Health inspection·February 6, 2026

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few appropriate discharge planning and the subsequent discharge of Resident 1 to a lower level of care without the permission of Resident ‘s Conservator and where Resident 1's needs could not be met. On 2/6/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the IJRP's implementation through observation, interview, and record review, the IJ was removed on 2/6/2026 at 3:40 p.m., in the presence of the facility's DON and Social Services Director (SSD). Non-compliance of F-627 remained at the scope and severity of D no actual harm with potential for more than minimal harm that is not immediate jeopardy The facility's IJRP included the following immediate actions:Resident-Specific Interventions On February 2/5/2026, Director of Nursing (DON), Designee in collaboration with the DON, conducted an immediate clinical review of Resident 1's status in collaboration with the general acute care hospital (GACH) including medication reconciliation and continuity of care. Current Resident 1 status on 2/5/2026 at acute hospital based on records did not appear to meet inpatient admission criteria and does not appear to require psychiatric hospitalization (medical facility providing 24/7 inpatient care for patient with severe mental health disorders) or to be an immediate danger to self and others at this time. The IDT including Social Service, Director of Rehabilitation (DOR), DON, Assistant Director of Nursing (ADON)/Quality Assurance (QA) Nurse, Director of Staff Development (DSD) and Minimum Data Set Nurse (MDSN) met on 2/6/2026 and review root cause ( process to identify the causes of problems or adverse events) and analysis to ensure a safe discharge planning were compliant and meet the criteria of the discharge protocol. Facility-Wide Resident Safety SweepOn 2/5/2026, the Interdisciplinary Team (Social Services Director, Director of Nursing, and Assistant Director of Nursing) conducted a review of 85 resident discharges occurring between 1/1/2026 and 1/31/2026. Of these, 15 residents were identified as having been discharged to a lower level of care, including home, Independent Living Facilities (ILF), Assisted Living Facilities (ALF), Residential Care Facilities for the Elderly (RCFE), and Recuperative Care Center. The review includes but not limited to the following: 1.Appropriate level of care determination2.Interdisciplinary Team (Social Service Director (SSD), Nursing, Therapy, Dietary) involvement 3.Legal representative notification/consent 4.Safe discharge destination 5.Medication Reconciliation and Continuity A review of 15 residents discharged to a lower level of care revealed one discrepancy involving Resident 1. No discrepancies were found for the other residents, who were all discharged safely to the community. Licensed nursing staff will notify the Social Services Director (SSD) of all resident discharges. Beginning 2/5/2026, discharge information is communicated to the SSD and reviewed during the weekly discharge planning meeting. The review includes assessment of cognitive impairment, elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) risk, behavioral symptoms, conservatorship or legal representative involvement, and discharge planning. Any identified variances are corrected immediately. Compliance with the discharge review process is sustained through interdisciplinary oversight, routine monitoring, and leadership accountability. Licensed nursing staff notify the Social Services Director (SSD) of all planned and unplanned discharges. Discharges are reviewed during the weekly interdisciplinary discharge planning meeting to ensure appropriate level of care, resident safety, legal representative involvement, and continuity of care. The Director of Nursing (DON) or designee provides final authorization prior to discharge. During weekends or when the SSD and DON are not physically present in the building, the Nursing Supervisor reviews discharge documentation, confirms completion of required steps, and notifies the SSD and DON for follow-up review. Discharge audits are completed routinely and reviewed through the Quality Assurance and Performance Improvement (QAPI- proactive approach to quality improvement) program. Any identified (continued on next page) 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 02/06/2026 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few variances are corrected immediately. Systemic Corrections ImplementedHard Stop Discharge Protocol (Effective Immediately)The Hard Stop Discharge Protocol was implemented effective immediately and initiated as a standardized checklist by the Interdisciplinary Team (IDT), including the Social Services Director (SSD), Director of Rehabilitation (DOR), Director of Nursing (DON), Dietary Services Supervisor (DSS), and Quality Assurance (QA). On 2/5/2026, the IDT reviewed and implemented this process. The IDT is responsible for completing and verifying all required elements of the discharge checklist, including interdisciplinary discharge planning, clinical readiness and safety, receiving provider or facility coordination, guardian or responsible party involvement, regulatory and program-specific requirements, notice and documentation, final review and authorization, handoff report to the receiving facility, and post-discharge follow-up as a best practice for risk mitigation. No resident may be discharged until all checklist steps are completed. All planned discharges, including those to Residential Care Facilities for the Elderly (RCFE), Assisted Living Facilities (ALF), Independent Living Facilities (ILF), and Recuperative Care, require final approval by the Administrator or Director of Nursing. Discharge planning begins at baseline admission and is reviewed at least 30 days prior to the projected discharge, again seven days prior to discharge, and prior to the day of discharge. During weekends or when IDT leadership is not physically present, the Nursing Supervisor or Administrator designee ensures checklist completion and communicates any outstanding items to the SSD and DON for follow-up. Compliance with the Hard Stop Discharge Protocol is reviewed during the weekly discharge planning meeting. Medical Records conducts ongoing audits of discharge documentation and reports findings to the DON. Any discrepancies identified are corrected timely. The checklist is as follows: 1. QA Nurse will be responsible for Resident Assessment & Participation 2. Interdisciplinary Team (IDT) Social Services Director (SSD), Director of Rehabilitation (DOR), Director of Nursing (DON), Dietary Services Supervisor (DSS), and Quality Assurance (QA). Will be responsible for reviewing discharge planning 3. DON/QA/DON Designee will be responsible for reviewing Clinical Readiness and Safety 4. Licensed nursing staff are responsible for communicating and providing a complete handoff to the receiving provider or facility at the time of discharge. This includes reviewing the resident's clinical status, medications, care needs, and any follow-up requirements to ensure a safe transition of care. Documentation of the handoff is maintained in the resident's medical record. 5. As part of the Hard Stop Discharge Protocol, the Social Services Director (SSD) and licensed nursing staff are responsible for notifying the resident's guardian or responsible party regarding discharge planning. They provide information on the resident's options for discharge destinations, including home, Residential Care Facilities for the Elderly (RCFE), Assisted Living Facilities (ALF), Independent Living Facilities (ILF), and Recuperative Care, and ensure the responsible party's preferences and consent are documented in the medical record. 6. The Social Services Director (SSD) is responsible for all resident discharge notices and documentation. This includes notifying the resident and/or guardian or responsible party, documenting the discharge plan, recording the resident's or guardian's choice of discharge destination (home, RCFE, ALF, ILF, or Recuperative Care), maintaining all related forms and communications in the medical record, and ensuring timely completion in compliance with regulatory requirements. 7. The Nursing Supervisor or licensed nursing staff are responsible for providing a complete handoff report to the receiving facility at the time of discharge. This report includes the residents' clinical status, medications, care needs, behavioral considerations, and any follow-up requirements to ensure a safe and seamless transition. Documentation of the handoff is maintained in the resident's medical record. 8. The SSD is responsible for post-discharge follow-up as the best practice and risk mitigation measure. This includes contacting the resident and/or guardian or (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 02/06/2026 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few responsible party after discharge to ensure the resident has safely arrived at the receiving setting, confirming that care needs and medications are being appropriately managed, identifying any emerging concerns, and documenting all follow-up actions in the medical record. A wellness check follow-up call is completed within 72 hours of discharge to verify the resident's safety, address any questions or issues, and provide additional support as needed. All planned discharges are subject to the approval of the Administrator or DON upon completion of the steps above. Staff EducationThe governing body provided in-service training on the Policy of Safe Discharge Planning to the Director of Nursing (DON) and Administrator on 2/6/2026. This training included review of the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety considerations, and compliance monitoring to ensure safe and regulated discharge practices. The governing body conducted a 1:1 in-service and competency validation with the Social Services Director (SSD) to review the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety requirements, and documentation expectations. All licensed nurses, Social Services staff, and Interdisciplinary Team (IDT) members were educated on CMS discharge requirements, resident rights, safe transitions of care, documentation expectations, legal representative notification, and high-risk discharge criteria. Training is provided by the Director of Nursing and Social Services Director, and attendance is documented in maintained logs. New hires receive this training during orientation from the DON to ensure ongoing compliance.Monitoring to Ensure Ongoing ComplianceAll resident discharges are audited by Medical Records using the Hard Stop Discharge Checklist. Audits are conducted daily for the first 2 weeks, weekly for the following 4 weeks, and monthly thereafter through the QAPI program to ensure ongoing compliance. The audit tool includes: a. Interdisciplinary Team (IDT) participation b. Level of care validationconsent documentation d. Medication reconciliation e. Safe destination confirmation On the day of discharge, the Licensed Nurse provides a complete report and handoff to the receiving facility prior to resident transfer. Medical Records reviews audit findings and reports results to the DON, ADON, and Quality Assurance (QA) team. Any identified discrepancies are corrected in a timely manner. Results reported to QAPI Committee by Director of Nursing and Social Service Director. 4. Quality Assurance & Performance Improvement (QAPI)The discharge process has been incorporated into the facility's QAPI program.An emergency QAPI meeting was held on 2/6/2026 to address the Immediate Jeopardy situation, with a follow-up scheduled for the next QAPI meeting on 2/10/82026Key actions include:Tracking and trending discharge variancesIdentifying root causesImplementing corrective actionsReporting findings to leadership Performance Goal: Achieve 100% compliance with discharge procedures.Findings: Resident 1's admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizoaffective disorder bipolar type, unspecified psychosis seizures, anemia (a condition where the body does not have enough healthy red blood cells), and anxiety disorder. The Face Sheet indicated Resident 1's Conservator was her Responsible Party (RP). During a review of Resident 1's Elopement Risk assessment dated [DATE], the Elopement Risk Assessment indicated Resident 1 was a high risk for elopement. During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 1 had a balance problem while standing, walking and a decreased muscular coordination. During a review of Resident 1's Social Services Discharge Plan dated 11/10/2025 and timed at 2:46 p.m., the Social Services Discharge Plan indicated Resident 1 came from a homeless environment and might need additional help once discharged home with the support of her Conservator. During a review of Resident 1's IDT Conference notes dated 11/14/25, the IDT Conference notes indicated Resident 1's Conservator attended the IDT meeting via telephone and there was no discharge (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 02/06/2026 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few planning discussed during the meeting. The IDT Conference Notes indicated the bed hold policy and discharge plan would be reviewed with Resident 1's Responsible Party (RP)/Conservator. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/19/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 1 was dependent (helper does all the effort and the resident makes none of effort to complete the activity) on staff to complete her activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily) Resident 1 did not have the ability to ambulate. The MDS indicated had no functional limitation in range of motion (ROM- is the extent of movement of a joint, measured in degrees of a circle) for upper and lower extremity. During a review of Resident 1's Physician's Order dated 1/28/2026 the Physician's Order indicated to discharge Resident 1 to RCC. During a review of Resident 1's Progress Note dated 1/28/2026 and timed at 1:20 p.m., the Progress Note indicated Resident 1 was discharged from the facility and picked up by an emergency transport team (EMT) personnel. The Progress Note indicated prior to Resident 1's departure, all standard safety checks were completed, including identity verification, confirmation of transfer destination, ensuring all necessary documents were attached to the transfer packet and securing the resident safely on a gurney (hospital bed with wheels) with straps. It also indicated Resident 1 was transferred to the RCC and a voice mail was sent to Resident 1's conservator notifying them of Resident 1's transfer. During a telephone interview on 2/3/2026 at 8:18 a.m., the Lead Coordinator at the GACH stated Resident 1 was found wandering in the streets on 1/30/2026, at 3:39 a.m. (approximately 9.1 miles from the RCC) with no shoes on, by the Fire Department and transferred to the GACH. During a review of Resident 1's Emergency Medical Service (EMS) Report dated 1/30/2026, the EMS report indicated Resident 1 was found wandering around the street, not alert or oriented, wearing a helmet with insect eggs all over her clothes and hands. The report indicated Resident 1 was transported to a GACH. During a review of the GACH's admission Record (Emergency Documentation), dated 1/30/2026, the Emergency Documentation indicated Resident 1 was admitted to the GACH on 1/30/2026 with active diagnoses of acute psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and altered mental status ([AMS] a changed level of awareness or mental state that falls short of unconsciousness). During an interview on 2/3/2026 at 9:37 a.m., Social Services Staff (SSS) 1 stated Resident 1 was conserved under a Public Guardian and was discharged from the facility to a RCC on 1/28/2026. SSS 1 stated the facility did not discuss the discharge planning and Resident 1's transfer to the RCC, with Resident 1's Conservator. SSS 1 stated the facility should have discussed Resident 1's discharge plan and subsequent discharge prior to Resident 1's discharge on [DATE]. SSS 1 stated no IDT meeting was held related to Resident 1's discharge plan prior to Resident 1's discharge. SSS 1 stated this was the first time she used this RCC. During an interview on 2/3/2026 at 10:47 a.m., the Director of Nursing (DON) stated Resident 1 was [AGE] years old, impulsive (the tendency to act or react quickly without planning, forethought, or consideration of potential consequences), had a one to one (a safety intervention where a dedicated staff member is assigned to monitor a single patient at all times), due to her fall risk, from the time of her admission [DATE]) until she was discharged (1/28/2026), she had no rehabilitation potential and did not meet the skill criteria needed to remain at the facility. The DON stated Resident 1 required a lower level of care where her medications would be managed, so she (DON) met with SSS 1, and the decision was made to transfer Resident 1 to the RCC. The DON stated Resident 1's physician was notified and an order obtained to discharge Resident 1 to the RCC for 24-hour care. The DON stated Resident 1's Conservator was not involved in Resident 1's discharge (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 02/06/2026 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete planning or discharge and there was no IDT meeting conducted related to Resident 1's discharge plan/discharge. The DON stated the facility should have waited for authorization from Resident 1's public guardian before discharging the resident to another level of care. During an interview on 2/3/2026 at 12:41 p.m., Resident 1's Conservator stated she visited Resident 1 in the facility (date unknown) and discussed transferring Resident 1 to a locked facility with SSS 1, but SSS1 never followed up with her regarding Resident 1's transfer. The Conservator stated she was responsible for making decisions for Resident 1 and the facility should not have transferred Resident 1 to another facility without her knowledge, involvement and approval, or the approval of someone else in the Public Guardian's office if she was not available. The Conservator stated Resident 1 was a Regional center client who had a mental disability and was developmentally delayed (a child not reaching developmental milestone compared to others of the same age). The Conservator stated transferring Resident 1 to an inappropriate facility placed the resident at risk for neglect and harm. During an interview on 2/3/2026 at 1:52p.m., Certified Nurse Assistant (CNA) 1 stated Resident 1 was alert to person only, could follow instructions, had a one to one sitter, required assistance getting dressed, and could not be left alone because she (Resident 1) was a high risk for falls and a wanderer (when a person with cognitive challenges leaves a safe place and walk away where they can be endangered and cannot trace back). During an interview on 2/4/2026, at 3:38 p.m., with Licensed Vocational Nurse, (LVN) 1 stated to discharge a resident out of the facility, the licensed nurse was to obtain a physician's discharge order, perform a skin assessment, notify the resident's family or conservator, prepare discharge paperwork, print the face sheet and medication summary, and contact the receiving facility. LVN 1 stated these steps were not fully completed during Resident 1's discharge to the RCC. LVN 1 stated he was unable to communicate with the conservator or the receiving facility. LVN 1 stated the conservator should have been informed and provided consent prior to Resident 1's discharge to ensure Resident 1's safety. Resident 1 was oriented only to self and lacked awareness of environment, place, and person, making the discharge unsafe without the conservator's consent. LVN 1 stated he did not communicate with the receiving nurse, did not perform medication reconciliation, and did not endorse Resident 1's medical history to the receiving facility. He stated paperwork was handed to the EMT personnel at the time of discharge. LVN 1 stated he failed to verify the type of setting at the RCC to ensure it could meet Resident 1's needs. LVN 1 stated these failures placed Resident 1 at risk for illness, hospitalization, and life-threatening complications. During a review of facility's undated Policy and Procedure (P&P) titled, Discharge Planning the P&P indicated the Social Service Director, or Designee shall be involved in discharge planning to ensure a safe discharge and successful transition to the next level of care or return to home. The Social Service Director or Designee will work with the IDT, physician, resident, and the resident's representative on the following: a. Discharge planning services (e.g. helping to place a resident on a waiting list for community congregate living, arranging intake for home care services for residents returning home, assisting with transfer arrangements to other facilities), and document in the resident's medical record efforts to involve the resident in discharge planning and efforts to create a successful transition of care. b. Changes to the discharge plan will be discussed with the resident and, if indicated, the resident's representative and documented in the resident's medical record. Event ID: Facility ID: 056433 If continuation sheet Page 6 of 6