Health inspection·May 1, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few record used by a licensed nurse to document medications given to a resident) dated 10/2024, the MAR indicated Resident 1 had a pain level rated eight out of 10 and was administered Tylenol Extra Strength 30 mL on 10/20/2024 at 5:20 p.m. During a concurrent interview and record review on 4/28/2025 at 2:54 p.m., with the Director of Nursing (DON), Resident 1's Pain Assessment Flow Sheet dated 10/20/2024 was reviewed. The Pain Assessment Tool indicated LVN 1 administered Tylenol Extra Strength 30 for mL to Resident 1 for pain to her tracheostomy stoma site. The DON stated LVN 1 documented Resident 1 had pain at her tracheostomy stoma site rated at an eight out of 10 but she could not find documentation that LVN 1 notified Resident 1's physician of Resident 1's pain. During an interview on 4/28/2025 at 3:51 p.m., Respiratory Therapist (RT) 1 stated he should have been notified of Resident 1's pain to her tracheostomy stoma site. RT 1 stated he would have notified Resident 1's physician for instructions for Resident 1's care. During a interview on 4/29/2025 at 1:32 p.m., LVN 1 stated Resident 1 reported she was having pain to her tracheostomy stoma site and she (LVN 1) administered Tylenol Extra Strength 30 mL to her but stated she did not notify Resident 1's physician of her pain because she did not notice the pain order said to notify the physician. During a review of the facility 's Policy and Procedure (P&P) titled, Change of Condition revised 4/2013, the P&P indicated if a resident has a change of condition the physicians shall be called promptly, and the licensed nurses shall complete a binder sheet. This sheet will list the resident's name, room number, reason for change and the start and end state of the License Nurse's observation and charting on all shifts. The staff will reassess the individual's pain and its consequences at regular intervals. For example, at least each shift. The attending physician will adjust pain interventions as indicated. During a review of the facility's undated License Vocational Nurse/Charge Nurse Job Description the Job Description indicated that part of their duties included notifying the subacute resident's attending physician and next of kin when there is a change in the subacute resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056433 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 056433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vermont Healthcare Center 22035 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 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 the resident, who had a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs), did not fall and sustain an injury during transfer from bed to a shower chair for one of three sampled residents (Resident 2). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 4) and Restorative Nursing Assistant (RNA) 1 used a mechanical lift (a device used to safely move and transfer individuals who have limited mobility, especially those who cannot bear weight independently) to transfer Resident 2 from a bed to a shower chair as recommended by the Physical Therapy (PT) department. 2. Develop a care plan for Resident 2's mode of transfer between surfaces with an intervention to prevent the resident's injury. 3. Ensure staff followed the facility's policy and procedure (P/P) titled, Total Mechanical Lift dated 9/29/2016, which indicated a mechanical lift is used to appropriately facilitate transfers of residents. 4. Ensure staff followed facility's P/P titled, Falls Prevention Program revised 2/2025, which indicated staff from all departments will be expected to contribute to the efforts of fall prevention for their residents. As a result of this deficient practice, Resident 2 sustained an acute (severe and sudden in onset) minimally displaced impacted (a fracture [broken bone] where the broken bone fragments are compressed together but the degree they are out of alignment is small) distal (sites located away from a specific area, most often the center of the body) fracture of the left femur (thigh bone) when she had an assisted fall (a fall in which a staff member was with the resident and attempted to minimize theimpact of a fall by slowing by slowing the resident's descent) while being transferred from a bed to a shower chair by CNA 4 and RNA 1 without using a mechanical lift. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of paraplegia. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 4/22/2025, the MDS indicated Resident 2 had no cognitive (thought process) impairment. The MDS indicated Resident 2's functional abilities to both her lower extremities (legs) were impaired, and she was dependent (helper does all of the effort, resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity) for toileting hygiene, shower/bathe and chair/bed to chair transfers. During a review of Resident 2's History and Physical (H&P), dated 4/15/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056433 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 056433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vermont Healthcare Center 22035 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 0689 Level of Harm - Actual harm Residents Affected - Few During a review of Resident 2's Physical Therapy (PT) Evaluation and Plan of Treatment, dated 4/16/2025, the PT Evaluation and Plan of Treatment indicated Resident 2 presented with balance deficits, decreased dynamic balance (the ability to maintain a stable posture and control movements while the body is in motion), decreased static balance (the ability to maintain an upright posture and keep the center of gravity within the limits of the base of support while standing or sitting still), gross motor (physical abilities involving large muscle groups and body movements, such as walking, running, jumping, and climbing) coordination deficits, pain, strength impairment, deficits in judgment and limitations in range of motion ([ROM] the direction a joint can move to its full potential). The PT Evaluation and Plan of Treatment indicated Resident 2 was totally dependent on transfers and with bed mobility. The PT Evaluation and Plan of Treatment indicated a recommendation for Resident 2 to use a mechanical lift during transfers. During a review of Resident 2's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 4/16/2025, the OT Evaluation and Plan of Treatment indicated Resident 2 presented with a decrease in activity tolerance affecting her ability to safely perform and complete self-care activities safely with her activities of daily living ([ADLs] (activities such as bathing, dressing and toileting a person performs daily) due to decreased activity tolerance, decrease strength, and decrease sitting tolerance. During a review of Resident 2's Change of Condition (COC) form, dated 4/19/2025, the COC indicated Resident 2 was observed sitting on the floor following an assisted fall. The COC indicated Resident 2 complained of pain to her left breast rated six out of 10 on a pain scale (an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). The COC indicated Resident 2 was medicated with Acetaminophen Extra Strength 500 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount)for moderate pain. During a review of Resident 2's Skin assessment dated [DATE], the Skin Assessment indicated Resident 2 had slight swelling to her left knee and her left knee was warm to touch. During a review of Resident 2's COC dated 4/24/2025, the COC form, indicated Resident 2 complained of a five out of 10 pain level to her left knee. The COC indicated Resident 2's physician was notified and an order for an X-Ray (a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) to Resident 2's left knee was given. During a review of Resident 2's Physician's Order dated 4/24/2025, the Physician's Order indicated to obtain an X-ray of Resident 2's left knee due to pain and swelling. During a review of Resident 2's Radiology (the branch of medicine that uses imaging technology to diagnose and treat disease) Report dated 4/24/2025, the Radiology Report indicated Resident 2 sustained an acute minimally displaced impacted fracture to her distal left femur. During an interview on 4/30/2025 at 10:36 a.m., Registered Nurse Supervisor (RNS) 2 stated, CNA 4 reported that Resident 2 had an assisted fall on 4/19/2025. RNS 2 stated on 4/19/2025, when she (RNS 2) entered Resident 2's room she found Resident 2 sitting on the floor. RNS 2 stated CNA 4 reported that she (CNA 4) and RNA 1 attempted to transfer Resident 2 from her bed to a shower chair without using a mechanical lift. RNS 2 stated she was not aware that Resident 2 refused to be transferred using the mechanical lift. RNS 2 stated CNA 4 and RNA 1 should have used a mechanical lift to transfer Resident 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056433 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 056433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vermont Healthcare Center 22035 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 0689 Level of Harm - Actual harm Residents Affected - Few During a telephone interview on 4/30/2025 at 10:57 a.m., CNA 4 stated on 4/19/2025, Resident 2 requested to be transferred from her bed to a shower chair using a mechanical lift. CNA 4 stated she had to look for a mechanical lift and sling (a flexible strap or belt used in the form of a loop to support or raise a weight), but Resident 2 did not want to wait and insisted on being transferred without using a mechanical lift. CNA 4 stated she asked RNA 1 to assist with Resident 2's transfer. CNA 4 stated when they attempted to transfer Resident 2, they realized she was too heavy, and they assisted her to the floor. CNA 4 stated for safety Resident 2 should have been transferred using a mechanical lift. During an interview on 4/30/2025 at 11:59 a.m., Resident 2 stated staff would usually transfer her by using a mechanical lift but on 4/19/2025 she insisted that CNA 4 transfer her from her bed to a shower chair without it because the sling hurts her back and she did not want to use the mechanical lift. Resident 2 stated during the transfer RNA 1 placed his (RNA 1) hand under her (Resident 2) left arm and at the same time put pressure on her left breast causing her pain. Resident 2 stated she screamed put me down, put me down! and she was assisted to the floor by CNA 4 and RNA 1. Resident 2 stated when she was on the floor, she noticed her left leg was twisted backwards and asked CNA 4 to place her leg forward. During an interview on 4/30/2025 at 12:48 p.m., RNA 1 stated on 4/19/2024 CNA 4 asked him to assist her with Resident 2's transfer from her bed to a shower chair. RNA 1 stated, during the transfer Resident 2 started leaning forward and they (CNA 4 and RNA 1) could not hold her up, so they sat her on the floor and requested help. RNA 1 stated he knew Resident 2 used a mechanical lift for transfers, but Resident 2 was in a hurry and insisted they not use the mechanical lift. RNA 1 stated if given the opportunity to redo the transfer he would have used the mechanical lift for the safety of the resident. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 3 on 4/30/2025 at 1:16 p.m., LVN 3 stated on 4/19/2025 CNA 4 called her and RNS 2 to Resident 2's room and they (LVN 3 and RNS 2) both found Resident 2 sitting on the floor. LVN 3 stated Resident 2 should have been transferred using a mechanical lift and if Resident 2 refused to be transferred using the mechanical lift, CNA 4 and RNA 1 should have notified her (LVN 3) and/or RNS 2. During an interview on 5/1/2025 at 9:25 a.m., the Director of Nursing (DON) stated because of Resident 2's diagnosis of paraplegia, a Care Plan did not have to be created with an intervention to use a mechanical lift when transferring Resident 2. The DON stated the recommendation from the Rehabilitation Department to use a mechanical lift when transferring Resident 2 should have been enough for the staff and the nurses should have followed PT's recommendation to use the mechanical lift to prevent Resident 2 from falling and sustaining an injury. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 5/1/2025 at 12:10 p.m., Resident 2's OT/PT Evaluation and a Plan of Treatment dated 4/16/2025 was reviewed. The OT/PT Evaluation and Plan of Treatment indicated Resident 2 was placed on the high risk for falls list and based on the evaluation and plan of treatment Resident 2 was required to be transferred using a mechanical lift. The DOR stated the nursing staff should have followed the recommendation from the OT/PT to use a mechanical lift when transferring Resident 2 to prevent Resident 2 from falling. The DOR stated the rehabilitation department communicates the residents' needs verbally and via their OT/PT evaluation to the nursing staff and they should have been aware of the recommendation to transfer Resident 2 using a mechanical lift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056433 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 056433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vermont Healthcare Center 22035 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's Policy and Procedure (P/P), titled, Falls Prevention Program revised 2/2025, the P/P indicated staff from all departments will be expected to contribute to the efforts of fall prevention for their residents. During a review of the facility's P/P, titled, Total Mechanical Lift dated 9/29/2016, the P/P indicated that a mechanical lift is used to appropriately facilitate transfers of residents. Event ID: Facility ID: 056433 If continuation sheet Page 6 of 6