Health inspection·December 15, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility. The DT stated updating and documenting changes were important for other staff to be aware of resident preferences, and failure to document could result in confusion and residents not receiving requested meals. During a review of Resident 1's Care Plan Report dated 11/19/2025, the Care Plan Report indicated no person-centered care plan was developed with goals and interventions addressing Resident 1 changes in food preferences or how the preferences would be met.During an interview on 12/15/2025 at 4:20 p.m., with Director of Nursing (DON), the DON stated care plan is a road map for staff to follow, and interdisciplinary team develop care plan to ensure the resident's needs and preferences were addressed and communicated to all staff for consistent care. The DON stated if care plan was not developed, communicated or followed, staff may provide inconsistent care, resulting in unmet needs or preferences.During a review of facility's policy and procedures (P&P) titled, Individualized Care Planning undated, the P&P indicated Each resident's care plan is developed and maintained as a dynamic, person-centered document based on comprehensive assessment findings and interdisciplinary input.Individualized care planning is informed by initial and ongoing assessments, clinical observations, resident and representative input, and interdisciplinary discussion.Resident choices, cultural considerations, and expressed preferences are incorporated into the care plan to the extent practicable and clinically appropriate. Refusal of care or preferences that differ from recommendations are documented and addressed through alternative approaches and education when indicated.Leadership and designated clinical staff oversee adherence to individualized care planning practices through routine review, education, and quality activities to support consistent resident-focused care. 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 12/15/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure food preferences were honored for one of three sampled residents (Resident 1).This deficient practice resulted in Resident 1 not consistently receiving his preferred meals and had the potential to affect Resident 1's nutritional intake and satisfaction with meals. Findings:During a review of Resident 1's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 7/9/2025 and was readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anxiety disorder (feeling of fear, dread, and uneasiness that interferes with daily life), and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing pr witnessing a traumatic event).During a review of Resident 1's History and Physical (H&P), dated 7/15/2025, the H&P indicated the resident had a fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/16/2025, the MDS indicated Resident 1 had intact cognition (ability to think and understand). The MDS indicated Resident 1 was independent for eating, dressing, and toileting hygiene. The MDS indicated Resident 1 needed supervision from staff for personal hygiene and bathing.During a review of Resident 1's Physician Order dated 11/14/2025, the Physician Order indicated an order of regular no added salt, regular texture, thin consistency, vegetarian diet, no meat, may have pancake, French toast, banana and peanut butter jelly at breakfast.During an interview on 12/15/2025 at 12:11 p.m., with Resident 1, Resident 1 stated the meals he received were inconsistent with his diet plan on multiple occasions. Resident 1 stated he completed the dietary request form during the week of 11/24/2025 to 11/29/2025, however on two occasions (11/25/2025 and 11/27/2025), he did not receive the requested egg with tuna sandwich for lunch and was told by kitchen staff there were no eggs available. Resident 1 stated he stopped completing the dietary request forms because the kitchen did not consistently follow his requests. Resident 1 stated he had meeting with the Administrator, Social Worker (SW) and Dietary Technician (DT) on 12/1/2025 regarding his meal plan, however on two subsequent occasions on 12/1/2025 and 12/5/2025 he continued to receive meals inconsistent with his food preferences, including shredded chicken and meat patty for lunch. During a concurrent interview and record review on 12/15/2025 at 1:34 p.m., with Dietary Technician (DT), Resident 1's Physician Order for 11/2025, Dietary Request Forms for 11/21/2025-11/29/2025 and Nutrition/Dietary Food Preference for 7/10/2025 were reviewed. The DT stated resident food preferences were assessed upon admission and quarterly, then forwarded to Dietary Supervisor (DS) to be entered on the meal ticket. The DT stated resident preferences would be honored whenever changes occurred and communicated to the kitchen. The DT stated Resident 1 had changes in his food preferences, which were verbally communicated to the kitchen as needed. The DT stated there was no documentation indicating an update to Resident 1's Nutrition/Dietary Food Preference since his admission to the facility. The DT stated updating and documenting changes were important for other staff to be aware of resident preferences, and failure to document could result in confusion and residents not receiving requested meals. During an interview on 12/15/2025 at 3:43 p.m., with Assistant Dietary Manager (ADM), the ADM stated dietary was responsible for documenting changes in resident food preferences and following up to ensure food preferences were provided. The ADM stated changes should be documented so all staff are informed and for consistency. The ADM stated failure to document changes in resident food preferences can result in residents not receiving preferred meals. During an interview on 12/15/2025 at 4:20 p.m., with Director of Nursing (DON), the DON stated (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 12/15/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents' food preferences were assessed upon admission by nursing, with dietary completing an assessment and follow up. The DON stated having documentation to ensure communication with all staff was important and failure to maintain written communication would likely result in residents not receiving preferred meals and lead to poor appetite and weight loss.During a review of facility's policy and procedures (P&P) titled, Policy Food Preferences undated, the P&P indicated Facility will honor and document individual resident food preferences to the fullest extent possible while maintaining physician-ordered dietary restrictions and promoting nutritional well-being.Facility will assess resident food preferences upon admission and as part of quarterly reviews or when there is a significant change in condition. Preferences will include cultural, religious, ethical, and personal dietary choices. Dietary staff will use documented preferences when preparing meals and will offer alternate selections when preferred foods are not available or contraindicated. Communication of changes to dietary preferences will be documented and shared with dietary services promptly. Residents or families may update preferences at any time by informing nursing or dietary staff. Event ID: Facility ID: 055952 If continuation sheet Page 4 of 4