Inspection·December 26, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation, and interview on 12/23/2024 at 3:18 p.m. with RNA 1, the Documentation Survey Report v2, dated 12/24/2024 for 7:00 a.m. to 3:00 p.m. shift was reviewed. The section for personal hygiene was left blank. RNA 1 stated personal hygiene included grooming, such as brushing hair and teeth. RNA 1 stated if it was left blank, not documented, it would mean it was not done. RNA 1 stated the Resident 3 ' s teeth looked like it had not been brushed in days. RNA 1 stated not assisting residents with oral hygiene was a type of neglect. RNA 1 stated the dayshift Certified Nurse Assistant (CNA) had left and she would call the current shift CNA to assist Resident 3 with brushing her teeth. 2). During a review of Resident 3 ' s care plan, titled At Risk for Decline in bilateral [both] lower extremities (BLE) ROM, dated 4/11/2024, the interventions indicated RNA to render active range of motion ([AROM] a movement where when residents use own muscles to move a joint through its full range of motion, without any external assistance) to right lower extremity, passive range of motion exercises ([PROM] a joint movement where a person's limb is moved by another person or a device, with the individual not actively contracting any muscles to create the movement) to left lower extremity and to apply Ankle-foot orthosis (AFO, brace that's worn around the foot, ankle, and lower leg to help stabilize and support the area) up to 4 hours as tolerated by the resident, every day, five times a week. During an interview on 12/23/2024 at 3:15 p.m. with Resident 3, Resident 3 stated she had not received RNA services in a couple of months. Resident 3 stated she was not getting the exercises and the splint on her feet. During a concurrent interview on 12/23/2024 at 3:18 p.m. with RNA 1 and Resident 3, RNA 1 stated she was not familiar with Resident 3. Resident 3 stated she had not seen RNA 1 before, and she had not received any services from her. During an interview on 12/26/2024 at 1:25 p.m. with Resident 3, Resident 3 stated today was the first day in long time they provided her exercises. Resident 3 stated the RNA did not place the splint on her foot. Resident 3 stated if RNA services were provided every day, she would have gotten better already. During a concurrent observation, interview and record review on 12/26/2024 at 4:32 p.m. with RNA 1, Resident 3 ' s Documentation Survey Report v2 (document), dated 12/2024 was reviewed. RNA 1 stated the box in the document dated 12/13/2024 and 12/20/2024 for every shift (Qshift) were blank. RNA 1 stated she was off on those days (12/13/2024 and 12/20/2024) and did not know if an RNA had worked. RNA 1 stated if it was not documented it was not done. RNA 1 stated she had not placed Resident 3 ' s AFO for about a week. RNA 1 stated not using the AFO could lead to worsening of foot drop (condition that makes it difficult to lift the front of the foot). RNA 1 stated she was the only RNA assigned today 12/26/2024 and did not know how many residents were assigned for RNA services. RNA 1 stated she could not get to every single resident because there were too many to see in one day. 3). During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 had diagnoses including cerebral infarction (lack of oxygen due to disruption in blood flow in an area of the brain) affecting left non-dominant side and muscle weakness. During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 usually understands and be understood by others. The MDS indicated Resident 2 required moderate assistance with eating, and was dependent with oral hygiene, toileting hygiene, shower/bathing, dressing and personal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 2 of 4 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 12/26/2024 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 0684 hygiene. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2 ' s care plan, titled At Risk for Decline with ROM on right upper (RUE) extremity, dated 8/6/2024, the interventions indicated for RNA to do RUE PROM exercises every day five times a week, as tolerated by resident; apply right elbow and right resting hand splint up to 4 hours or as tolerated. Residents Affected - Few During an interview on 12/23/2024 at 2:55 p.m., Resident 2 stated he did not receive RNA exercises 5 times a week. Resident 2 stated he only received RNA services about three times a week. 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 the facility should provide residents ' services necessary to maintain good personal and oral hygiene to residents who were unable to carry out ADL. During a review of the facility ' s P&P titled Restorative Nursing Programs, undated, the P&P indicated the facility shall ensure residents receive appropriate restorative programs. The P&P indicated the restorative nurse assistant shall be scheduled for specific restorative and rehabilitative duties by the Director of Nursing, or designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 3 of 4 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 12/26/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe storage of two tube feeding formula bottles for one of three sampled residents (Resident 3.) This deficient practice had the potential for other residents to access and drink the formula and cause adverse reactions like diarrhea or upset stomach. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including hemiplegia (severe or complete loss of strength) and hemiparesis (mild loss of strength) following cerebral infarction (lack of oxygen due to disruption in blood flow in an area of the brain) affecting left non-dominant side and adult failure to thrive (a state of overall decline that may be caused by chronic diseases and functional impairments). During a reviewof Resident 3 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 11/15/24, the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required set up assistance with eating, moderate assistance with oral hygiene, dependent with, toileting hygiene, shower, dressing, and putting on/taking off footwear and maximal assistance with personal hygiene. During a reviewof Resident 3 ' s care plan, titled On Gastric Tube (a tube surgically inserted into the stomach through the abdomen to administer food, liquids, and medicine) feeding ., dated 6/19/2023, the interventions indicated the facility would administer enteral feedings as ordered. During a concurrent observation and interview on 12/26/2024 at 4:30 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 noted two (2) bottles of Jevity (brand name of tube feeding formula) on top of Resident 3 ' s bedside table. LVN 1 stated the tube feeding bottles should not have been left at the resident ' s bedside table as other residents could drink them and cause diarrhea or upset stomach. LVN 1 stated tube feedings were prescribed by the physician and should be treated as medication. LVN 1 stated, the tube feeding bottles should have been stored in an area where temperature and lights were in controlled condition. During a review of the facility ' s policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, dated 11/2018, the P&P indicated the facility should store unopened liquid enteral formulas in temperature and light-controlled conditions (cool, away from direct sunlight). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 4 of 4