Health inspection·March 30, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 5's H&P, dated 2/2/2023, the H&P indicated, Resident 5 was alert, oriented times four (4) (aware of person, place, time, an event). During a review of Resident 5's MDS, dated [DATE], the MDS indicated, Resident 5 had the ability to express ideas and wants and had clear comprehension. The MDS indicated Resident 5 made independent decisions that were reasonable and consistent. During a review of Resident 5's NTR - Notification Form, dated 2/2/2023 the NTR indicated, Resident 5 had an AD, however a copy of it had not been presented to the facility. During a review of Resident 5's PA, dated 2/3/2023, the PA indicated, Resident 5 informed the SW she had an AD at home. The PA indicated, Resident 5's FM would provide a copy of the AD when able. During an interview on 3/28/2023 at 12:23 p.m., with Resident 5, Resident 5 stated she had an AD, but she was not sure if her husband had given a copy to the facility. During an interview on 3/29/2023 at 10:50 a.m., with the Director of Staff Development (DSD), DSD stated, it is the responsibility of the SW and the Registered Nurse (RN) to follow up with a resident's FMs to obtain their ADs and to ensure the ADs are in the resident's medical records. The DSD stated, the facility lacks the appropriate follow up when it comes to obtaining residents ADs, especially when the resident is transferred from the general acute care hospital (GACH). The DSD stated, if a resident report to staff that they have an AD it is important to obtain a copy of it and put it in the resident's medical records to ensure residents receive the appropriate end of life treatment and care. During an interview on 3/29/2023 at 3:12 p.m., with the SW, the SW stated, it was her responsibility to review the medical records of newly admitted residents and if a resident reports to her that they have an AD, she stated, she was responsible for ensuring a physical copy of the AD was obtained. The SW stated, if the AD was not in the resident's chart, she asks the resident to have their FM bring it to the facility. The SW stated, she follows up with the resident regarding their AD during her SW visit with each resident. The SW stated, Resident 3, 5, and 9 informed her during their initial PA that they have ADs, but stated she forgot to follow up on getting a copy of it. The SW stated it was important to have the resident's AD so staff can know the residents end of life wishes. During a review of the facility's Policy and Procedure (P/P), titled, Advance Directives for Health Care, dated 1/1/2020, the P/P indicated the facility supports a patient's right to participate actively in health care decision-making. Through education and inquiry about advance directives, patients will be encouraged to communicate their preferences and values to others. If an advance health care directive has been completed, staff during the patient's admission will request a copy, scan it, and place it in the patient's medical record under advanced directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555599 If continuation sheet Page 2 of 10 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 555599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Torrance Memorial Med Ctr Snf/Dp 3330 West Lomita Blvd Torrance, CA 90505 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 ensure two out of 16 sampled residents (121 and 122) had access to the call light with prompt response from the nursing staff to provide assistance with toileting in a timely manner. Residents Affected - Some These deficient practices resulted in Resident 121 and 122 being left without assistance when they requested help to the restroom. Resident 121, who was on spinal precautions (efforts to prevent movement of the spine in those with a risk of spine injury) following back surgery, and required assistance to the restroom, went on his own when he could get no one to help him, and twisted his back causing him pain. Resident 122 who was alert and continent (able to control the elimination of urine and feces) was embarrassed when after requesting assistance to the restroom and didn't receive it, had an accident in bed. These deficient practices had the potential to cause falls, injury, and pain. Findings: a. During a review of Resident 121's Face Sheet, the Face Sheet indicated Resident 121 was admitted to the facility on [DATE] with a diagnosis of lumbar spondylosis (age related breakdown of vertebrae and disks of the lower back). During a review of Resident 121's Physician Orders (PO) dated 3/22/2023, the POs indicated for Resident 121 to get out of bed with assistance and use of a front wheel walker ([FWW] a device used to aid walking, provides extra stability for those experiencing issues with mobility). The PO indicated to administer Bisacodyl ([laxative] a medication used to facilitate evacuation of the bowels) 10 milligrams ([mg] a unit of measurement), one suppository (A form of medicine contained in a small piece of solid material, that melts at body temperature) via rectum (final section of the large intestine, terminating at the anus) every 12 hours as needed for constipation. During a review of Resident 121's Occupational Therapy (OT) Inpatient Evaluation (OTIE), dated 3/23/2023, the OTIE indicated Resident 121's current level of function post-surgery was max assistance with lower extremity (legs, ankles, and feet) and minimal assistance with transfers. The OTIE indicated Resident 121's current OT impairments or limitations was basic activity of daily living ([ADL] task such as eating, bathing, dressing, grooming and toileting) deficits, endurance (ability to sustain a prolonged effort or activity) deficits, and mobility (ability to move freely and easily) deficits. During a review of Resident 121's OT daily documentation, dated 3/24/2023, the OT notes indicated Resident 121 was on spinal precautions and required supervision and a FWW for toilet transfers. During a review of Resident 121's Medication Administration Record (MAR), the MAR indicated Resident 121 received a Bisacodyl 10 mg suppository at 5:32 p.m., on 3/24/2023. During a review of Resident 121's Nursing Progress Notes (NPN) dated 3/24/2023, and timed at 8:02 p.m., the NPNs indicated at 7 p.m., Resident 121 reported he went to the restroom by himself because his call light fell on the floor. The NPNs indicated, Resident 121 reported he called a number that was written on his white board (communication board between staff and residents) for assistance and the person who answered told him they would be there, but no one came. The NPNs indicated, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555599 If continuation sheet Page 3 of 10 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 555599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Torrance Memorial Med Ctr Snf/Dp 3330 West Lomita Blvd Torrance, CA 90505 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 121 twisted his back as he proceeded to the restroom by himself and when he got to the restroom, he pulled the call light string for help, but no one came. During an interview on 3/28/2023 at 10:05 a.m., and a subsequent interview on 3/29/2023 at 3:20 p.m., Resident 121 stated he had been constipated for about six days and was given a laxative and a suppository. Resident 121 stated when he had to go to the restroom after receiving the suppository, he tried calling for help by using the call light button and then he called the phone extension that was written on his white board, but no one came to assist him. Resident 121 stated he got up by himself because he really had to use the restroom, but his FWW was not close to him, so he walked along the wall to the restroom that was located on the other side of the room. Resident 121 stated, when he got to the restroom he pulled the call light string, and stated he sat there for what felt like 40 minutes. Resident 121 stated, when he turned to clean himself, he twisted his back and stated, twisting like that following back surgery was very painful. Resident 121 stated, when a nurse finally came to assist him back to bed, she apologized for not helping him sooner and stated it was shift change. Resident 121 stated this made him very upset that he called for help, and no one came, and he was scared he could have reinjured his back. During an interview on 3/29/2023 at 2:32 p.m., RN 2 stated the incident with Resident 121 happened during change of shift on 3/24/2023 and when she came to work the next day (3/25/2023) Resident 121 was still very upset when she talked to him. RN 2 stated, getting report at change of shift was not a good reason not to answer a call light to help residents. RN 2 stated the importance of answering call lights is for resident safety, especially for Resident 121 to prevent further injury to his spine after surgery. RN 2 stated Resident 121 required assistance for ambulation and toileting. During an interview on 3/30/2023 at 7:24 a.m., CNA 2 stated on 3/24/2023 she was feeding another resident and when she finished, she saw the purple call light blinking in the hallway for the room of Resident 121. CNA 2 stated when she entered Resident 121's room, there were two CNAs assisting Resident 121 back to bed, but they were having a hard time getting Resident 121 in bed due to pain in his back that happened when he twisted his back when he was cleaning himself. CNA 2 stated Resident 121 was not supposed to turn and wipe himself due to his spinal surgery and stated when the call light system has a purple blinking light, it means the resident needs help in the restroom. During an interview on 3/30/2023 at 3:01 a.m., the Director of Nursing (DON) stated it is urgent and important to answer call lights promptly even at change of shift, especially for Resident 121 because of his spinal precautions. b. During a review of Resident 122's Face Sheet, the Face Sheet indicated Resident 122 was admitted to the facility on [DATE] with a diagnosis of right total hip replacement. During a review of Resident 122's Care Plan (CP) dated 3/11/2023, the CP indicated Resident 122 was at risk for self-care deficits, goals for Resident 122 indicated for her to function at optimal levels for ADLs, and Interventions included supervising Resident 122 during ambulation with a FWW and to provide Resident 122 with assistance with ADLs. During a review of Resident 122's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/17/2023, the MDS indicated Resident 122 had the ability to be understood and to understand others. The MDS indicated, Resident 122 required one-person and/or two-person physical assist with transferring, walking, and toileting. The MDS indicated, Resident 122 was not steady moving on and off the toilet and was only able to stabilize with staff assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555599 If continuation sheet Page 4 of 10 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 555599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Torrance Memorial Med Ctr Snf/Dp 3330 West Lomita Blvd Torrance, CA 90505 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 122's MAR, dated 3/27/2023 and timed at 8:59 a.m., the MAR indicated, Resident 122 received Docusate Sodium (a laxative or stool softener) 100 mg. twice per day. During a review of Resident 122's Bowel and Bladder Detailed Entry Report (BBDER) dated 3/27/2023 and timed at 12:41 p.m., the BBDER indicated, Resident 122 had an extra-large incontinent (not able to control urine or bowels) bowel movement. The BBDER indicated Resident 122 was continent of bowel functions from 3/11/2023 to 3/29/2023. During an interview on 3/30/2023 at 9:14 a.m., Resident 122 stated on Monday 3/27/2023 she took a laxative and after finishing breakfast she pressed her call button for assistance to use the restroom. Resident 122 stated, a nurse (name unknown) came in and assisted her roommate (Resident 117), Resident 122 stated she informed the nurse she was the one who called for help and told the nurse Oh please help me, my stomach is gurgling, and I need to go to the bathroom right now. Resident 122 stated, the nurse told her she would go call someone to help her (this nurse was not assigned to Resident 122). Resident 122 stated, she informed the nurse she would not be able to hold her bowels and if the nurse could please help her, but the nurse proceeded to leave the room. Resident 122 stated, she had an accident in bed and was very embarrassed because she was continent of bowels. Resident 122 stated her CNA (CNA 1) was feeding another resident at the time and had to come and clean her up afterwards. During an interview on 3/30/2023 at 9:16 a.m., Resident 200 (Resident 122's roommate) stated she witnessed the nurse come in and help their other roommate (Resident 117) but when Resident 122 informed the nurse it was her that called for help, the nurse said she would go call someone else to help Resident 122 to the bathroom. Resident 200 stated she felt bad because Resident 122 was so embarrassed when she had an accident in bed and staff had to clean her. During an interview on 3/30/2023 at 9:27 a.m., CNA 1 stated Resident 122 was very alert and continent, but she did remember one time that week, having to clean Resident 122 due to an incontinent bowel movement. During an interview on 3/30/2023 at 3:01 p.m., the DON, stated if a resident pressed the call light, the expectation was that any nurse could help the resident and they do not have to be assigned to that resident. During a review of the facility's policy and procedure (P/P), titled Standard of Professional Performance-Physical Comfort, Hygiene, and Activities of Daily Living, revised 2/2020, the P/P indicated, the standard for hygiene was to provide hygiene assistance according to patient conditions, needs, and ability to provide for self. The standard for ADLs was to provide the patient opportunities to meet their needs for bowel and bladder elimination. During a review of the facility's P/P titled, Call Lights revised 3/2022, the P/P indicated every resident was to have immediate access to the call light and the staff phone number was to be provided on the white board for immediate access by telephone. Staff was to respond to call lights in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555599 If continuation sheet Page 5 of 10 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 555599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Torrance Memorial Med Ctr Snf/Dp 3330 West Lomita Blvd Torrance, CA 90505 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 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 observation, interview, and record review, the facility failed to ensure a physician's order was obtained for the care of a nephrostomy tube (a tube placed in the kidney to drain urine directly from kidney) for one of sampled residents (Resident 117) out of a total sample size of 16 residents. Residents Affected - Some As a result of this deficient practice Resident 117's nephrostomy dressing was changed every five to six days and had the potential for infection to develop, skin break down and inconsistency of care. Findings: During a review of Resident 117's Registration Record (Face Sheet), the Face Sheet indicated Resident 117 was admitted to the facility on [DATE] with diagnoses including pyelonephritis (bacterial infection causing inflammation of the kidneys) and sepsis (the body's overwhelming and life-threatening response to an infection which can lead to tissue damage, organ failure, and death). During a review of Resident 117's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/25/2023, the MDS indicated Resident 117 had the ability to understand and be understood by others. The MDS indicated Resident 117 was able to make independent decisions that were reasonable and consistent The MDS indicated Resident 117 had a diagnosis of other artificial openings of urinary tract status. During an observation and concurrent interview with Registered Nurse 3 (RN 3) on 3/29/2023 at 12:40 p.m., Resident 117's nephrostomy dressing was observed with RN 3 present. RN 3 stated, Resident 117's dressing was dated 3/24/2023 (dressing changed five days prior). RN 3 stated, dressing changes are done on an as needed (PRN) basis. During an interview on 3/30/2023 at 10:01 a.m., RN 3 stated, when she realized Resident 117's nephrostomy tube dressing was dated, 3/24/2023, she looked for a physician's order for the dressing change but could not find one. RN 3 stated she called Resident 117's physician and obtained an order on 3/29/2023 (11 days after Resident 117 was admitted ) to apply a dry Mepilex (brand of dressing) dressing and to change the dressing every three days and PRN if soiled (dirty). RN 3 stated, her process for residents who have lines and tubes, is to monitor them every shift, to make sure the site is clean and to change the dressing as PRN. RN 3 stated, it was important to have a doctor's order for nephrostomy tube care, so nurses had a reminder to check the dressing and the site as ordered but acknowledged the order was not there until 3/29/2023. During an interview and concurrent record review with RN 2 on 3/30/2023 at 11:31 a.m., Resident 117's Electronic Medical Record (EMR) indicated Resident 117's nephrostomy tube dressing was changed on admission to the facility (3/18/2023), on 3/24/2023 (6 days after admission) and on 3/29/2023. RN 2 stated the facility's policy was to provide nephrostomy tube care every shift and confirmed there was no order for the care of Resident 117's nephrostomy tube until 3/29/2023. RN 2 stated orders for dressing changes were necessary and upon admission to the facility, the admitting nurse should have realized there was no order for a dressing change and should have called Resident 117's physician to obtain an order. RN 2 stated, dressing changes for nephrostomy tubes are important to prevent infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555599 If continuation sheet Page 6 of 10 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 555599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Torrance Memorial Med Ctr Snf/Dp 3330 West Lomita Blvd Torrance, CA 90505 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/30/2023 at 3:28 p.m., the Director of Nursing (DON) stated there should be orders from the physician for residents that require nephrostomy tube dressing changes, and the expectation is for nurses to call the admitting physician to obtain an order if one was not present on admission. The DON stated it was important to check the nephrostomy tube site and dressing to ensure the nephrostomy tube and dressing were intact to prevent infections. The DON stated the facility's procedure guide indicated the nephrostomy site dressing should be changed daily or per the physician's order. During a review of the Facility's procedure guide (PG) titled, Nephrostomy and Cystostomy Tube Dressing Changes, revised 11/28/2022, the PB indicated, nurses are to change the nephrostomy dressings daily and as needed if soiled. Complications associated with nephrostomy tube dressing changes may include increased risk for infection, skin irritation and skin breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555599 If continuation sheet Page 7 of 10 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 555599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Torrance Memorial Med Ctr Snf/Dp 3330 West Lomita Blvd Torrance, CA 90505 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure [NAME] 1 (CK 1) performed hand hygiene (washed and/or sanitized hands) after removing his gloves and before putting on a new set of gloves during tray line (a system of food preparation) on six different occasions. This deficient practice resulted in hands being unclean and had the potential to transmit infectious microorganisms (agents that can produce disease) and increase the risk of cross contamination and food borne illness. Findings: During an observation on 3/29/2023 at 12 p.m., in the kitchen during tray line preparation, CK 1 prepared a lunch plate on the main tray line, proceeded to place a plate of food on the Transitional Care Unit ([TCU] a short-term care unit) tray line, removed his gloves, and donned (put on) a new pair of gloves without washing his hands. During an observation on 3/29/2023 at 12:04 p.m., 12:09 p.m., 12:16 p.m., and 12:24 p.m., in the kitchen during tray line preparation, CK 1 removed his gloves and donned a new pair of gloves without washing his hands. During an observation on 3/29/2023 at 12:12 p.m., in the kitchen during tray line preparation, CK 1 removed his gloves, opened the door on the upright food warmer, removed a plate with toast, placed the plate on the TCU tray line, and donned a new pair of gloves without washing his hands. During an observation and concurrent interview on 3/29/2023 at 12:20 p.m., with the Director of Clinical Nutrition (DCN) in the kitchen during tray line preparation, CK 1 removed his gloves and donned a new pair of gloves without washing his hands. The DCN stated, staff must wash their hands after removing gloves and before applying new gloves. The DCN stated, all dietary staff were aware of the facility's policy on hand hygiene and it was the normal practice for staff to wash their hands after removing gloves. During an interview on 3/29/2023 at 12:31 p.m., with CK 1, CK 1 stated, the steam tables designated for the TCU were down, so he had to prepare the TCU plates on the main tray line and take the plate to the TCU tray line for completion. CK 1 stated, he normally wore the same gloves during tray line preparation, but was told by his colleague, he must remove his gloves whenever he leaves the main tray line. CK 1 stated, he was aware he must wash his hands after removing his gloves. CK 1 stated hand washing was important to prevent cross contamination, and not washing his hands can cause residents to get sick with food borne illness and experience nausea, vomiting, and diarrhea. During an interview on 3/29/2023 at 12:40 p.m., with the DCN, the DCN stated, staff must always wash their hands after removing gloves. Hand hygiene is important to prevent cross contamination in the kitchen which can lead to residents developing food borne illnesses. During a review of the facility's policy and procedure (P&P), titled, Infection Prevention, Hand Hygiene, dated 2021, the P&P indicated, hand hygiene is to be performed immediately before and after glove use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555599 If continuation sheet Page 8 of 10 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 555599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Torrance Memorial Med Ctr Snf/Dp 3330 West Lomita Blvd Torrance, CA 90505 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 ensure three of five sampled residents (Resident 1, 5, and 79) were offered the pneumococcal vaccine ([PNA] a vaccine that prevents the most common and severe forms of pneumonia). Residents Affected - Some This deficient practice placed Residents 1, 5, and 79 at higher risk of acquiring pneumonia. Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE], with a diagnoses of left lower extremity (leg) osteomyelitis (bone infection). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 3/6/2023, the MDS indicated, Resident 1 had the ability to express ideas and wants, had clear comprehension (capability of understanding something) and was up to date with his PNA vaccine. During a review of Resident 1's admission History Form (AHF), dated 2/27/2023, the AHF indicated, Resident 1 previously received the PNA vaccine. Continued review of the AHF indicated there was no date documented for Resident 1's PNA vaccine. During a concurrent interview and record review on 3/30/2023 at 9:23 a.m., with Registered Nurse 6 (RN 6), Resident 1's Immunization History (IH) was reviewed. The IH indicated, Resident 1 previously received the PNA vaccine but there was no date documented for the administration of the PNA vaccine. RN 6 stated, without the name of the PNA vaccine and an administration date, she was unable to determine Resident 1's eligibility to receive the PNA vaccine. b. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated, Resident 5 was admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease ([COPD] a lung disease that causes decreased airflow and breathing related problems). During a review of Resident 5's MDS, dated [DATE], the MDS indicated, Resident 5 had the ability to express ideas and wants, had clear comprehension and was up to date with her PNA vaccine. During a review of Resident 5's AHF dated 2/1/2023, the AHF indicated Resident 5 previously received the PNA vaccine. Continued review of the AHF indicated there was no date documented for Resident 5's PNA vaccine. During a concurrent interview and record review on 3/30/2023 at 9:23 a.m., with (RN 6, Resident 5's IH was reviewed. The IH indicated Resident 5 previously received the PNA 7 vaccine on, 1/1/1996. RN 6 reviewed Resident 5's vaccine information on the California Immunization Registry (CAIR) data base and the information obtained indicated Resident 5's last PNA vaccine was 1/1/1996. RN 6 stated, the PNA vaccine was recommended every five years. RN 6 stated, Resident 5 was not offered the PNA vaccine because her medical record indicated Resident 5 has already it. c. During a review of Resident 79's admission Record (Face Sheet), the Face Sheet indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555599 If continuation sheet Page 9 of 10 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 555599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Torrance Memorial Med Ctr Snf/Dp 3330 West Lomita Blvd Torrance, CA 90505 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 79 was admitted to the facility on [DATE], with a diagnosis of right leg above the knee amputation (surgical removal) with a wound vacuum (type of therapy to help wounds heal). During a review of Resident 79's History and Physical (H&P), dated 3/16/2023, the H&P indicated, Resident 79 had a past medical history of diabetes ([DM] a chronic condition that affects how the body processes sugar) with ketoacidosis (a complication of DM), and electrolyte imbalance (too much or not enough of certain minerals in the body). During a review of Resident 79's MDS, dated [DATE], the MDS indicated, Resident 79 had the ability to express ideas and wants, had clear comprehension and was not eligible for the PNA vaccine. The MDS indicated the PNA vaccine was medically contraindicated. During a concurrent interview and record review on 3/30/2023 at 9:23 a.m., with RN 6, Resident 79's IH was reviewed. The IH indicated, Resident 79 was [AGE] years old and under the PNA vaccine section, not applicable (n/a) was checked. RN 6 stated, Resident 79 was not offered the PNA vaccine because the resident was not eligible to receive the PNA vaccine because she was under [AGE] years old. During a concurrent interview and record review on 3/30/2023 at 9:23 a.m., with RN 6, the facility's Pneumococcal Vaccine policy and the Centers for Disease Control and Prevention's (CDC) website were reviewed. RN 6 stated, she was not familiar with the facility's PNA vaccine policy and was not aware the facility followed the CDC recommendation for eligibility which indicated, the PNA vaccine was recommended for persons 19 -[AGE] years old with diabetes. RN 6 stated, nursing staff were responsible for ensuring a residents vaccine history was assessed on admission and if a resident was eligible for the PNA vaccine the PNA vaccine should be offered. RN 6 stated, if the resident reported they received the PNA vaccine or if the resident's medical record indicated the resident had previously received the PNA vaccine, the PNA vaccine would not be offered. RN 6 stated, it was important for residents to receive the PNA vaccine to protect them from PNA which could complicate a resident's health, especially for residents with compromised immune systems. RN 6 stated, severe cases of PNA could lead to death. During an interview on 3/30/2023 at 3:15 p.m., with the Director of Nursing (DON), the DON stated, nursing staff were responsible for assessing the resident's eligibility for the PNA vaccine on admission to the facility. The DON stated it was important to offer the PNA vaccine to residents to prevent them from developing the pneumococcal infection. During a review of the of the facility's policy and procedure (P&P), titled Vaccination Protocol/ Vaccine Information Sheet, dated 1994, and revised 2021, the P&P indicated, all patients will be screened to determine if they are current on their pneumococcal adult vaccination in the Transitional Care Unit (TCU). Eligibility requirements of the pneumococcal vaccine can be found at https://www.cdc.gov/vaccine/vpd/pneumo/hcp/recommendation.html During a review of the CDC's website, https://www.cdc.gov/pneumococcal/vaccination.html, the website indicated, the CDC recommends pneumococcal vaccination for adults [AGE] years old and older, and for adults 19 through [AGE] years old with certain underlying medical conditions or other risk factors including diabetes. The CDC recommend persons over [AGE] years of age who received the pneumococcal conjugant (PCV13) vaccine also receive the pneumococcal 23 vaccine at least one year apart, then the series is complete. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555599 If continuation sheet Page 10 of 10