Health inspection·September 15, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 1's concern in a timely manner by filing grievance for her as soon as she found out about the complaint. The SSD stated, she should not have assumed that Resident 1 knew how to file the grievance. The SSD stated it was the resident's right to file the grievance.During an interview on 9/15/2025, at 2:50 p.m., with the Director of Nursing (DON), the DON stated, the SSD should have provided the information regarding how to file grievance and the process of grievance to Resident 1 and family members since there was an ongoing complaint regarding brief change. The DON stated that the residents should know how to file grievance to exercise their rights. During a review of the facility's Policy and Procedure(P&P) titled, Grievance/Concerns, undated, the P&P indicated, The staff shall respond promptly and appropriately to concerns or complaints expressed by residents or their family, friends, or responsible party. Filing of Grievance: Grievances must be submitted to the coordinator or designee within 30 days of becoming aware of the alleged discrimination action. The coordinator or designee shall conduct an investigation of the complaint to determine its validity. The investigation may be informal, but it must be thorough, affording all interested parties/persons an opportunity to submit evidence relevant to the complaint. The coordinator or designee will issue a written decision on the grievance no later than 30 days after its filing.During a review of the facility's Policy and Procedure(P&P) titled, Social Service Director: Job Description, undated, the P&P indicated, Major Duties and Responsibilities: The Social Service Director will assist residents in voicing and obtaining resolution to grievances. The Director will review complaints and grievances made by the resident and make a written report indicating what action(s) were taken to resolve the complaint or grievance. Event ID: Facility ID: 055952 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 055952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Torrance Care Center West, Inc 4333 Torrance Blvd Torrance, CA 90503 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 - Few 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** Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives and interventions to meet the residents' needs for one of three sampled residents (Resident 1) regarding adjustment of the adult brief (a type of absorbent, tabs-style adult diaper designed for moderate to heavy incontinence) fitting.This failure resulted in Resident 1 feeling embarrassed due to the leakage of urine from the improper adjustment of the adult brief and avoiding activities due to uncomfortable fitting of the adult brief.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmission was on 4/17/2025 with diagnoses including cerebral infarction (loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and left above the knee amputation (AKA-surgical removal of the portion of the leg above the knee joint).During a review of Resident 1's History and Physical (H&P), dated 4/17/2025, the H&P indicated, Resident 1 had the capacity (ability) to understand and make decision.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 1 required maximal assistance (Helper does more than half the effort) from two or more staff for bed mobility, transfer, dressing, hygiene, moderate assistance (Helper does less than half the effort) from one staff for bathing, and set up or touching assistance (Helper sets up or cleans up) for eating.During a concurrent observation and interview on 9/15/2025, at 11:25 a.m., with Resident 1 in her room, Resident 1 was wearing green track pants (soft, comfortable trousers, originally designed for athletic activities and warm-ups, now widely worn as casual wear) and her pants were wet. Resident 1's adult brief was crooked to left side. Resident 1 stated, she felt so uncomfortable and irritated because the staff did not know how to adjust her brief. Resident 1 stated, she has been having this issue since the admission. Resident 1 stated some staff were having an attitude when she asked them to change her before leaking. Resident 1 stated, she has been complaining about this issue, but no one did anything for her. Resident 1 stated, she did not participate in activities because she was worried about leakage due to crooked adult brief because of poor application by the staff.During an observation on 9/15/2025, at 11:35 a.m., in Resident 1's room, the Director of Nursing (DON) and Certified Nurse Assistant (CNA) 1 were changing Resident 1's adult brief. DON and CNA 1 had to make multiple adjustments per Resident 1's requests and Resident 1 verbalized her frustration when CNA 1 did not follow her instructions.During an interview on 9/15/2025, at 12:10 p.m., with CNA 1, CNA 1 stated, she understood why Resident 1 was frustrated. CNA 1 stated, she witnessed Resident 1's pants get wet due to poorly applied adult brief on many occasions. CNA 1 stated that Resident 1 refused to go to activities sometimes. CNA 1 stated there was no detailed instruction or intervention to follow how to adjust Resident 1's adult brief. CNA 1 stated, she felt bad for Resident 1.During a concurrent interview and record review on 9/15/2025, at 1:04 p.m., with the Director of Staff Development (DSD), Resident 1's Interdisciplinary Team Meeting (IDT meeting - a collaborative discussion among diverse healthcare professionals to develop, coordinate, and support a patient's care plan, ensuring a comprehensive, person-centered approach) Notes, dated from 4/2025 to 9/2025 were reviewed. There were no specific and resident centered interventions for ongoing Resident 1's adult brief adjustment complaint. The DSD stated that the IDT developed the care plan and its interventions for each resident. The DSD stated that the IDT failed to recommend comprehensive and resident centered interventions for Resident 1's adult brief issue.During a concurrent interview and record review on 9/15/2025, at 1:42 p.m., with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055952 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 055952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Torrance Care Center West, Inc 4333 Torrance Blvd Torrance, CA 90503 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the Minimum Data Set Coordinator (MDSC), Resident 1's Care Plan (CP), revised 8/14/2025, the CP Focus indicated, Resident 1 had aggressive behavior during diaper change. The CP goal indicated, Resident 1 will have no evidence of behavior problems by review date (10/9/2025). The CP Interventions indicated to explain why behavior was inappropriate, approach in a calm manner, and attempt to determine underlying cause. The MDSC stated, Resident 1's care plan goal was not objective and measurable. The MDSC stated that interventions were generic (not specific). The MDSC stated Resident 1's care plan did not address the actual issue of accommodating Resident 1's requests to adjust her adult brief in a comfortable way.During an interview on 9/15/2025, at 2:50 p.m., with the DON, the DON stated, care plans are created to guide the staff on how to care for residents with identified problems. The DON stated, without a care plan with specific interventions, a resident may have a recurrence of an issue or a worsening of a condition. The DON stated, IDT meeting should have developed individualized resident centered care plans and interventions. The DON stated, these interventions should have been implemented and reevaluated for effectiveness. The DON stated that Resident 1's care plan was not specific and individualized due to lack of recommendation from the IDT meeting. The DON stated that Resident 1's adult brief adjustment issue would not be resolved unless specific and resident centered interventions were implemented. The DON stated it might lead to a delay in delivery of care and services.During a review of the facility's Policy and Procedure(P&P) titled, Care Planning-Interdisciplinary Team, undated, the P&P indicated, Policy Statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.During a review of the facility's Policy and Procedure(P&P) titled, Comprehensive Care Plan, undated, the P&P indicated, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. Person-centered care means focusing on the resident as the locus of control and supporting the resident in making their own choices and having control over their daily lives. 2. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. 7. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Event ID: Facility ID: 055952 If continuation sheet Page 4 of 4