents (Resident 2 and 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Resident 2 ' s Informed Consent (IC, voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was signed by a physician. 2. Ensure Resident 3 ' s Attending Physician (MD) reviewed and signed the resident's Order Summary every month. These deficient practices had the potential for inaccurate documentation and inaccurate medical interventions for Resident 2 and Resident 3. Findings: a. During a review of Resident 2 ' s admission Record on 4/26/2025, the admission Record indicated Resident 2 was admitted to facility on 10/22/2021 and readmitted on [DATE] with diagnoses including seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), diabetes mellitus (DM, disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2 ' s Minimum Data Set (MDS – a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 2 ' s cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were impaired. During a review of Resident 2 ' s Order Summary Report, the report indicated the following physician ' s order: - 2/28/2025: Divalproex Sodium (a medication used to treat certain types of seizures and bipolar disorder) Tablet Delayed Release (a type of medication that is designed to release its active ingredients at a slower rate) 500 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) to give 1 tablet by mouth three times a day for mood disorder manifested by uncontrolled extreme mood swings causing anger outburst affecting daily living activities, and tally by hash-marks for its use. During a concurrent interview and record review on 4/26/2025 at 2:54 p.m. with the Medical Records Director (MDR), Resident 2 ' s IC for Depakote Sodium, dated 2/28/2025 was reviewed. The IC indicated the form was signed by Resident ' s responsible party and cosigned by a licensed nurse indicating Resident ' s Representatives had received information from the MD regarding the medication and have agreed to receive the treatment. The MDR stated she was responsible for ensuring the facility audits were done timely and the residents ' medical records were complete including physician signatures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 11 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The MDR stated the IC was not signed by the physician. The MDR stated she should have followed up with the physician to make sure the IC was signed for accurate documentation and to avoid inaccurate treatment. During a concurrent interview and record review on 4/27/2025 at 3:10 p.m. with Registered Nurse (RN) 1, Resident 2 ' s IC, dated 2/28/2025 was reviewed. The IC indicated the form was not signed by the physician. RN 1 stated the physician should have signed the form indicating that the medication information was discussed with the resident or resident representative and consent was obtained to receive the treatment for accurate documentation and accurate treatment. During a review of the current facility provided policy and procedure titled, Policy: Informed Consent, last reviewed on 7/2024, the policy and procedure indicated, The physician and/or prescriber must sign an informed consent form after explaining all necessary information to the residents or their representatives. b.During a review of Resident 3 ' admission Record on 4/26/2025, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with the following diagnoses including psychosis (a state where a person's perception of reality becomes distorted, leading to hallucinations, delusions, and disorganized thinking), muscle weakness, and dementia. During a record review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decision making were impaired. During a concurrent interview and record review on 4/26/2025 at 1:50 p.m. RN 3, Resident 3 ' s Order Summary dated 1/2025 to 4/2025 were reviewed. The Order Summary indicated the Order Summary Reports were not signed by the Attending Physician (MD). RN 3 stated MD should have reviewed and signed the Order Summary indicating that the order summary was reviewed and approved by the MD. RN 3 stated the failure had the potential for Resident 3 to receive inaccurate care. During a concurrent interview and record review on 4/26/2025 at 2:54 p.m. with the Medical Records Director (MDR), Resident 3 ' s Order Summary dated 1/2025 to 4/2025 were reviewed. The MDR stated MD should have signed Resident 3 ' s Order Summary every month to indicate the physician approved the orders required for Resident 3 ' s care. During an interview on 4/27/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated MDR was responsible for ensuring the facility audits were done timely and the residents ' medical records were complete. The DON stated the MDs should have reviewed and signed the Order Summary for Resident 3 during follow up visits, at least every 60 days. The DON stated Resident 3 was at risk of receiving inaccurate medications or incorrect medication dosages negatively effecting Resident 3 ' s well-being. During a record review of the facility-provided policy and procedure titled, Charting and Documentation, last reviewed on 7/2024, the policy and procedure indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition shall be documented in the resident ' s medical record 3. Documentation in the medical record will be objective (not opiniated or speculative), complete, and accurate. During a record review of the facility-provided policy and procedure titled, Physician Services, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 12 of 13 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 555707 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm last reviewed on 7/2024, the policy and procedure indicated, The attending physician must perform relevant tasks at the time of each visit, including a review of the resident ' s total program of care and appropriate documentation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555707 If continuation sheet Page 13 of 13