Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0825
Provide or get specialized rehabilitative services as required for a resident.
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 provide occupational therapy (OT,
rehabilitative profession that provides services to increase and/or maintain a person ' s capability to
participate in everyday life activities) and/or physical therapy (PT, a rehabilitation profession that restores,
maintains, and promotes optimal physical function) treatments based on the physician ' s order and therapy
treatment plan for three of four sampled residents (Residents 1, 2, and 4).
Residents Affected - Some
These deficient practices had the potential to delay recovery and discharge planning for Residents 1, 2,
and 4.
Findings:
a. A review of Resident 1 ' s Registration Record indicated Resident 1 admitted to the facility on [DATE] for
right hip replacement (procedure to replace diseased part of the hip with an artificial part).
A review of Resident 1 ' s Resident Care Team Meeting notes dated 11/1/23 and updated on 11/6/23
indicated Resident 1 required moderate assistance with bed mobility, maximum assistance with transfer
training, minimal assistance with gait (walking). It also indicated Resident 1 was here for pain management
and rehab[ilitation]. Will continue with PT and OT.
During an interview on 11/6/23 at 2:15pm, the Clinical Director of Nursing (CDN) stated there was no
Minimum Data Set (MDS, a standardized assessment and care-screening tool) assessment completed for
Resident 1 yet due to the recent admission.
A review of Resident 1 ' s Order Sheet indicated an order for OT evaluation and treatment on 10/31/23. The
order sheet indicated an order dated 11/2/23 for OT treatment Monday, Tuesday, Wednesday, Thursday, and
Friday for two (2) weeks.
A review of Resident 1 ' s OT Inpatient Evaluation dated 11/1/23 indicated Resident 1 required substantial
or maximal assistance with toileting hygiene and lower body dressing. The OT evaluation indicated an OT
treatment plan frequency for Monday, Tuesday, Wednesday, Thursday, and Friday for 2 weeks.
A review of Resident 1 ' s OT Inpatient Daily Treatment documentation indicated there was no OT treatment
provided on Thursday 11/2/23.
During an observation on 11/6/23 at 10:45 am in Resident 1 ' s room, Resident 1 was wearing a
(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 4
Event ID:
555599
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
11/06/2023
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 0825
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
hospital gown and sitting up in the bed. Resident 1 stated she received a little bit of PT and OT. Resident 1
stated she did not receive any OT on Thursday (11/2/23) or on the weekend.
During an interview and concurrent record review of Resident 1 ' s medical records on 11/6/23 at 11:30 am,
the Rehabilitation Services Manager (RSM) stated Resident 1 admitted to the facility on [DATE] for PT and
OT. RSM confirmed the OT evaluation dated 11/1/23 indicated a treatment frequency plan of Monday,
Tuesday, Wednesday, Thursday, and Friday for 2 weeks. RSM confirmed a physician ' s order dated 11/2/23
for OT treatment Monday, Tuesday, Wednesday, Thursday, and Friday for 2 weeks. RSM confirmed that no
OT treatment was provided on Thursday 11/2/23. RSM reviewed the therapy staffing schedule and stated
an OT staff was sick and not able to work so the OT staff was short that day. RSM stated there was no
other OT staff to replace the sick OT staff.
b. A review of Resident 2 ' s Registration Record indicated Resident 2 admitted to the facility on [DATE] for
recent cerebral vascular accident (CVA, blood flow stops to a part of the brain, brain damage due to
blocked blood flow).
A review of Resident 2 ' s Order Sheet indicated an order dated 10/9/23 for OT evaluation and treatment.
The Order Sheet also indicated an order dated 10/11/23 for OT treatment Monday, Tuesday, Wednesday,
Thursday, Friday, and Saturday for 2 weeks. The Order Sheet also indicated an order dated 10/25/23 for OT
treatment Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday for 2 weeks.
A review of Resident 2 ' s MDS dated [DATE] indicated Resident 2 had no cognitive impairments, had
functional limitation in range of motion on both sides of the lower extremities. The MDS also indicated
Resident 2 required dependence in toileting hygiene, lower body dressing, supervision with eating and oral
hygiene.
A review of Resident 2 ' s Occupational Therapy Evaluation dated 10/10/23 indicated Resident 2 required
maximal assistance with bed mobility, total assistance with toileting, lower extremity dressing, and
moderate assistance with upper extremity dressing. The OT evaluation indicated an OT treatment plan
frequency for Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday for 2 weeks.
A review of Resident 2 ' s OT Inpatient Daily Treatment documentation indicated no OT treatments were
provided on Saturday 10/21/23, Friday 10/27/23, Wednesday 11/1/23, and Friday 11/3/23.
During an observation and interview on 11/6/23 at 2:43 pm, Resident 2 was sitting up in bed with the head
of bed up about halfway. Resident 2 was wearing a hospital gown and drinking a yogurt drink with the right
arm. Resident 2 ' s had a visitor in the room. Resident 2 stated the therapists were all very good, but they
did not have enough staff. Resident 2 stated sometimes they were short of therapy staff.
During an interview and concurrent record review of Resident 2 ' s medical records on 11/6/23 at 11:52 am,
RSM stated Resident 2 admitted to the facility on [DATE] for PT and OT. RSM confirmed the OT evaluation
dated 10/10/23 indicated a treatment frequency plan of Monday, Tuesday, Wednesday, Thursday, Friday,
and Saturday for 2 weeks. RSM confirmed a physician ' s order dated 10/11/23 for OT treatment Monday,
Tuesday, Wednesday, Thursday, Friday, and Saturday for 2 weeks and a physician ' s order dated 10/25/23
for OT treatment Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday for 2 weeks. RSM
confirmed that no OT treatment was provided on Saturday 10/21/23, Friday 10/27/23, Wednesday 11/1/23,
and Friday 11/3/23. RSM reviewed the Rehab staffing calendar and stated on 10/21/23 and 10/27/23 only
one OT staff was scheduled to work that day and on 11/1/23 and 11/3/23 one OT staff
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555599
If continuation sheet
Page 2 of 4
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
11/06/2023
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 0825
was out sick and stated there was no other OT staff to replace the sick OT staff.
Level of Harm - Minimal harm
or potential for actual harm
c. A review of Resident 4 ' s Registration Record indicated Resident 4 admitted to the facility on [DATE] for
pseudomonas bacteremia (type of infection in the body).
Residents Affected - Some
A review of Resident 4 ' s Order Sheet indicated an order dated 10/20/23 for OT evaluation and treatment
and an order dated 10/20/23 for PT evaluation and treatment. The Order Sheet also indicated an order
dated 10/23/23 for OT treatment Monday, Tuesday, Wednesday, Thursday, and Friday for 2 weeks and an
order dated 10/23/23 for PT treatment Monday, Tuesday, Wednesday, Thursday, and Friday for 2 weeks.
A review of Resident 4 ' s MDS dated [DATE] indicated Resident 4 was severely impaired in cognitive skills
(mental processes involved in gaining knowledge and comprehension, includes thinking, knowing,
remembering, judging, problem-solving) for decision making. The MDS also indicated Resident 4 required
dependence in toileting hygiene, oral hygiene, and moderate assistance with dressing. The MDS also
indicated the activities of walking and chair transfers did not occur.
A review of Resident 4 ' s Occupational Therapy Evaluation dated 10/21/23 indicated Resident 4 required
dependent assistance with toileting hygiene, maximal assistance with lower body dressing, and moderate
assistance with upper body dressing. The OT evaluation indicated an OT treatment plan frequency for
Monday, Tuesday, Wednesday, Thursday, and Friday for 2 weeks.
A review of the OT Inpatient Daily Treatment documentation indicated no OT treatments were provided on
Monday 10/23/23, Friday 10/27/23, Wednesday 11/1/23 and Thursday 11/2/23.
A review of Resident 4 ' s PT Evaluation dated 10/21/23 indicated Resident 4 required moderate assistance
for bed mobility and Resident 4 did not stand. The PT evaluation indicated an PT treatment frequency plan
for Monday, Tuesday, Wednesday, Thursday, and Friday for 2 weeks.
A review of the PT Inpatient Daily Treatment documentation indicated no PT treatments were provided on
Tuesday 10/24/23 and Thursday 10/26/23.
During an observation and interview on 11/6/23 at 10:59 am, Resident 4 was wearing a hospital gown and
sitting up in bed with the head of bed up more than halfway. Resident 4 had difficulty hearing and could not
answer specific or general questions regarding therapy services.
On 11/6/23 at 12:30 pm, during an interview and record review of Resident 4 ' s medical records, RSM
stated Resident 4 admitted to the facility on [DATE] for PT and OT. RSM confirmed the OT evaluation dated
10/21/23 indicated a treatment frequency plan of Monday, Tuesday, Wednesday, Thursday, and Friday for 2
weeks. RSM confirmed a physician ' s order dated 10/23/23 for OT treatment Monday, Tuesday,
Wednesday, Thursday, and Friday for 2 weeks. RSM confirmed OT treatments were not provided on
Monday 10/23/23, Friday 10/27/23, Wednesday 11/1/23, and Thursday 11/2/23. RSM reviewed the therapy
staff schedule and stated on 10/23/23 and 10/27/23 there were only 2 OTs scheduled because one OT was
on vacation and on 11/1/23 and 11/2/23 one OT staff was out sick.
In the same interview and record review, RSM confirmed the PT evaluation dated 10/21/23 indicated a
treatment plan frequency of Monday, Tuesday, Wednesday, Thursday, and Friday for 2 weeks. RSM
confirmed a physician ' s order dated 10/23/23 for PT treatment Monday, Tuesday, Wednesday, Thursday,
and Friday for 2 weeks. RSM confirmed PT treatments were not provided on Tuesday 10/24/23 and
Thursday
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555599
If continuation sheet
Page 3 of 4
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
11/06/2023
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 0825
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
10/26/23. RSM reviewed the therapy staff schedule and stated on 10/24/23 and 10/26/23 there were only
three PTs on staff that day, one PT was on vacation and another PT was on a leave of absence.
In the same interview, RSM stated residents were usually admitted to this unit because they needed
rehabilitation such as PT and OT so that residents could improve their functional mobility and their
independence with activities of daily living (basic activities such as eating, dressing, toileting) and get them
close to maximum functioning before they move to the next level of care. It was important for residents to
receive their therapy treatments as ordered because therapy services was to help residents get better and
stronger and get to the next level of care. RSM stated that therapy was not a skill or profession that could
be replaced by nursing or activities. RSM stated if residents did not receive their therapy as ordered and per
the treatment plan, then it could delay and take longer for residents to get better, and they may have to stay
longer at the facility.
During an interview with Physical Therapist (PT 1) and RSM on 11/6/23 at 2:31 pm, PT 1 stated she was
responsible for scheduling therapy staff at the unit. PT 1 stated PT and OT staff were scheduled to treat
about eight residents a day. PT 1 stated sometimes if a treatment was missed on a weekday, she would try
to make it up and schedule the resident on a Saturday. PT 1 stated the last couple weeks was unusual and
they had a lot of staffing issues and that it did not happen often. RSM stated the rehabilitation unit did not
use registry or have a float pool and that the facility should look at back up options for staffing so that all
residents received their therapy treatments as ordered and based on their therapy treatment plan.
A review of the facility ' s policies and procedures dated 1/31/20, titled, Rehabilitation orders and
treatment/intervention plan indicated the therapist will provide services for specific rehabilitation orders.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555599
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
FAQ · About this visit
Common questions about this visit
What happened during the November 6, 2023 survey of TORRANCE MEMORIAL MED CTR SNF/DP?
This was a inspection survey of TORRANCE MEMORIAL MED CTR SNF/DP on November 6, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TORRANCE MEMORIAL MED CTR SNF/DP on November 6, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide or get specialized rehabilitative services as required for a resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.