Health inspection·July 31, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who resided at the facility and was transferred to a General Acute Care Hospital (GACH) 2 on 6/23/2025 for evaluation and treatment and was readmitted to the facility on [DATE] after Resident 1 was treated and stabilized at the GACH 1. This deficient practice resulted in Resident 1 remaining at GACH 1 for 3 days after Resident 1 was deemed appropriate to go back to the facility on 7/28/2025. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (medical condition where a part of the brain is damaged or dies due to a lack of blood supply) affecting left dominant side, metabolic encephalopathy (brain dysfunction), and multiple pressure injuries.During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/12/2025, the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort to perform tasks) on activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Physician's Order dated 7/23/2025 at 10:07 a.m., the Physician's Order indicated that Resident 1 will transfer to the GACH for further evaluation and treatment.During a review of Resident 1's Nurse Progress Note dated 7/23/2025 at 12:30 p.m., the Nurse Progress Note indicated Resident 1 was transferred to GACH 2. During a review of the GACH 1 untitled Case management Printout Report, on 7/25/2025 at 9:08 a.m., the orders indicated Resident 1 was to discharge to nursing facility. During a review of Resident 1's GACH 1 record titled, Referral to ombudsman, the record indicated a first failed initial attempt to readmit to the facility was on 7/25/2025. The notes indicated on 7/25/2025 and 7/28/2025 Case Manager (CM) 2, spoke with Marketer 1 who stated the facility had no beds available.During a telephone interview on 7/31/2025 at 10:50 a.m., Marketer 1 stated he notified GACH 1's case manager that the facility had no bed available for Resident 1 on 7/25/2025 and 7/28/2025.During a concurrent interview and record review on 7/31/2025 at 11:17 a.m., with the Director of Nursing (DON), the facility census for 7/25/2025 and 7/28/2025 was reviewed. The DON stated the facility did not have a bed available for Resident 1 on 7/25/2025 but had a bed available for Resident 1 on 7/28/2025. The DON stated Resident 1 should have been readmitted on [DATE] because the facility was Resident 1's home. During a review of the facility's policy and procedure (P/P) titled Bed Holds and Returns, undated, the P/P indicated the resident will be permitted to return to the facility, to his or her previous room (if available) or immediately upon the first availability of a bed in a semi-private room. The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. If there was not an available bed in that part, the Page 1 of 2 056433 056433 07/31/2025 Vermont Healthcare Center 22035 S. Vermont Avenue Torrance, CA 90502

F 0627 resident would be given the option to take an available bed in another distinct part of the facility and return to the previous distinct part when a bed becomes available. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056433 Page 2 of 2