Health inspection·July 15, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and 3) were free from physical abuse when Resident 1, who had a history of schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (excessive worry and feelings of fear, dread, and uneasiness), and major depressive disorder ([MDD] a mood disorder that causes a persistent feeling of sadness and loss of interest), suddenly without any provocation, hit Resident 2 on the left side of his face and then proceeded to hit Resident 3 on the right side of his face causing Resident 3 to fall to the floor. Resident 1 was arrested by the local area police. These deficient practices resulted in Resident 2 being transferred to a General Acute Care Hospital (GACH 1) where he was assessed with facial fractures (break in the bone) and Resident 3 being transferred via 911 (emergency services) to GACH 2 where he was treated for facial lacerations that required stitches. Findings During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) MDD and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/23/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired (a level of cognitive decline where individuals experience noticeable difficulties with memory, language judgement, and problem-solving, impacting their ability to manage daily activities independently). The MDS indicated Resident 1 required set up or clean up assistance (helper sets up or cleans up; resident completes activity) to complete activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Psychiatric Evaluation dated 6/24/2025, the Psychiatric Evaluation indicated Resident 1 presented with heightened psychomotor agitation (a state of increased physical activity and restlessness, often accompanied by mental distress or inner tension), marked anxiousness, irritability, uncooperativeness, guarded demeanor (a manner of behavior that is cautious, reserved, and restrained, often indicating a reluctance to [NAME] one's true feelings or thoughts) and restlessness. During a review of Resident 1's Change in Condition (COC) Evaluation dated 6/29/2025, the COC Evaluation indicated Resident 1 without any reason, suddenly hit a resident (Resident 3) who was walking in the hallway. The COC Evaluation indicated Resident 3 was hit on his face causing bleeding to his mouth. The COC Evaluation indicated Resident 1 was redirected to his room and away from others but continued to be physically violent to others. The COC Evaluation indicated 911 was called and Resident 1 was closely watched/guarded by male staff until the local police department arrived at the facility. During a review of Resident 1's Nursing Note dated 6/29/2025, the Nursing Note indicated Resident 1 was taken into custody by a local Page 1 of 3 055952 055952 07/15/2025 Torrance Care Center West, Inc 4333 Torrance Blvd Torrance, CA 90503

F 0600 Level of Harm - Actual harm Residents Affected - Few area police department. During a review of Resident 2's Face Sheet, the Face Sheet, indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia (a chronic mental health disorder characterized by persistent delusions (having false or unrealistic beliefs), hallucinations (to see, hear, feel, or smell something that does not exist), and paranoia (an extreme fear and distrust of others). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired The MDS indicated Resident 2 required supervision or touch assistance (helper provides verbal cues and or touching/steadying and/or contact guard assistance as resident completes activity) to complete his ADLs. During a review of Resident 2's COC Evaluation dated 6/29/2025, the COC Evaluation indicated Resident 2 was walking in the hallway when Resident 1 suddenly hit him on his left cheek without any provocation. The COC Evaluation indicated Resident 2's skin below his left eye was discolored, an ice pack was applied, neuro checks were initiated, and Resident 2 was closely monitored. During a review of Resident 2's physician order dated 6/29/2025, the physician order indicated to transfer Resident 2 to a GACH for further evaluation. During a review of Resident 2's Face Sheet, from GACH 1, the Face Sheet indicated Resident 2 was admitted to GACH 1 on 6/30/2025, after being transferred from GACH 2's emergency room (ER) where he was initially transported after the assault on 6/29/2025. During a review of Resident 2's GACH 1 Department of Emergency Medicine History of Present Illness, dated 6/30/2025, the History of Present Illness indicated Resident 2 was transferred from GACH 2 following an assault. The report indicated a Computed Tomography Scan ([CT scan] medical imaging that uses x-rays (a form of electromagnetic radiation that can penetrate most objects) was conducted. During a review of Resident 2's CT scan dated 6/30/2025, the CT scan indicated the following: 1. A fracture of the left zygomatic arch (the upper jawbone and cheek). 2. A fracture of the left lateral orbital wall (the outer wall of the eye socket, side of the eye), which is slightly angled medially (a position that points toward the middle of the body) 3. A fracture of the left malar eminence (the cheekbone). 4. A commuted fracture (a type of fracture where the bone breaks into multiple pieces of there or more) of the anterior (nearer the front) and posterior (further back in position) lateral wall of the left maxillary sinus (on the left side of the nose) as well as the left orbital floor (the bottom of the eye socket). 5. A fracture of the posterior left nasal bone as well as the anterior left nasal bone with associated paranasal (near or alongside the nasal cavity) soft tissue swelling During a review of the Department of Emergency Medicine Medical Decision Making note, the Medical Decision Making note indicated for Resident 2 to follow up with Oral Maxillofacial Surgery (a surgical specialty focused on the diagnosis and treatment of diseases, injuries, and defects of the head, neck, face, and jaws) and to schedule an appointment as soon as possible for a visit in two days. During an interview on 7/15/2025 at 11:27 a.m., Resident 2 stated he was standing in the hallway by the double doors, outside Resident 1's room, when Resident 1 hit him on the left side of his face. Resident 2 stated after Resident 1 hit him in his face he (Resident 2) was taken to GACH 2. Resident 2 stated Resident 1 also hit another resident (Resident 3), who was also standing in the hallway immediately after hitting him (Resident 2). During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis of MDD, and anxiety. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was intact. During a review of Resident 3's COC dated 6/29/2025, the COC indicated Resident 3 was hit by another resident (Resident 1) on his face/cheek and had minimal bleeding to his mouth. The COC indicated Resident 3 was walking in the hallway when Resident 1 suddenly and unprovoked hit him on his face, resulting in Resident 3 landing on the floor and bleeding from his mouth. The COC indicated Resident 3's physician instructed that Resident 3 be transferred to 055952 Page 2 of 3 055952 07/15/2025 Torrance Care Center West, Inc 4333 Torrance Blvd Torrance, CA 90503

F 0600 Level of Harm - Actual harm Residents Affected - Few a GACH via paramedics. During a review of GACH 3's Emergency Department (ED) Provider Note dated 6/29/2025, the ED Provider Note indicated Resident 3 was admitted to GACH 3 on 6/29/2025. The ED Provider Note indicated Resident 3 presented to the ER for evaluation of facial trauma following an assault. The ED Provider Note indicated Resident 3 fell backwards, striking the back of his head, and lost consciousness for several seconds. The ED Provider Note indicated Resident 3 had a small facial laceration to his left cheek, measuring one centimeter ([cm] a unit of measurement) in length, and a laceration to his left lateral lip (measurement unknown), The ED Provider Note indicated Resident 3's facial laceration on his left cheek and mucosa (the moist, inner lining of the mouth) of the mouth were repaired (with stitches). During an interview on 7/15/2025 at 12:10 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 1 was quite tall, not talkative, and only came to the staff when he needed something. CNA 3 stated on 6/29/2025 around breakfast time (exact time unknow), he was at the nursing station when he heard a commotion (a state of confusion and noisy disturbance) and shouting from the area near Resident 1's room. CNA 3 stated when he responded to the commotion, he saw Resident 3 on the floor with facility staff who were assisting him. During an interview on 7/15/2025 at 1:12 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was around the corner from Resident 1's room preparing medications when she heard a commotion and shouting. LVN 2 stated when she responded she found Resident 2 in the hallway near Resident 1's room, holding his face. LVN 2 stated, when Resident 2 was asked what happened, he only stated Resident 1's name. LVN 2 stated she saw Resident 1 standing by his room and she yelled Resident 1's name to get his attention when she saw Resident 3 walk past Resident 1 and Resident 1 hit Resident 3 causing Resident 3 to fall to the floor. LVN 2 stated she screamed for help and other staff came quickly to respond to the commotion. During a telephone interview on 7/15/2025 at 1:31 p.m., with CNA 1, CNA 1 stated she was standing in the hallway and saw Resident 2 standing in the hallway next to Resident 1's room, when suddenly Resident 1 came out of his room and hit Resident 2 in the face. CNA 1 stated she screamed and LVN 2 responded. CNA 1 stated she was helping Resident 2 while LVN 2 was trying to get Resident 1's attention when suddenly Resident 1 hit Resident 3 causing Resident 3 to fall to the floor. During an interview on 7/15/2025 at 2:37 p.m., with the Director of Nursing (DON), the DON stated Resident 1 stepped out of his room and hit Resident 2 and then in a matter of seconds, turned to his left and hit Resident 3. The DON stated Resident 2 and Resident 3 were both transported to separate GACHs following the assault by Resident 1. The DON stated Resident 2 was found to have facial fractures and follow up with an oral surgeon was being done. The DON stated Resident 3 sustained bruises and lacerations to his face and received stitches on the corner of his lip. During a review of the facility's undated Policy and Procedure (P/P) titled Abuse, Neglect, and Exploitation the P/P indicated each resident had the right to be free from abuse. The P/P indicated residents must not be subjected to abuse by anyone, including, but not limited to other residents. 055952 Page 3 of 3