Health inspection·June 10, 2025

F 0684 done. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 10:50 a.m., RN 3 stated FM 1 called her on [DATE] sometime around 6:30 a.m., and requested to hold Resident 1's Tacrolimus because Resident 1 had an appointment, and a blood test was going to be done. RN 3 stated she endorsed FM 1's request to LVN 1 but she (RN 3) did not call Resident 1's physician to obtain an order to hold Resident 1's medication. RN 3 stated she should have notified Resident 1's physician and obtained an order to hold the medication because she was unable to hold the medication without the physician's order. Residents Affected - Few During an interview on [DATE] at 2:50 p.m., Resident 1's physician stated he should have been notified of FM 1's request to hold Resident 1's Tacrolimus so he could have given an order to hold the medication if appropriate. Resident 1's physician stated Tacrolimus was a drug to prevent lung transplant rejection and there was a risk of lung rejection if not taken as prescribed. During a review of the facility's undated Policy and Procedure (P/P) titled Administering Medications the P/P indicated medications are administered in accordance with prescriber orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056192 If continuation sheet Page 2 of 6 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 056192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Post Acute Care Center 21521 S. Vermont Avenue Torrance, CA 90502 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to recognize severe weight loss that was experienced by one of three sampled residents (Resident 1), when Resident 1 went from 92 pounds (lbs.), on 4/7/2025 to 72.75 lbs. on 5/5/2025 (a weight loss of 19.25 lbs. in less than a month). Residents Affected - Some The facility failed to: 1. Ensure there were no discrepancies in the calculation of the percentage of food Resident 1 consumed between 4/14/2025 and 5/4/2025 when the Weekly Summary Nurse Progress Note indicated Resident 1's food intake was between 51% to 100% versus the Document Survey Report that indicated Resident 1's food intake was 38.9% to 71.4%. 2. Follow Resident 1's Care Plan interventions to monitor Resident 1's weight loss/gain of three lbs. in a week and five lbs. in one month. 3. Notify Resident 1's physician and the facility's Registered Dietician (RD) 1 of Resident 1's poor dietary intake resulting in a severe weight loss of 19.25 lbs. in less than 30 days. 4. Give clear instructions on how to calculate the percentage of food consumed by Resident 1 and other residents. 5. Follow the facility's Policy and Procedure (P/P), titled, Nutritional Screening/Assessment/Resident Care Planning that indicated the facility's RD would be made aware of residents who eat poorly. 6. Follow the facility's P/P, titled, Weight Change Protocol that indicated early identification of a weight problems and possible causes can minimize complications. Residents who experience significant changes in weight or insidious weight loss will be assessed by the facility's RD who will assess, nutritionally diagnose, suggest interventions, monitor, and evaluate the success of the interventions. These deficient practices resulted in Resident 1 experiencing a severe weight loss of 19.75 lbs. in less than 30 days that was unrecognized by facility staff because of a discrepancy in how Resident 1's food intake was documented, which resulted in a delay in care and treatment. Resident 1 was transferred to a General Acute (GACH) where she was diagnosed with failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), severe electrolyte (minerals needed by the body to function) abnormalities, severe protein-calorie malnutrition (occurs when an individual's diet lacks the necessary nutrients needed to maintain health), cachexia (a metabolic condition involving involuntary weight loss due to a loss of muscle and fat mass), and had a nasogastric tube ([NGT] a thin, flexible tube inserted through the nose and down to the stomach to deliver nutrition) was inserted. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including lung transplant status (a surgical procedure where one or both of a resident's diseased or damaged lungs were replaced with healthy lungs from a deceased donor), and diabetes mellitus ([DM] a disorder characterized by difficulty in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056192 If continuation sheet Page 3 of 6 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 056192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Post Acute Care Center 21521 S. Vermont Avenue Torrance, CA 90502 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 0692 blood sugar control and poor wound healing). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's Physician's Orders, dated 2/19/2025, the Physician's Orders indicated a regular texture diet, thin/regular liquids three times a day. Residents Affected - Some During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/25/2025, the MDS indicated Resident 1 had mild cognitive impairment (a brain condition that causes noticeable but mild memory and thinking problems). During a review of Resident 1's Nutritional Review Screening, dated 2/27/2025, the Nutritional Review Screening indicated RD 1 recommended a regular texture diet, thin/regular liquids, with an eight ounce (oz) diabetic high protein nutrition ([HPN] a supplemental shake to aide in meeting the daily protein needs in a resident's diet) shake three times a day. The Nutritional Review Screening indicated Resident 1's estimated caloric needs were 1400-1600 kilocalories ([kcals] a unit of measurement used to measure the energy content of food and beverages) daily. The Nutritional Review Screening indicated Resident 1 had an intake of food/fluid of 51% to 100%, an ideal body weight ([IBW] the weight associated with the lowest risk of mortality for a given height, age, sex, and frame size) of 95 lbs., weighed 90 lbs., and needed to gain weight. During a review of Resident 1's Physician's Orders, dated 2/21/2025, the Physician's Orders indicated Resident 1 was to receive a diabetic HPN shake, eight oz three times a day between meals. During a review of Resident 1's untitled Care Plan, dated 2/21/2025, the Care Plan indicated Resident 1 needed a dietary supplement for weight maintenance. The Care Plan's goal indicated Resident 1 would eat 75-100% of each meal and dietary supplements. The Care Plan's interventions included monitoring Resident 1's weight loss/gain of three lbs. in a week and five lbs. in a month. During a review of Resident 1's Weight Summary, dated 4/7/2025, the Weight Summary indicated Resident 1 weighed 92 lbs. During a review of Resident 1's Weekly Summary Nurse Progress Note, dated 4/20/2025 and timed at 5:01 p.m., the Weekly Summary Nurse Progress Note indicated Resident 1's average meal intake for the week (4/14/2025 - 4/20/2025) was 76% to 100%. During a review of Resident 1's Documentation Survey Report, dated 4/2025, the Documentation Survey Report indicated Resident 1 had a total of 21 meals between 4/14/2025 and 4/20/2025 with an average meal intake of 38.9% to 63.1 % which did not match the 4/20/2025 Weekly Summary Nurse Progress Note that indicated Resident 1's average meal intake was 76-100%. During a review of Resident 1's Weekly Summary Nurse Progress Note, dated 4/28/2025 and timed at 3:29 p.m., the Weekly Summary Nurse Progress Note indicated Resident 1's average meal intake for the week (4/21/2025 - 4/28/2025) was 51%-75%. During a review of Resident 1's Documentation Survey Report, dated 4/2025, the Documentation Survey Report indicated Resident 1 had a total of 21 meals between 4/21/2025 and 4/27/2025 with an average meal intake of 47.4% to 71.4%, which did not match the 4/28/2025 Weekly Summary Nurse Progress Note that indicated Resident 1's average meal intake of 51%-75% for the 21 meals. During a review of Resident 1's Weekly Summary Nurse Progress Note, dated 5/4/2025 and timed at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056192 If continuation sheet Page 4 of 6 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 056192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Post Acute Care Center 21521 S. Vermont Avenue Torrance, CA 90502 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5:36 p.m., the Weekly Summary Nurse Progress Note indicated Resident 1's average meal intake for the week 4/28/2025 -5/4/2025) was 51% to 75%. During a review of Resident 1's Documentation Survey Report, dated 4/2025 through 5/2025, the Documentation Survey Report indicated Resident 1 had a total of 21 meals between 4/28/2025 and 5/4/2025 with an average meal intake of 47.4% to 71.4%, which did not match the 4/28/2025 Weekly Summary Nurse Progress Note that indicated Resident 1's average meal intake for the week was 51% to 75%. During a review of Resident 1's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/2025, the MAR indicated Resident 1 received HPN eight oz three times a day between 4/1/2025 and 4/9/2025, but there was no documentation to indicate the percentage of HPN that Resident 1 consumed. During a review of Resident 1's Physician's Orders, dated 5/5/2025 and timed at 8:54 a.m., the Physician's Order indicated Resident 1 may go out on pass. During a review of Resident 1's Progress Note, dated 5/5/2025 and timed at 9:20 a.m., the Progress Note indicated Resident 1 went out on pass with (FM) 1. During a review of Resident 1's Progress Note, dated 5/5/2025 and timed at 4:49 p.m. the Progress Note indicated FM 1 called the facility and reported Resident 1 was being admitted to the GACH for evaluation due to suspected lung rejection (a condition where the body's immune system attacks the transplanted lung, mistaking it as a foreign body). During a review of the GACH's Conditions of Service Notice, dated 5/5/2025, the Conditions of Service Notice indicated Resident 1 was admitted to the GACH on 5/5/2025 at 11:45 p.m. During a review of the GACH's History and Physical (H&P), dated, 5/6/2025 and timed at 12:30 a.m., the H&P indicated Resident 1 presented with failure to thrive and severe electrolyte abnormalities. During a review of the GACH's Nutritional Assessment, dated 5/6/2025 and timed at 1:44 p.m., the Nutrition Assessment indicated Resident 1 weighed 72.75 lbs. (19.25 lbs. less than her weight of 92 lbs. on 4/7/2025), had a severe protein-calorie malnutrition, and cachexia. During a review of the GACH's Discharge summary, dated [DATE], the Discharge Summary indicated Resident 1 had starvation ketoacidosis (a condition where the body, due to prolonged fasting or inadequate calorie intake, produces excessive ketones [(ketosis) a byproduct of fat breakdown in the body] as an alternative fuel source. Ketosis is a normal response to fasting, starvation ketoacidosis develops when this process is exacerbated, potentially leading to serious health issues) and was placed on an NGT feeding. During an interview on 6/6/2025 at 8:07 a.m., FM 1 stated on 5/5/2025 at approximately 9:30 a.m., she picked up Resident 1 for a follow up appointment for her lung transplant. FM 1 stated Resident 1's lung transplant physician suspected Resident 1 had an infection in her lungs or that her lung transplant was rejecting and planned to admit Resident 1 to the GACH when there was an available bed. FM 1 stated the GACH called her at approximately 10 p.m., (5/5/2025) with an available bed, Resident 1 was admitted to the GACH and diagnosed with dehydration (a condition where the body lacks sufficient water) and was severely malnourished (a poor state of nutrition, where the body does not receive enough essential nutrients, it needs to function properly). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056192 If continuation sheet Page 5 of 6 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 056192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Post Acute Care Center 21521 S. Vermont Avenue Torrance, CA 90502 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 0692 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/9/2025 at 12:02 p.m., The Director of Nursing (DON) stated licensed nurses were responsible for monitoring residents' food intake, the CNAs record the percentage of food eaten by residents' each meal and should report food intake below 50% or refusal to eat to the licensed nurses. The DON stated if a resident ate less than 50% in a week or two, they should notify the resident's physician and RD. Residents Affected - Some During an interview on 6/9/2025 at 2:13 p.m., the Director of Staff Development (DSD) stated if a resident eats less than 50% of a meal the CNA should report that to a licensed nurse, if three meals were missed, the licensed nurses should notify the resident's physician and the RD. During an interview on 6/10/2025 at 11:11 a.m., LVN 2 stated she calculated Resident 1's weekly food intake by adding the percentage of the meals she ate (three meals per day times seven [21 meals]) and divided the total percentage by the number of meals (21). LVN 2 stated the average meal intake for Resident 1 between 4/21/2025 through 4/27/2025 was 48% and was inaccurately documented on the Documentation Survey Report, dated 4/2025. During an interview on 6/10/2025 at 12:05 p.m., The DON stated if Resident 1's meal intake had been accurately calculated to indicate that she was eating less than an average of 50% of her food, Resident 1's Physician and RD 1 should have been notified to obtain care instructions. The DON stated the licensed nurses determine the average meal intake of the residents' each week by looking at the trends of the past meals documented by the CNAs. During an interview on 6/10/2025 at 12:36 p.m., Certified Nursing Assistant (CNA) 3 stated they do not calculate the exact amount of what the resident drank, they only estimate if it is 50% or more based on how heavy the bottle is. CNA 3 stated if it seems the resident drank less than half of the HPN shake, they document the resident did not drink it. If it seems the resident drank more than half of the HPN shake, they document the resident drank all of it. During an interview on 6/10/2025 at 2:50 p.m., Resident 1's physician stated he should have been notified if Resident 1 was experiencing poor food intake, he could have evaluated her medications, ordered labs and possibly had her transferred to the GACH for evaluation and treatment. During a review of the facility's Policy and Procedure (P/P) titled Nutritional Screening/Assessment/Resident Care Planning dated 2023, the P/P indicated the facility Registered Dietitian will be made aware of residents who eat poorly. During a review of facility's undated P/P titled Weight Change Protocol the P/P indicated early identification of a weight problems and possible causes can minimize complications. Residents who experience significant changes in weight or insidious weight loss will be assessed by the facility RD who will assess, nutritionally diagnose, suggest interventions, monitor, and evaluate the success of the interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056192 If continuation sheet Page 6 of 6