Health inspection·February 9, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to follow its policies and procedures regarding individualized care planning by failing to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) addressing one of three sampled residents` (Resident 1) prednisone (a powerful steroid used to decrease swelling, inflammation, and allergies) use. This deficient practice increases the risks for Resident 1 to not understand the purpose of the medication's use, the possibility of treatment failure, and the lack of interventions for staff to monitor Resident 1 for any harmful adverse side effects related to taking the medication. FindingsDuring a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on 2/26/2025, with diagnoses including muscle weakness (loss of strength), dysphagia (having difficulty swallowing), hypertensive heart disease with heart failure (a damaged heart due to long-term high blood pressure resulting in inefficient pumping), and chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow, making it difficult to breath). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/5/2025, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was with moderate impairment. The MDS also indicated Resident 1 needed partial/moderate assistance (helper does less than half the effort) for toileting needs, showering or bathing, and assistance when applying footwear. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order:- 2/12/2026 8:02 p.m., a telephone order for Prednisone (a powerful steroid used to decrease swelling, inflammation, and allergies) oral tablet 20 milligrams (mg-a unit of measurement), give one tablet by mouth one time a day for cough for five days. During an interview with Assistant Director of Nursing (ADON) on 2/6/2026 at 3:16 p.m., the ADON stated, The purpose of creating a care plan is to create goals for the resident (Resident 1) and address the needs. The ADON stated licensed staff did not develop a care plan for Resident 1`s prednisone use. The ADON stated staff should have created a care plan because there are side effects that could potentially be caused by the use of medications. The ADON stated care plan has goals and interventions such as monitoring of vital signs, any potential side effects, or to see if the resident was exhibiting any side effects. The ADON stated if the resident exhibits any side effects, staff are required to notify the doctor if the medication would need to be continued or discontinued. The ADON stated the failure here was not developing a care plan to address Resident 1`s Prednisone usage. During a review of the facility provided policy & procedure (P & P) titled Care Plans, Comprehensive Person-Centered with last revision date of 3/2022, the P & P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is Page 1 of 2 555707 555707 02/09/2026 Imperial Care Center 11441 Ventura Blvd Studio City, CA 91604

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few developed and implemented for each resident. The policy also stated; 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change.; 555707 Page 2 of 2