Health inspection·June 5, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, by failing to report an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) to the State Survey Agency (SSA) no later than two hours for one of four sampled residents (Resident 2) when on 5/31/2025 at 5 p.m. Resident 2's Family Member (FM) 1 reported to Skilled Nursing Facility (SNF- a healthcare setting that provides 24-hour medical care and rehabilitation services to individuals who need more care than they can receive at home, but not as much as they would in a hospital) 1 that Resident 2 was assaulted (an act of causing physical harm or unwanted physical contact to another person, or, in some legal definitions, the threat or attempt to do so). The allegation of abuse was reported to the SSA on 6/2/2025 at 4:04 p.m. This deficient practice had a potential to result in unidentified abuse and placed Resident 2 at risk for further abuse. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 4/25/2025 with diagnoses including dementia (a general term for a decline in mental ability that interferes with daily life, encompassing symptoms like trouble remembering, thinking, or making decisions), muscle weakness (generalized), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities, and other symptoms that significantly affect daily functioning). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 4/29/2025, the MDS indicated Resident 2 sometimes understood and was sometimes understood. The MDS indicated Resident 2 required substantial to maximal assistance (helper does more than half the effort) with showering and toileting and required partial to moderate assistance (helper does less than half the effort) with eating, oral hygiene, upper and lower body dressing, putting on and taking off footwear and personal hygiene. During a review of Resident 2's Change in Condition (COC- when there is a sudden change in a resident's condition) Assessment Form, dated 5/30/2025 at 10:45 p.m., the COC Assessment Form indicated Resident 2 had a scratch under left eye. At 10:45 p.m. Resident 2 was observed walking out from Room A, Resident 2 was found with mild blood around left eye area. During assessment Resident 2's left eye was red on the inside and the scratch under the left eye was bleeding. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555707 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 06/05/2025 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)