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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056433 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 07/31/2025 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)