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 (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 2 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 08/14/2025 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)