Health inspection·August 14, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Fall Risk Evaluation (used to find out if you have a low, moderate, or high risk of falling) was accurately documented to reflect the fall risk of one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services. Findings:Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 12/7/2024 and was readmitted on [DATE] with diagnoses including encephalopathy (any condition that damages or impairs the brain, leading to changes in brain function or structure), dementia (a progressive state of decline in mental abilities), and anxiety (a common mental health condition characterized by excessive worry, fear, and unease).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/25/2025, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, and requires partial to moderate assistance (the helper does less than half the effort) with oral hygiene, showering, upper and lower body dressing, and putting on and taking off footwear and requires supervision or touching assistance (helper provides verbal cues and or touching or contact guard assistance) with eating, walking 10 feet and walking 50 feet.During a review of Resident 1's Change in Condition (COCwhen there is a sudden change in a resident's condition) Assessment Form, dated 7/3/2025 at 3:50 a.m., the COC Assessment Form indicated Resident 1 had a fall. At 3:50 p.m. Certified Nursing Assistant (CNA) 1 notified Registered Nurse (RN) 1, Resident 1 is sitting on the floor between the resident's bed and bathroom door.During a review of Resident 1's Fall Risk Evaluation, dated 7/22/2025 at 1:17 a.m., the Fall Risk Evaluation indicated Resident 1 had a fall risk score of 16 (total score is 10 or greater, the resident should be considered at high risk for potential fall).During a review of Resident 1's Fall Risk Evaluation, dated 7/22/2025 at 1:35 a.m., the Fall Risk Evaluation indicated Resident 1 had a fall risk score of 18.During a review of Resident 1's COC, dated 8/3/2025 at 8:18 a.m., the COC indicated Resident 1 had a status post unwitnessed fall, complaint of right groin and leg pain, middle forehead redness, left anterior knee redness. The COC indicated at 7:20 a.m. CNA 1 reported to the charge nurse Resident 1 was on the floor.During a review of Resident 1's Fall Risk Evaluation, dated 8/3/2025 at 8:18 a.m., the evaluation indicated Resident 1's had a fall risk score of 16.During a review of Resident 1's Fall Risk Evaluation, dated 8/7/2025 at 1:44 p.m., the evaluation indicated Resident 1's had a fall risk score of 17.During a review of Resident 1's Fall Risk Evaluation, dated 8/9/2025 at 8:56 p.m., the evaluation indicated Resident 1's had a fall risk score of 15.During a concurrent interview and record review on 8/14/2025 at 9:24 a.m. with the Administrator (Adm), Resident 1's Fall Risk Evaluation dated 7/22/2025 was reviewed. The Adm stated was not sure why Resident 1 had multiple Fall Risk Evaluations for 7/22/2025 and will get the Minimum Data Set Coordinator (MDS) to answer the questions.During a Residents Affected - Few Page 1 of 2 555707 555707 08/14/2025 Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concurrent interview and record review on 8/14/2025 at 9:27 a.m. with the MDS, Resident 1's Fall Risk Evaluation dated 7/22/2025 was reviewed. The MDS stated Resident 1 was discharged then returned to the facility on 7/21/2025. The MDS stated Resident 1 had multiple fall risk evaluations on 7/22/2025 because the nursing staff did not communicate with each other. The MDS stated was unsure which fall risk evaluations were accurate.During a concurrent interview and record review on 8/14/2025 at 3 p.m. with the Director of Nursing (DON), Resident 1's Fall Risk Evaluation dated 7/22/2025 was reviewed. The DON stated Resident 1 prior to fall on 8/3/2025 was not a high risk for falls but all residents in this facility are fall risk due to poor cognitive awareness and safety issues. The DON stated Resident 1 was able to ambulate without devices and had a prior fall in Resident 1's room without injury on 7/3/2025. The DON stated Resident 1 was discharged prior due to behavioral issues and returned to the facility on 7/21/2025. The DON stated the facility has a new system for the Fall Risk Evaluation, the DON stated was aware that two entries were done on 7/22/2025 one was from the nurse from 7 a.m. to 3 p.m. shift and the other was from the nurse from the 3 p.m. to 11 p.m. shift. The DON stated was not sure which fall risk evaluation was accurate. The DON stated the one Registered Nurse (RN) 2 did indicated Resident 1 had a fall risk score of 16 and RN 3's fall risk evaluation indicated Resident 1's fall risk score was 18. The DON stated RN 2 and RN 3's fall risk evaluation was inaccurate because RN 2 and RN 3 indicated Resident 1 had no falls in the past three (3) months and that is inaccurate because Resident 1 had a fall on 7/3/2025. The DON stated RN 2 inaccurately documented Resident 1's COC because Resident 1 did have a COC for behaviors and that is why Resident 1 was readmitted on [DATE]. The DON stated RN 2 inaccurately documented Resident 1's medications, the record indicates Resident 1 takes one to two of the listed medications, but it should indicate Resident 1 takes three to four of the listed medications. The DON reviewed the fall risk evaluation for Resident 1 for 8/7/2025 and the DON stated the fall risk evaluation was inaccurate because it indicated Resident 1 had none of the listed predisposing diseases. The DON stated assessment must be accurate because if assessments are not accurate there is a potential to not have the appropriate intervention for the residents.During a review of the facility's Policies and Procedures (P&P) titled, Charting and Documentation, last reviewed on 7/2025, the P&P indicated, documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.During a review of the facility's P&P titled, Falls and Fall Risk, Managing, last reviewed on 7/2025, the P&P indicated, based on previous evaluations and current data, the staff will identify related to the resident's specific risk and cause to try to prevent the resident from falling and to try to minimize complications from falling. 555707 Page 2 of 2