Health inspection·March 26, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 complete a change of condition (CIC/COC- noticeable shift or alteration in a patient's physical, mental, or functional stated, requiring attention and potentially promoting further medical evaluation or intervention) evaluation for three out of five residents when Resident 2, Resident 3, and Resident 5 were exposed to Coronavirus disease ([COVID 19] an infectious disease caused by the SARS-SoV-2 virus). Residents Affected - Some This failure has the potential to result in missing identification of potential symptoms or complications, risking the health and safety of the residents. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 12/27/2024 with diagnosis including Hemophilus influenzae (a type of bacteria that can cause various infections, especially in children, ranging from mild ear infections to serious illnesses like meningitis) During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 1/3/2025, indicated Resident 2 was cognitively (functions your brain uses to think, pay attention, process information, and remember things) intact. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort to complete task) with oral hygiene, setup or clean-up assistance with eating, dependent (helper does all the effort) with toileting hygiene and showering. During a review of Resident 2's Order Summary Report, orders as of 3/26/2025, the Order Summary Report indicated an order for novel respiratory precautions for 10 days due to Covid 19 exposure on 3/19/2025. During a review of Resident 2's Change in Condition evaluation, for the month of March 2025, the CIC evaluation indicated, the facility did not complete the CIC evaluation when Resident 2 was exposed to COVID 19. b. During a review of Resident 3's admission Record, the admission Record indicated the facility readmitted Resident 3 on 2/11/2025 with diagnoses including pneumonia (an infection of the lungs that may be caused by bacteria, viruses, or fungi) and influenza (a highly contagious viral infection that primarily affects the respiratory system). During a review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognitive (functions your brain uses to think, pay attention, process information, and remember things) skills for daily Page 1 of 4 056433 056433 03/26/2025 Vermont Healthcare Center 22035 S. Vermont Avenue Torrance, CA 90502

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some decision making was severely impaired. The MDS indicated Resident 3 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, showering and personal hygiene. During a review of Resident 3's Order Summary Report, orders as of 3/26/2025, the Order Summary Report indicated an order for novel respiratory precautions for 10 days due to Covid 19 exposure on 3/19/25. During a review of Resident 3's Change in Condition evaluation, for the month of March 2025, the CIC evaluation indicated, the facility did not complete the CIC evaluation when Resident 3 was exposed to COVID 19. c. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 3/11/2024 with diagnoses including chronic respiratory failure (your lungs can not effectively exchange oxygen and carbon dioxide over a long period, leading to low oxygen and high [NAME] dioxide levels in your blood) and pneumonia (an infection of the lungs that may be caused by bacteria, viruses, or fungi). During a review of Resident 5's MDS, dated [DATE], indicated Resident 5 had moderately impaired cognitive (functions your brain uses to think, pay attention, process information, and remember things). The MDS indicated Resident 5 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, showing and personal hygiene. During a review of Resident 5's Order Summary Report, orders as of 3/26/2025, the Order Summary Report indicated an order for novel respiratory precautions for 10 days due to Covid 19 exposure on 3/19/2025. During a review of Resident 5's Change in Condition evaluation, for the month of March 2025, the CIC evaluation indicated, the facility did not complete the CIC evaluation when Resident 5 was exposed to COVID 19. During a concurrent interview and record review on 3/26/2025 at 11:44 a.m. with RN 1, Change in Condition Evaluation, dated for the month of March. RN 1 stated that there was no CIC evaluation for Resident 2,3 and 5. RN 1 stated that the facility should complete a CIC when Resident 2, 3 and 5 was exposed to COVID 19, including the first 72 hours of monitoring. During an interview on 3/26/2025 at 1:33 p.m. with the Director of Nursing (DON), the DON stated that if a resident is exposed to COVID-19, It is considered as a significant change in condition and requires completing a CIC evaluation as part of the proper protocol. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's condition or status, revised February 2014, the P&P indicated, the nurse supervisor/ charge nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. 056433 Page 2 of 4 056433 03/26/2025 Vermont Healthcare Center 22035 S. Vermont Avenue Torrance, CA 90502

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to wear proper personal protective equipment ([PPE] specialized clothing and equipment like gloves, gown, masks, and eye protection, used to create a barrier between healthcare workers and potential sources of infection) prior to entering the rooms of three out of five sampled residents (Resident 6, Resident 7 and Resident 8), which were designated as Novel Respiratory Precaution room. Residents Affected - Some a. Housekeeping (HK) 1, Certified Nurse Aid (CNA) 1 entered Resident 6 and Resident 7's room without proper PPE. b. one Charge Nurse (CN) 1 entered Resident 8's room without proper PPE. These failures have the potential to result in an increased number of transmitted diseases in the facility, adding to the total accumulation of Coronavirus disease ([COVID 19] an infectious disease caused by the SARS-SoV-2 virus) cases among resident 28 and staff 25 over the previous two weeks. Findings: a. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 10/19/2018, with diagnosis including asthma (a chronic lung condition that causes inflammation and narrowing of the airways). During a review of Resident 6's Minimum Data Set ([MDS] a resident assessment tool), dated 12/23/2024, indicated Resident 6 had severely impaired cognitive (functions your brain uses to think, pay attention, process information, and remember things). The MDS indicated Resident 6 required maximal assistance (helper does more than half the effort to complete task) with eating, oral hygiene, personal hygiene, dependent (helper does all the effort) with toileting hygiene and showering. During a review of Resident 6's Order Summary Report, orders as of 3/26/2025, the Order Summary Report indicated an order for novel respiratory precautions for 10 days per COVID-19 exposure on 3/19/2025. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 12/12/2022, with diagnosis including chronic kidney disease (your kidneys are damages and cannot filter blood effectively, leading to waste buildup and other health problems). During a review of Resident 7's MDS, dated [DATE], indicated Resident 7 was cognitively intact. The MDS indicated Resident 7 required moderate assistance with toileting hygiene, showering, personal hygiene, setup or clean-up assistance with eating and oral hygiene. During a review of Resident 7's Order Summary Report, orders as of 3/26/2025, the Order Summary Report indicated an order for novel respiratory precautions for 10 days per COVID 19 exposure on 3/19/2025. During a concurrent observation and interview on 3/25/2025 at 11:59 a.m. with HK 1, in front of Resident 6 and Resident 7's room, Novel Respiratory Precaution sign was observed on the door, HK 1 entered the room wearing only a mask while Resident 6 and Resident 7 remained in the room. HK 1 stated 056433 Page 3 of 4 056433 03/26/2025 Vermont Healthcare Center 22035 S. Vermont Avenue Torrance, CA 90502

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that staff must wear a gown, eye protection, filtered mask and gloves upon entering a Novel Respiratory precaution room to prevent the spread of infection. HK 1 also stated that she did not wear eye protection, gloves, and a gown because she did not touch anything and was only picking trash. During a concurrent observation and interview on 3/25/2025 at 12:04 p.m. with CNA 1, in front of Resident 6 and Resident 7's room, observed CNA 1 entering the room holding a lunch tray and wearing a mask while Resident 6 and Resident 7 remained in the room. CNA 1 stated that staff required to wear a gown, eye protection, filtered mask and gloves upon entering a precaution room. CNA 1 also stated that he did not wear a gown, eye protection, and gloves because he was not providing direct patient care. b. During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 11/18/2024, with diagnosis including chronic obstructive pulmonary disease (a group of lung disease that damage the airways and lungs, making it difficult to breathe). During a review of Resident 8's MDS, dated [DATE], indicated Resident 8 was cognitively intact. The MDS indicated Resident 8 required maximal assistance with toileting hygiene, personal hygiene, dependent with showering and setup or clean-up assistance with eating. During a review of Resident 8's Order Summary Report, orders as of 3/26/2025, the Order Summary Report indicated an order for novel respiratory precautions for 10 days due to COVID exposure on 3/19/2025. During a concurrent observation and interview on 3/25/2025 at 2:14 p.m. in front of Resident 8's door, observed CN 1 touching and adjusting Resident 8's wheelchair between the door and Resident 8's bed while wearing only a mask, with Resident 8 remaining next to the wheelchair. CN 1 stated that she wore mask only without other necessary PPE. CN 1 also stated that she should be wearing full PPE, not just the mask. During an interview on 3/25/2025 at 3:00 p.m. with the infection preventionist (IP), the IP stated that Novel Respiratory Precaution required contact and droplet isolation which required staff to wear a filtered mask, a gown, eye protection, gloves upon entering the room every time. During an interview on 3/26/2025 at 2:20 p.m. with the Director of Nursing (DON), the DON stated that staff must wear a full PPE each time they enter the novel respiratory precaution room, including a gown, a mask, gloves and eye protections such as a face-shield or goggles. During a review of the facility's policy and procedure (P&P) titled, isolation-categories of transmission-based precautions, revised October 2018, the P&P indicated, staff required to wear gloves, a disposable gown upon entering the room for contact isolation, wear masks, gloves, gown and goggles upon entering the room for droplet isolation. 056433 Page 4 of 4