Health inspection·December 23, 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 one of two sampled residents (Resident 1) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical well-being, when Registered Nurse (RN 2) and RN 3 failed to complete the admission assessment timely when Resident 1 was re-admitted to the facility on [DATE]. This deficient practice had the potential to result in Resident 1 receiving inadequate care. Findings: During a review of Resident 1's admission Record, dated 01/02/2026, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, judgment, and behavior), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy levels, and behavior), and schizoaffective disorder (a mental illness that mixes symptoms of schizophrenia, such as hallucinations, delusions, and disorganized thinking, with symptoms of intense mood swings). During a review of Resident 1's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition), dated 07/10/2025, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/30/2025, the MDS indicated Resident 1 needed moderate assistance for personal hygiene, shower/bathe, and lower body dressing (a helper does less than half the effort of the activity). The MDS indicated Resident 1 needed supervision or touching assistance for toileting, oral hygiene, and upper body dressing (a helper provides verbal cues or touching assistance throughout the activity or intermittently). During a review of Resident 1's Change of Condition (COC - when a resident experiences any physical, mental, or psychosocial change from his/her baseline status), dated 12/09/2025, the COC indicated that on 12/09/2025 at 4 a.m., Resident 1 was found at the end of the hall banging his walker against the facility doors attempting to break and exit [the] facility. Staff attempted [to] redirect, however unsuccessful due to [Resident 1] lashing out at staff and becoming verbally and physically aggressive. [Resident 1] proceeded down the hall ignoring de-escalation attempts by staff and proceeded to [NAME] the walker against the walls and paintings on the wall. The COC further indicated that 911 [was] called for transport to the hospital for evaluation and for being a danger to [Resident 1's self] and others. During a phone interview on 12/23/2025 at 10:45 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated when he began his shift on 12/08/2025 at approximately 11 p.m., he found Resident 1 asleep and sitting in a chair in front of the nursing station. CNA 1 stated he assisted Resident 1 back to his room to lay on his bed. CNA 1 stated that at approximately 3 a.m., another resident started to yell and scream and that was enough to [wake up Resident 1. CNA 1 stated when CNA 1 returned from his break, another CNA (which CNA 1 could not recall) had changed Resident 1's adult diaper. CNA 1 stated he saw Resident 1 walking around with his walker at about 4 Residents Affected - Few Page 1 of 3 555707 555707 12/23/2025 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 a.m. CNA 1 stated he then heard Resident 1 mad and crashing the back door with his walker. CNA 1 stated he saw numerous staff members approach Resident 1, but CNA 1 was unable to assist because he was preoccupied with another resident. CNA 1 stated he remembers RN 2 calling 911 because Resident 1 took his walker and tried to hit people. CNA 1 stated staff members tried to offer [Resident 1] cookies or juice but it didn't work. CNA 1 stated he saw Resident 1 spit on one of the CNAs. CNA 1 stated Resident 1 only calmed down when he saw the police, and Resident 1 was then transferred to an acute hospital. CNA 1 stated he recalls Resident 1 was re-admitted to the facility on [DATE] around 2 p.m. to 3 p.m. During an interview on 12/23/2025 at 11:47 a.m. with RN 1, RN 1 stated an admission assessment is completed when a resident is admitted or re-admitted to the facility. RN 1 stated that a registered nurse can endorse (give the task to the next shift to complete) other assessments like fall risk, dehydration, skin if [the RN does not] have time to finish those, but the priority is the admission assessment and obtaining doctor's orders when a resident returns to the facility from an acute hospital. RN 1 stated the importance of timely completing the admission assessment is to get a baseline of your patient from head to toe so you know where they start when they arrive. During a concurrent interview and record review on 12/23/2025 at 12:03 p.m. with RN 1, Resident 1's electronic medical record was reviewed. RN 1 stated Resident 1's clinical admission assessment was completed on 12/23/2025 at approximately 3 a.m. by the night shift nurse. RN 1 stated there was no licensed nursing note regarding Resident 1's re-admission on [DATE] in the afternoon. RN 1 stated the clinical admission assessment should have been documented on 12/22/2025 when resident was admitted in the afternoon. During a phone interview on 12/23/2025 at 12:37 p.m. with RN 2, RN 2 stated Resident 1 came back from the hospital yesterday on 12/22/2025 around 2 p.m. or 2:30 p.m. RN 2 stated she was the assigned nurse when Resident 1 was re-admitted to the facility, and RN 2 was also assigned to another resident who was being admitted around the same time. RN 2 stated that when Resident 1 arrived, RN 2 did [her] assessment with the patient. When asked what kind of assessment RN 2 performed, RN 2 stated: I just checked if [Resident 1] is ok and how he feels and if he has pain. When asked if RN 2 completed an admission assessment, RN 2 stated, I endorsed it to the treatment nurse and next shift because at this time I had 2 residents come in. RN 2 stated, If a patient comes at 2:30 p.m., then the next shift needs to continue and do all the assessments. RN 2 stated she did not document any admission assessment for Resident 1 when he arrived on 12/22/2025. During a phone interview on 12/23/2025 at 1:35 p.m. with RN 3, RN 3 stated she recalls Resident 1 being re-admitted on [DATE], and RN 3 received report from RN 2. RN 3 stated RN 2 was working on another admission and RN 2 mentioned [Resident 1] was also admitted and [RN 2] hadn't done much for that one yet. RN 3 stated that usually whoever the RN is when a patient arrives is the one who needs to complete the admission assessment. RN 3 stated, if the [resident] comes before 2:45 p.m., the admission needs to be done by the prior shift. RN 3 stated that RN 3 had seen in the facility's computer system that Resident 1 had arrived at 2:01 p.m. RN 3 stated: Since [Resident 1] came at 2:01 p.m., the prior nurse should have done the admission assessment. RN 3 stated she asked if RN 2 had completed the admission assessment, and RN 2 replied that the treatment nurse said she's going to do it. RN 3 stated that she called Resident 1's primary doctor and psychiatrist to notify them of Resident 1's arrival and to obtain doctor's orders. RN 3 stated she had a new admission on her shift and was unable to complete Resident 1's admission assessment. RN 3 stated at the end of her shift, RN 3 realized [Resident 1's] admission assessment wasn't done by the treatment nurse. RN 3 stated she endorsed Resident 1's admission assessment to the night nurse whose shift was from 11 p.m. to 7 a.m. During an interview on 12/23/2025 at 2:36 p.m. with the Director of Nursing (DON), the DON stated a registered nurse needs to perform a head-to-toe 555707 Page 2 of 3 555707 12/23/2025 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 assessment (checking the overall well-being of a resident starting from his/her head down to the toes) when a resident is admitted or re-admitted to the facility. The DON stated it is important to complete an admission assessment when a resident is re-admitted because the nursing staff needs to know if there are any new changes and compare it to the patient's baseline status. When asked which shift is responsible for completing the admission assessment if a resident arrives at the facility at 2:01 p.m., the DON stated the morning shift [from 7 a.m. to 3 p.m.] can start but it can be continued by the afternoon shift [from 3 p.m. to 11 a.m.]. The DON stated the admitting nurse (the assigned nurse who is present when a resident arrives at the facility) needs to assess the patient's condition when they arrive is most important, and at the very least document the clinical admission assessment. DON stated the admitting nurse can then endorse the other assessments to the following shift. During a review of the facility's policy and procedure (P&P) titled, admission Assessment and Follow Up: Role of the Nurse, dated 9/2012, the P&P indicated the following: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. The P&P indicated the nurse needs to conduct a physical assessment, which .should be recorded in the resident's medical record. including the date and time the assessment was performed.[and] all relevant assessment data obtained during the procedure. 555707 Page 3 of 3