Inspection·April 5, 2024

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication, then the medication is started. LVN 8 stated there was not a note in the chart stated informed consent was obtained by the resident/resident representative. LVN 8 stated the staff should be an advocate for the residents. LVN 8 stated the residents should be informed and educated on the benefits and risks of the medication they were taking. During an interview on 4/4/2024 at 4:00 p.m. with Registered Nurse (RN) 7, RN 7 stated the informed consent was for giving authorization for the resident to take the medication. RN 7 stated if not signed the resident my not want to give medication to the Resident. During an interview on 4/5/2024 at 11:00 a.m., with the Director of Nursing (DON), the DON stated an informed consent was for psychotropic medications and restraints. The DON stated that an informed consent should be completed before the medication was started. The DON stated the doctor gives the informed consent to resident/resident representative. The DON stated there could be an adverse reaction and the resident/resident representative did not agree to this medication. DON stated it was the resident's right to refuse a medication. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, the P&P indicated, an informed consent will be obtained from physician prior to administering psychotherapeutic drugs. Residents and/or representatives have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 2 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 81's admission Record (Face Sheet), the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord) motor system that manifest as rigidity and tremors of the body), hydrocephalus (a condition in which excess cerebrospinal fluid buildup), and ataxia (a lack of balance coordination and trouble walking). During a review of Resident 81's History and Physical (H&P), dated 1/19/2024, the H&P indicated, Resident 81 has the capacity for medical decision making. During a review of Resident 81's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 1/24/2024, the MDS indicated, Resident 81's cognition (ability to learn reason, remember, understand, and make decisions) was oriented and able to recall information. The MDS indicated, Resident 81 activities of daily living ([ADL] activities related to personal care) Resident 81 required maximal assistance with toileting hygiene, showering, and sit to stand. During an interview on 4/4/2024 at 11:36 a.m. with Director of Nursing (DON) 1, the DON 1 stated Resident 81 was admitted to the facility on [DATE] wearing an Aspen collar. the DON 1 stated there was not care plan developed for the Aspen collar. The DON 1 stated Resident 81 should have had a care plan for the Aspen collar. The DON 1 stated the purpose of the care plan is to set goals and interventions for the Aspen collar being worn by Resident 81. The DON 1 stated having a care plan will guide the nurses on the interventions for the Aspen collar. During an interview on 4/4/2024 at 12:19 p.m. with Minimum Data Set Coordinator (MDS)1, the MDS 1 stated there was no care plan for Resident 81 in regard to the Aspen collar. MDS 1 stated a care plan for the Aspen collar should have been developed to formulate on the goals and interventions. MDS 1 stated a care plan was needed to guide the nurses and interventions to provide better care for Resident 81. Based on interview and record review the facility failed to: 1. Ensure a care plan (the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was formulated for two of 15 sampled residents (Residents 54 and Resident 81). This deficient practice had the potential for the affected residents not to receive the care and services needed and the provision of a poor-quality care. 2. Ensure they implemented the care plan to measure the arm circumference and the external catheter (a flexible tube inserted into an opening in the body for various medical reasons) length of a peripherally inserted central catheter ([PICC]- a long thin tube inserted into the upper arm to give medication) line for one of two sampled residents (Resident 86). This deficient practice had the potential for staff to be unaware of complications associated with the PICC line. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 3 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0656 Findings: Level of Harm - Minimal harm or potential for actual harm a. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 54's diagnoses included type 2 diabetes mellitus (abnormal blood sugar), epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own). Residents Affected - Some During a review of Resident 54's History and Physical (H&P), dated 1/3/2024, the H&P indicated Resident 54 did not have the capacity to understand and make decisions. A review of Resident 54's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 1/8/2024, the MDS indicated the resident was assessed to have a severe cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 54 required dependent assistance from staff for activities of daily living (ADLs) such as oral hygiene, toileting, showering, and positioning. During an interview on 4/5/2024 at 9:45 a.m. with Licensed Vocational Nurse (LVN) 7, LVN 7 stated a care plan was for the plan of care for the resident. LVN 7 stated this would cover specific diagnoses, to show interventions for the residents. LVN 7 stated it would affect the resident if there was not a care plan. LVN 7 stated without a care plan there would not be a way to know what to look for or what interventions we have done with the resident. During a concurrent interview and record review on 4/5/2024 at 9:33 a.m. with Registered Nurse (RN) 6, Resident 54's Care Plans were reviewed. There was no care plan regarding diabetes for resident 54. RN 6 stated there was not a specific care plan for diabetes for Resident 54. RN 6 stated one should have been implemented. During an interview on 4/5/2024 at 11:00 a.m., with the Director of Nursing (DON), the DON stated a care plan was for the specific plan of care regarding the resident. The DON stated care plans are very important so the staff can monitor the patient. The DON stated when there was a diagnosis there should be a care plan to watch for problems, signs and symptoms, and interventions for the residents. c. During a review of the admission Record, Resident 86 was admitted to the facility on [DATE], with diagnoses that included discitis (an infection of the intervertebral disc space [the area between each individual part of the spine]), and acute respiratory failure (disease or injury that affects breathing). During a review of Resident 86's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated 3/15/2024, it indicated the resident was cognitively intact (ability to reason, understand, remember, judge, and learn). During a concurrent interview and record review on 4/4/24 at 4:04 pm, with Registered Nurse (RN) 7, Resident 86's care plan for intravenous therapy (medication delivered into the vein) of Vancomycin (a strong antibiotic) was reviewed. The interventions for this area included measuring the external catheter length of the PICC line upon admission and with each dressing change and to measure the arm circumference upon admission. RN 7 stated she does not know where any of these measurements are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 4 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some being documented and is unable to find any documentation of these measurement in Resident 86's medical record. RN 7 stated it is important to have these measurements charted because if the arm circumference is increasing, it can mean the resident has an infection or a deep vein thrombosis (a blood clot that forms in a deep vein). During an interview on 4/5/24 at 10:36 am, with RN 6, RN 6 states it is important to measure the external length of a PICC line so you can see if it is being pulled out more which can mean the PICC line is dislodged (out of place). RN 6 also states it is important to measure the arm circumference because that is how you can identify swelling which can mean the resident has an infection. RN 6 states she does not currently see any charting on the external catheter length or the arm circumference in the medical record but if the measurements were taken, it would have been documented in the resident's progress notes. During an interview on 4/5/24 at 11:01 am, with the Director of Nursing (DON), the DON stated it is important to measure the external catheter length, so staff knows if the catheter is coming out more, and if there is a large change, they need to notify the doctor immediately. The DON also stated is it important to measure the arm circumference because a big change can indicate the resident has an infection. During a review of the policy and procedure (P&P) titled, The Resident Care Plan, (undated), the P&P indicated, the resident care plan shall be implemented for each resident on admission, and developed throughout the assessment process. It is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 5 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a care plan for one out five Residents (Resident 11). Residents Affected - Few This deficient practice of not having a revised care plan placed Resident 11 at risk of not having the appropriate interventions for a contracted (a tightening of the muscles that causes the joint to shorten and become stiff) neck. Findings: During a review of Resident 11's admission Record (Face Sheet), the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included contractures (a condition of shortening and hardening of muscles, tendons, and rigidity of joints), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing related problems), and encephalopathy (damage or disease that affects the brain). During a review of Resident 11's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 3/13/2024, the MDS indicated, Resident 11's cognition (ability to learn reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 11 was dependent with toileting hygiene, and showering. During an observation on 4/2/2024 at 9:20 a.m., in Resident 11's room, Resident 11 was observed lying in bed. Resident 11's was contracted and leaning to the left side. A pillow was placed on Resident 11's back. Resident 11's neck was unsupported. During a concurrent interview and record review on 4/3/2024 at 4:09 p.m., with Infection Preventionist (IP) 1, Resident 11's Care Plan, dated 3/13/2024 was reviewed. The Care Plan indicated, on 3/13/2024 the focus was Resident 11's contractures to both the upper and lower extremities (arms, legs) with interventions including Restorative Nursing Assistant ([RNA] nursing interventions that promotes the resident ability to adapt to living independently and safely as possible) services. IP 1 stated the Care Plan focus was on Resident 11's contractures but did not specify the interventions for the neck. IP 1 stated Resident 11's neck had been in that abnormal position. IP 1 stated the Care Plan did not address the interventions for Resident 11's neck. IP 1 stated the Care Plan needed to be revised to reflect interventions for Resident 11's contracted neck to possibly add to the resident's comfort. During a concurrent interview and record review on 4/4/2024 at 11:13 a.m., with MDS Coordinator (MDS) 1, Resident 11's Care Plan, dated 3/13/2024 was reviewed. The Care Plan indicated, on 3/13/2024 the focus contractures to both upper and lower extremities with interventions including RNA services. MDS 1 stated Resident 11 had a contracture to the left side of the neck. MDS 1 stated the Care Plan did not address the left neck contracture. MDS 1 stated the Care Plan should have had interventions to care for Resident 11's contracted neck. MDS 1 stated the care plan should have been revised. MDS 1 stated the Care Plan was a tool used to monitor Resident 11's decline and improvement of his contractures. During a review of the facility's policy and procedure (P&P) titled, The Resident Care Plan, date unknown, the P&P indicated, To provide an individualized nursing care plan and to promote continuity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 6 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm of resident care .the nursing section of the care plan must indicate long and short term goals with plans for restorative and rehabilitative nursing care .it is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 7 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one out five Residents (Resident 11) had a comprehensive assessment completed. Residents Affected - Few This deficient practice of not having a comprehensive assessment completed for Resident 11's contracted neck placed the resident at risk for worsening condition. Findings: During a review of Resident 11's admission Record (Face Sheet), the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included contractures (a condition of shortening and hardening of muscles, tendons, and rigidity of joints), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing related problems), and encephalopathy (damage or disease that affects the brain). During a review of Resident 11's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 3/13/2024, the MDS indicated Resident 11's cognition (ability to learn reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 11 was dependent with toileting hygiene, and showering. During an observation on 4/2/2024 at 9:20 a.m. in Resident 11's room, Resident 11 was observed lying in bed. Resident 11 had a contracture to the neck. Resident 11's neck was leaning to the left side with a pillow placed on Resident 11's back. Resident 11's neck was unsupported. During a concurrent interview and record review on 4/2/2024 at 2:43 p.m., with Physical Therapist (PT) 1, Resident 11's Joint Mobility Screening, dated 2/20/2024 was reviewed. The Joint Mobility Screening did not address Resident 11 neck. PT 1 stated Resident 11's neck was in a fixed position to the left side. PT 1 stated she did the body screening for Resident 11. PT 1 stated the Joint Mobility Screening did not address Resident 11's neck. PT 1 stated the neck was considered a joint (the place where two or more bones are connected). PT 1 stated it was important to screen the whole body of the resident including the neck. PT 1 stated Resident 11's neck should have been included in the Joint Mobility Screening. PT 1 stated after the screening the recommendations would be put in place and a plan of care developed to include proper body positioning. PT 1 stated by not including the neck in the screening Resident 11 was at risk for worsening of the joint in the neck. During a concurrent interview and record review on 4/2/2024 at 2:43 p.m., with Infection Preventionist Nurse (IPN) 1, Resident 11's Joint Mobility Screening, dated 2/20/2024 was reviewed. The Joint Mobility Screening did not address Resident 11 neck. IPN 1 stated 1 the neck was a joint connected to the cervical spine. IPN 1 stated Resident 11's neck was in an abnormal position. IPN 1 stated the Joint Mobility Screening should have addressed if Resident 11's neck was in a declining condition. IPN 1 stated PT 1 did the screening and presented a plan for Resident 11. IPN 1 stated it was not clear if the left side of Resident 11's neck was improving or declining. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, dated 3/2021, the P&P indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 8 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0676 well-being .staff are to accommodate dignity and well-being to the extent possible and in accordance with the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 9 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to groom one out five Residents (Resident 139). Residents Affected - Few This deficient practice of not grooming Resident 139 had the potential of not receiving the necessary goods and services. Findings: During a review of Resident 139's admission Record (Face Sheet), the Face Sheet indicated Resident 139 was admitted to the facility on [DATE]. Resident 139's diagnoses included aphasia (a language disorder that affects a person's ability to communicate), chronic kidney disease (the kidneys fail to filter waste out the body), and metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). During a review of Resident 139's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 3/26/2024, the MDS indicated Resident 139 was not able to cognitively (ability to learn, reason, remember, understand, and make decisions) recall information when asked to repeat information. The MDS indicated Resident 139 was dependent on staff for personal hygiene including combing the hair and shaving. During an observation on 4/2/2024 at 10:00 a.m. Resident 139 was observed lying in the bed. Resident 139 was not groomed. During an observation on 4/2/2024 at 1:30 p.m. Resident 139 was observed lying in the bed. Resident 139 was not groomed. During an observation on 4/3/2024 at 9:30 a.m. Resident 139 was observed in the hallway seat on a wheelchair. Resident 139 was not groomed. During a concurrent observation and interview on 4/3/2024 at 3:23 p.m., with Social Worker (SS) 1, SS 1 stated Resident 139 was not shaved. SS 1 was not able to locate any documentation of refusal to be shaved by Resident 139. SS 1 stated it was important to shave and groom Resident 139 because it would help the resident feel good. SS 1 stated if Resident 139 was shaved the resident's family could see the resident looking clean and shaved. During a concurrent observation and interview on 4/4/2024 at 10:24 a.m., with Director of Nursing (DON) 1, DON 1 stated Resident 139 was not completely shaved. DON 1 stated Resident 139 refused to be shaved. DON 1 stated there was no documentation Resident 139 was refusing to be shaved. DON 1 stated upon admission Resident 139 had longer hair and was not shaved. DON 1 stated it was important to shave Resident 139 because it was a part of activities of daily living (ADLs, selfcare activities performed daily such as grooming, personal hygiene, and dressing). DON 1 stated it would help Resident 139 to feel better by looking clean shaven and by having a well-kept appearance. DON 1 stated the goal was to keep Resident 139's appearance well-kept and the goal was for the resident to get better. During a concurrent observation and interview on 4/4/2024 at 10:40 a.m., with MDS 1 Coordinator, MDS 1 stated Resident 139 did not look well groomed. MDS 1 stated Resident 139 had behavioral issues. MDS 1 stated there was no documentation Resident 139 was refusing to be shaved. MDS 1 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 10 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 139 was a new admission [DATE]) and it had been noticeable that Resident 139 was not shaved since 3/31/2024. MDS 1 sated Resident 139 needed to be groomed. MDS 1 stated Resident 139 should have been shaved. MDS 1 stated when Resident 139 refused care, the facility needed to create a plan to make sure Resident 139's ADLs were performed daily. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 3/2023, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .refuses care and treatment to retore or maintain functional abilities and the refusal is documented and the resident and the representative has been informed of the risk and benefits of the proposed care or treatment. Event ID: Facility ID: 555719 If continuation sheet Page 11 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure a PICC line dressing was changed every 7 days and as needed if the dressing is soiled or lifting at the edges for 1 of 2 sampled residents (Resident 86). Residents Affected - Few This deficient practice had the potential to cause an infection in Resident 86. Findings: During a review of the admission Record, Resident 86 was admitted to the facility on [DATE], with diagnoses that included discitis (an infection of the intervertebral disc space [the area between each individual part of the spine]), and acute respiratory failure (disease or injury that affects breathing). During a review of Resident 86's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated 3/15/2024, it indicated the resident was cognitively intact (ability to reason, understand, remember, judge, and learn). During a review of Resident 86's Care Plan dated 3/13/24 for Intravenous therapy (medication delivered into the vein) of Vancomycin (a strong antibiotic), the interventions included changing the PICC line dressing and securement device every 7 days and as needed. During an observation on 4/2/24 at 11:30 am, Resident 86 has a PICC line to the right upper arm. The dressing was lifting at the edges and was dated for 3/24 with the day illegible (not clear enough to read). During a concurrent observation and interview on 4/3/24 at 1:56 pm, in Resident 86's room with Registered Nurse (RN) 6, RN 6 looked at the PICC line on the right upper arm. RN 6 states the dressing is lifting at the edges most likely due to perspiration (sweating) and states it is dated for either 3/26/24 or 3/28/24. After RN 6 reviewed resident chart, she states it is dated for 3/26/24. During an interview on 4/3/24 at 2:10 pm, with RN 6, RN 6 stated that PICC line dressing should be changed every 7 days and as needed. As needed means they change it more frequently than 7 days if the dressing is dirty, if the dressing is coming off, blood underneath dressing, and if it is damaged. Once they change the dressing, the dressing needs to have the date that it was changed. During an interview on 4/5/24 at 11:30 am, with the Director of Nursing (DON), the DON states that PICC line dressing is changed every 7 days and more frequent if the dressing is lifting, dirty, has blood or water gets in it. The DON further states that PICC line dressing change is important because it prevents infection. During a review of the policy and procedure, titled Peripheral and Midline IV Dressing Changes, revised 3/24, it indicated to change the dressing if it becomes damp, loosened, or visibly soiled and at least every 7 days. It also indicated that after placing a new dressing on, to label the dressing with date and time of dressing change and initials. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 12 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure there was a physician order for one out of five Residents (Resident 81) to wear an Aspen collar (a device to help the neck to heal by supporting the bones in the neck). This deficient practice of not having a physician order placed Resident 81 at risk for inadequate monitoring. Findings: During a review of Resident 81's admission Record (Face Sheet), the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord), hydrocephalus (a condition in which excess cerebrospinal fluid buildup), and ataxia (a lack of balance coordination and trouble walking). During a review of Resident 81's History and Physical (H&P), dated 1/19/2024, the H&P indicated Resident 81 had the capacity for medical decision making. During a review of Resident 81's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 1/24/2024, the MDS indicated Resident 81's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 81 required maximal assistance with toileting hygiene, showering, and sit to stand. During an observation on 4/2/2024 at 9:47 a.m., in Resident 81's room, Resident 81 was observed wearing an ASPEN collar. The Aspen collar was loose around Resident 81's neck. During a concurrent observation and interview on 4/3/2024 at 8:54 a.m., with Resident 81, in the activity room, Resident 81's Aspen collar was loose around the neck area. Resident 81 stated he was not told how long he would need to wear the Aspen Collar. Resident 81 stated no one told him how to use the Aspen collar. During an interview on 4/4/2024 at 11:36 a.m., with Director of Nursing (DON) 1, DON 1 stated Resident 81 did not have the Aspen collar on properly. DON 1 stated Resident 81 was admitted to the facility with an Aspen collar on 1/18/2024. DON 1 stated the Aspen collar should be better fitted around Resident 81's neck. DON 1 stated there was no physician order for the Aspen collar. DON 1 stated a physician order was needed to monitor the effects of the resident wearing the Aspen collar. During a concurrent observation and interview on 4/4/2024 at 12:19 p.m., with MDS (Coordinator) 1, MDS 1 stated Resident 81 did not have physician orders for an Aspen collar. MDS 1 stated a physician order was needed to monitor Resident 81. MDS 1 stated the physician order would indicate how to take care of the Aspen collar. MDS 1 stated the Aspen collar should have a tighter fit around Resident 81's neck. MDS 1 stated the Aspen collar was not fitted correctly and prevented Resident 81 from healing. During a review of the facility's policy and procedure (P&P) titled, Physician orders and Telephone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 13 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0711 Level of Harm - Minimal harm or potential for actual harm Orders, dated 1/2004, the P&P indicated, Physician's orders shall be obtained prior to the initiation of any medication or treatment from a person lawfully authorized to prescribe for and treat human illness .A resident shall be admitted or accepted for care on the order of a physician .Treatment (specific treatment, frequency, and site). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 14 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure an enteric coated (a coating on a medication to prevent it from dissolving in the stomach) medication was not crushed for 1 of 4 residents (Resident 57). This deficient practice had the potential for Resident 57 to experience adverse drug reactions from the medication being administered differently from how they were ordered. Findings: During a review of Resident 57's admission Record, it indicated Resident 57 was readmitted on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the brain), and atrial fibrillation (irregular heart rhythm). During a review of Resident 57's History and Physical, dated 5/22, it indicated Resident 57 does not have the capacity to understand and make decisions. During a review of Resident 57's Medication Administration Record, dated 5/11/23, it indicated Resident 57 is receiving Aspirin Enteric Coated ([EC]- a coating on a medicine to prevent absorption in the stomach) Tablet Delayed Release 81 milligrams ([mg]- unit of measurement) one time per day to be taken by mouth. During an observation on 4/4/24 at 8:10 am, outside of Resident 57's room, with Licensed Vocational Nurse (LVN) 6, LVN 6 was preparing Resident 57's morning medications. LVN 6 stated Resident 57 received a pureed diet and so the medications need to be crushed and placed in apple sauce to be given. During a concurrent interview and record review on 4/4/24 at 8:30 am, the surveyor interrupted the medication pass and LVN 6 was asked to pull out bottle of aspirin and look at Resident 57's order for aspirin. LVN 6 read Resident 57's order for aspirin which states it is enteric coated, and looked at the bottle for aspirin which also states it is enteric coated. LVN 6 stated enteric coated means it is a delayed release medication and if it is crushed and given to the resident, it will alter the effect the medication will have in the body. The resident should be taking a different form of aspirin that can be crushed and given to the resident. During an interview on 4/5/24 AT 11:23 am, with the Director of Nursing (DON), the DON stated enteric coated aspirin has a coating on it that prevents it from dissolving in the stomach to prevent acidity and stomach ulcers, if it is crushed, the purpose of the medication having the enteric coating will be defeated and the medication will be absorbed in the stomach. During a review of the policy and procedure titled, Administering Medications, dated 4/19, it indicated medications are administered in a safe and timely manner, and in accordance with prescriber orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 15 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow up with the Pharmacist's Medication Regiment Review ([MRR] an evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) for one out of five Residents (Resident 8). This deficient practice of not following the MRR recommendations had the potential for Resident 8 to have an adverse effect from not reviewing the insulin sliding scale (varies the dose of insulin based on blood glucose level). Findings: During a review of Resident 8's admission Record (Face Sheet), the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (a condition the body in which the body has trouble controlling blood sugar), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems), and heart failure (a condition in which the heart does not pump enough oxygen rich blood to meet the body's needs). During a review of Resident 8's History and Physical (H&P), dated 1/20/2024, the H&P indicated, Resident 8 has the capacity to understand and make decisions. During a review of Resident 8's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 1/5/2024, the MDS indicated, Resident 1's cognition (ability to learn reason, remember, understand, and make decisions) was oriented and able to recall information. The MDS indicated, Resident 8 activities of daily living ([ADL] activities related to personal care) required moderate assistance with toileting hygiene, and showering. During a concurrent interview and record review on 4/4/2024 at 3:38 p.m. with Registered Nurse (RN) 8, Resident 8's Pharmacist's Medication Regimen (MRR), dated 3/2024 was reviewed. The MRR indicated, Resident 8 was to have a follow up with Medical Doctor (MD) regarding pattern of recorded blood glucose values with Insulin Lispro sliding scale. RN 8 stated the process is to notify the MD of the pharmacist findings. RN 8 stated if the MD makes changes from the recommendation; it will go into the nursing progress notes that changes are made to the medication order. RN 8 stated we would write done on the MRR if someone notified the MD and make a nurse progress note. RN 8 stated there was no documentation that the MD was notified of the recommendations. RN 8 stated Resident 8 had become hypoglycemic (a condition when the blood sugar is abnormal) in February 2024. RN 8 stated it was important to follow up with the MD because Resident 8 had the potential to become hypoglycemic. During a concurrent interview and record review on 4/4/2024 at 3:38 p.m. with Registered Nurse (RN) 5, Resident 8's Pharmacist's Medication Regimen (MRR), dated 3/2024 was reviewed. The MRR indicated, Resident 8 was to have a follow up with Medical Doctor (MD) regarding pattern of recorded blood glucose values with Insulin Lispro sliding scale. RN 5 stated the process is to check the MRR and follow up with the MD. RN 5 stated she is the one that told the MD about the pharmacist recommendations. RN 5 stated she was not able to locate any documentation that she followed up with the MD. RN 5 stated it was important to follow up with the recommendations for Resident 8 to prevent an adverse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 16 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reaction to the insulin medication. RN 5 stated the Resident 8 had the potential of having hypoglycemic (too low blood sugar) or hyperglycemic (too high blood sugar). During an interview on 4/5/2024 at 1:53 p.m. with Pharmacist (Rx) 1, the Rx 1 stated a MRR was done in the month of March. Rx 1 stated the recommendation was done due to Resident 8 elevation of blood sugar in the 200s. Rx 1 stated no one notified him for clarification of his recommendation of the insulin sliding scale. Rx 1 stated once I put in the recommendations the RNs are to notify the MD. Rx 1 stated he was not aware Resident 8 had become hypoglycemic in the month of February. Rx 1 stated its important for the MRR to be reviewed and the follow ups to prevent an adverse effect for the Residents. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews, dated 5/2019, the P&P indicated, The consultant pharmacist reviews the medication regimen of each resident at least monthly .potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences. During a review of the facility's policy and procedure (P&P) titled, Registered Nurse Job Description, dated 8/2011, the P&P indicated, The Registered Nurse is responsible for assuring physicians' orders are followed and quality care is provided .Documentation and follow-up with timely notification of physician and family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 17 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility did not ensure an expired and discontinued bottle of Pro-Stat (Concentrated Liquid Protein Medical food) was discarded from medication cart #3. This deficient practice had the potential for unintentional administration of the expired and discontinued medication which can result in adverse drug effects. Findings: During a concurrent observation and interview on 4/4/24 at 1:15 pm, with Licensed Vocational Nurse (LVN) 4, medication cart #3 was inspected. A bottle of expired Nutricia Pro-Stat Concentrated Liquid Protein Medical Food was found with an expiration date of 3/30/24. LVN 4 stated it is not okay to have expired medication in the cart because if a resident receives an expired medication, it will not have the appropriate effect. During an interview on 4/5/25 at 11:26 am, the Director of Nursing (DON), stated the medication carts should be inspected on their shift by the LVN and if it is expired, they need to properly dispose of it and get a new bottle, and if the medication is discontinued, they need to properly dispose of it. During a review of the policy and procedure titled, Storage of Medications, dated 11/20, it indicated discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 18 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to: 1. Ensure laundry rubber gloves were properly cleaned and stored after use. Residents Affected - Many This deficient practice of not having the laundry rubber gloves cleaned stored placed the Residents at risk for the spread of infection. 2. Ensure there is a comprehensive water management program in place to prevent Legionella (a bacteria that causes Legionnaires [a severe form of pneumonia - lung infection/inflammation usually caused by infection] and other waterborne pathogens (any organisms or agent that can cause disease) to grow and spread in the facility. This deficient practice had the potential for residents of the facility to contract a waterborne pathogen including Legionella. Findings: a. During an observation on 4/5/2024 at 10:20 a.m. there were blue rubber gloves placed on the sink where the staff washes their hands. During a concurrent observation and interview on 4/5/2024 at 10:21 a.m. with Maintenance Supervisor (MS) 1. MS 1 stated the blue rubber gloves should not be hanging on the sink. MS 1 stated the process is to wear the blue rubber gloves when washing the linen while. MS 1 stated the staff are to remove the blue rubber gloves and clean the blue rubber gloves with bleach wipes. MS 1 stated after the blue rubber gloves are cleaned, they are to be hung on the hooks. MS 1 stated the sink is used for the staff to wash their hands. MS 1 stated by not having gloves in the correct area had the potential to spread germs. During an interview on 4/5/2024 at 10:30 a.m. with Laundry Aide (LA) 1, LA 1 stated the blue rubber gloves are used to separate the clothes or linen. LA 1 stated after the linen is separated, I am to remove the blue rubber gloves and disinfect with bleach wipes. LA 1 stated the blue rubber are not to left on the sink. LA 1 stated the blue rubber gloves are hung on a hook after wiping with bleach wipes. LA 1 stated leaving the blue rubber gloves on the sink is putting the Residents at risk for the spread of germs. During a review of the facility's policy and procedure titled, Sorting, Washing, and Drying, date unknown, the P&P indicated, Wear rubber gloves and gown to empty hampers/barrels containing soiled linens into containers used for sorting linens in laundry; sort linens as hampers are emptied .Remove and disinfect rubber gloves; remove gown and laundry after each individual use and wash hands. b. During an interview on 4/3/24 at 8:41 am with Infection Prevention Nurse (IPN), IPN was asked for policies and procedures and other documents related to their water management program and Legionella. IPN stated he could not find any of those specific documents. During an interview on 4/3/24 at 9:16 am with the Administrator (ADM) and IPN, the administrator states they are not using an outside company contracted with the facility to test their water for Legionella. ADM states their maintenance supervisor is currently working on mapping out the piping on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 19 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm how water is distributed through the facility but needs assistance from their corporate office to help complete the task. They are currently in the works to have an outside company called King-Pak to test their water for Legionella but currently do not have any testing in place. ADM and IPN was asked if they have any documents related to their water management program and/or prevention of legionella and other waterborne pathogens. Residents Affected - Many During an interview on 4/3/24 at 10:50 am with the Maintenance Supervisor (MS) and IPN, the MS stated they are in the works to have an outside company, King-Pak, come in to perform water testing for Legionella. They have a packet from King-Park that outlines what the water management program will look like and states this has been in the works since December 2023. The MS and IPN acknowledged they currently do not have a water management program in place and states they do not have any current measures or assessment plan to prevent waterborne pathogens. IPN stated it is important to have a system in place to ensure the residents and staff do not acquire any illnesses. During a concurrent interview and record review on 4/4/24 at 11:41 am with the IPN, regarding their infection prevention control plan (IPCP), a binder containing policies and procedures related to their IPCP was reviewed. The binder contained a policy and procedure titled Legionella Water Management Program, dated 4/2023. The policy and procedure indicated that as part of the IPCP, the facility has a water management program which is overseen by the water management team. IPN stated they just started putting together a water management team after the last conversation with the ADM, but do not have any of the other components as indicated on the policy and procedure. They also do not have a detailed description and diagram of the water system in the facility, identification of areas in the water system that could encourage growth and spread of waterborne pathogens, identification of situations that can lead to Legionella growth, or measures to control the introduction and/or spread of Legionella as indicated in the policy and procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 20 of 21 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 555719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imperial Crest Health Care Center 11834 Inglewood Avenue Hawthorne, CA 90250 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)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident had 80 square feet of living space. This deficient practice had the potential to interfere with residents being able to move around freely or store their personal items. Findings: During an observation on 4/4/24 at 12:30 p.m. in resident room [ROOM NUMBER], 111, 117, 129, and 131, there were three occupied beds noted. During an interview on 4/5/24 at 1:10 p.m. with ADM, ADM stated a resident may feel claustrophobic (fear of tight spaces) due to the room being smaller. An issue can present depending on how many belongings each resident has. During a review of the Client Accommodations Analysis, dated 4/2/24, the analysis indicated resident room [ROOM NUMBER] measured 236.4 square feet. The analysis indicated room [ROOM NUMBER] is for a capacity of three residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 21 of 21