Inspection·May 21, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that when there is an abuse allegation we are to report within two hours even if the resident is confused, start the investigation, and take care of Resident 4 as fast as possible. The SSD stated not initiating the investigation sooner could make Resident 4 feel dismissed and cause psychological harm. During an interview on 5/21/2025 at 4:00 p.m. with the Administrator (ADM), the ADM stated the staff is to report Abuse of any kind. The ADM stated the process is to report anytime the staff suspects, hears anything, and they are to report within 2 hours. The ADM stated it was important to report within 2 hours to prevent the behavior from continuing which could cause more abuse. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 3/2023, the P&P indicated all reports of resident abuse findings of all investigations are documented and reported. The P&P indicated abuse was suspected it must be reported immediately to the administrator and to other officials. The P&P indicated immediately is defined as within two hours of an allegation involving abuse. 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 05/21/2025 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 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility licensed staff failed to ensure the Medical Director (a licensed physician who oversees and manages the medical aspects of a healthcare organization or facility) was notified after licensed staff could not reach the primary physician for one out of three sampled residents (Resident 1). This deficient practice resulted in facility staff had to call 911 to transport the resident to the General Acute Care Hospital (GACH) . Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (COPD, a chronic lung disease causing difficulty in breathing), obstructive uropathy (refers to any condition where the normal flow of urine is blocked or impeded within the urinary tract), and anemia (a condition where the body doesn ' t have enough healthy red blood cells). During a review of Resident 1 ' s History and Physical (H&P), dated 4/22/2025, the H&P indicated Resident 1 did not follow commands, was non-responsive (a patient who is not reacting or responding to external stimuli, such as verbal commands, touch or pian, and non-verbal (communication that conveys messages without using spoken or written words and involves facial expression). During a review of Resident 1 ' s change of conditions (COC) interact assessment form, dated 4/26/2025, the COC indicated at 8:00 p.m. Resident 1 had no significant urine output and to transfer the resident tothe GACH. The COC indicated GACH had no available beds. The COC indicated at 10:00 p.m. the physician was made aware with no reply. The COC indicated Resident 1 blood pressure ([BP] -the force of circulating blood on the walls of the arteries) was 118/72 millimeters of mercury ([mm/hg] -a unit of pressure commonly used to measure blood pressure). During a review of Resident 1 ' s COC, dated 4/27/2025, the COC indicated Resident 1 had hematuria (the presence of blood in the urine) with reduced urine output and an order from the physician to transfer resident to the GACH. The COC indicated Resident 1 could not be transferred to GACH and 911 was called at 8:27 a.m. The COC indicated at 8:38 a.m. the physician was informed of the changes in the transfer plans but no response. The COC indicated the BP was 103/60mmhg. During a review of Resident 1 ' s Minimum Data Set (MDS] a resident assessment tool), dated 5/12/2025 the MDS indicated Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) rarely/never understands. The MDS indicated Resident 1 was dependent (helper does all of the effort. Residents do none of the effort to complete the activity) on staff for showering, toileting hygiene, and dressing. The MDS indicated Resident 1 had an indwelling catheter (a medical device used to drain urine from the bladder and allow it to flow into a collection bag). During a concurrent interview and record review on 5/19/2025 at 4:14 p.m. with Director of Nursing (DON), Resident 1's COC, dated 4/26/2025 and 4/27/2025 was reviewed. The COC dated 4/26/2025 indicated the COC indicated at 8:00 p.m. Resident 1 had no significant urine output and transferred the resident to the GACH. The COC form indicated the GACH had no available beds. The COC indicated at 10:00 (continued on next page) 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 05/21/2025 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 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few p.m. the physician was made aware with no reply. The COC dated 4/27/2025 indicated Resident 1 had hematuria with reduced urinary output and an order from the physician to transfer resident to the GACH. The COC indicated Resident 1 could not be transferred to the GACH and 911 was called at 8:27 a.m. The COC indicated at 8:38 a.m. the physician was informed of the changes in the transfer plans but no response. The DON stated Resident 1 had hematuria in the urine and it was considered a change of condition. The DON stated the physician did not return the licensed staff call on 4/26/2025 p.m. and on 4/27/2025. The DON stated that when the physician did not return our calls the next step was to call the Medical Director. The DON stated the Medical Director was not called from 10:00 p.m. to 8:27 a.m. and there was a lot that could have happened; the resident could have been bleeding from somewhere in the body. The DON stated 911 was called because the physician did not return our call, and the blood pressure had dropped from 118/72 mm/hg to 103/60 mm/hg. During a telephone interview on 5/20/2025 at 2:25 p.m. with the Medical Director, the Medical Director stated staff should have called him if the primary physician did not return their call. The Medical Director stated the facility can call anytime of the day or night if the physician does not call back. The Medical Director stated the facility needed to have followed the protocol once the physician had not returned their call and the resident is not doing well. During a review of facility ' s policy and procedures (P&P) titled, Change of Condition, date unknown, the P&P indicated the facility is to ensure proper assessment and follow through for any resident with change of condition. The P&P indicated upon a change of condition for any reason, nursing staff members are to take the following if for some reason physician cannot be reached, alternative physician shall be contacted. The P&P indicated if alternate cannot be reached, the Medical Director is to be contacted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555719 If continuation sheet Page 4 of 4