Other·August 23, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during an investigation of a Complaint during an Abbreviated Survey. Complaint Number: CA00584222. Representing the Department of Public Health: Surveyor ID: 19152 RN, HFEN The inspection was limited to the specific Complaint incidents investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were written for Complaint Number: CA00584222.

F557 SS=D Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 08/03/2018 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 1 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility's nursing staff failed to ensure a resident's (A) dignity was maintained and was not uncomfortable following an episode of fecal incontinence when a Certified Nursing Assistant (CNA) put his finger inside the Resident A's rectum in order to clean him. This deficient practice placed Resident A at risk for having feelings of embarrassment, shame and violation. Findings: A review of Resident A's Admission Records indicated the resident was re-admitted to the facility on 4/1/16, with diagnoses that included muscle wasting and atrophy (partial or complete wasting away of a part of the body), generalized muscle weakness, lack of coordination, abnormal posture and multiple sclerosis (a progressive disease involving damage to the nerve cells in the brain and spinal cord, symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue). A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 3/17/18, indicated Resident A's cognition skills for daily decision making were intact, required extensive assistance with one FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 2 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE person physical assist for toilet use, personal hygiene, was frequently incontinent (involuntary voiding of urine and stool) during urination and occasionally incontinent during bowel movements. During an interview on 4/26/18, at 10:20 a.m., the Assistant Director of Nursing (ADON) stated he was informed by Licensed Vocational Nurse 1 (LVN 1) alleging that while receiving care, CNA 1's finger touched Resident A's anal area. The ADON stated he conducted an interview with CNA 1 and during the interview CNA 1 acknowledged Resident A's allegations that CNA 1 placed his finger inside of the resident's rectum. During an interview on 4/26/18, at 10:50 a.m., CNA 1 stated around 10/2017 or 11/2017, he was called into work on the 11 p.m.- 7 a.m., shift. CNA 1 stated Resident A had a large, bowel movement that was dry. CNA 1 stated he and CNA 2 had to clean around and inside Resident 1's anal area. CNA 1 stated his finger slightly entered Resident A" rectum and Resident A reported him to the Director of Nursing (DON). During an interview on 4/26/18, at 11:20 a.m., CNA 2 stated there were two occasions in year 2017, when Resident A had a large bowel movement. CNA 2 stated Resident A was alert and oriented to name, place, date and time, mostly continent (having control of the elimination of urine and feces) of his bowel and incontinent (not having control of the elimination of urine or feces) of urine. CNA 2 further stated when Resident A had a large bowel movement, the resident had so much feces that she and CNA 1 had to clean inside Resident A's rectum so that he would not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 3 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE develop a rash. During an interview on 4/26/18, at 3:13 p.m., LVN 1 stated Resident A informed the Director of Staff Development (DSD) not to assign CNA 1 to him because during care, CNA 1 shoved his finger up his "ass". Resident A stated when he reported the incident the DON, the DON just laughed and smirked at him. During an interview on 5/8/18 at 9 a.m., the DON stated he could vaguely recall the incident involving Resident A, was not sure when the incident occurred, and did not have any notes regarding Resident A's allegation. During an interview on 5/8/18, at 1:10 p.m., Resident A stated he had a bowel movement on himself and needed to be cleaned. Resident A stated when CNA 1 cleaned him, he was not sure which position to lie in, however the resident felt CNA 1's finger go inside of his rectum. Resident A stated he was not sure how far the CNA's finger went inside his rectum, but, knew it went in far enough to make the resident uncomfortable. Resident A further stated he did not believe this was an accident because CNA 1 stated "Sorry, but I have to get you clean." Resident A further stated at the time of the incident, he just wanted an apology but, has not received an apology yet.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 08/03/2018 §483.12(b) The facility must develop and implement written policies and procedures that: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 4 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility's failed to follow its policy and report an allegation of sexual abuse to the Department of Public Health (DPH) as mandated by law for one of three sampled residents (Resident A). Resident A alleged a certified nursing assistant (CNA 1) placed his finger in the resident's rectum during care. This deficient practice of failing to report an allegation of abuse to DPH could have placed Resident A and other residents at risk for further harm. Findings: A review of Resident A's Admission Records indicated the resident was re-admitted to the facility on 4/1/16, with diagnoses that included muscle wasting and atrophy (partial or complete wasting away of a part of the body), generalized muscle weakness, lack of coordination, abnormal posture and multiple sclerosis (a progressive disease involving FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 5 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE damage to the nerve cells in the brain and spinal cord, symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue). A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 3/17/18, indicated Resident A's cognition skills for daily decision making were intact, required extensive assistance with one person physical assist for toilet use, personal hygiene, was frequently incontinent (involuntary voiding of urine and stool) during urination and occasionally incontinent during bowel movements. During an interview on 4/26/18, at 10:20 a.m., the Assistant Director of Nursing (ADON) stated he was informed by Licensed Vocational Nurse 1 (LVN 1) alleging that while receiving care, CNA 1's finger touched Resident A's anal area. The ADON stated he conducted an interview with CNA 1 and during the interview CNA 1 acknowledged Resident A's allegations that CNA 1 placed his finger inside of the resident's rectum. The ADON stated during an interview, Resident A stated the incident occurred a week ago, however, the ADON stated he was aware that Resident A reported the same allegation previously, at sometime in 2017. The ADON stated during an interview, Resident A indicated this was the first time CNA 1 placed his finger in the resident's rectum. The ADON stated he assumed Resident A's previous allegation against CNA 1 made in 2017, was the same as the current allegation. The ADON stated during an interview with Resident A, Resident B (Resident A's roommate) stated the same thing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 6 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE happened to him as well with CNA 1 but was not sure of the date of which the incident occurred. The ADON stated during an interview with CNA 1, CNA 1 stated he had not been assigned to Resident A during the time of the resident's current accusation, however, acknowledged the incident that occurred a year ago when Resident A accused him of putting his finger in the resident's rectum. The ADON stated the Director of Nurses (DON) and the Director of Staff Development (DSD) addressed the incident with CNA 1, however the DSD stated she did not have any notes regarding the allegation that was reported last year. The Administrator stated the allegation of abuse should have been reported to the DPH when it was first acknowledged back in 2017. During an interview on 4/26/18 at 10:50 a.m., CNA 1 stated around 10/2017 or 11/2017, he was called into work on the 11 p.m.- 7 a.m., shift. CNA 1 stated Resident A had a large, bowel movement that was dry. CNA 1 stated he and CNA 2 had to clean around and inside Resident 1's anal area. CNA 1 stated his finger slightly entered Resident A" rectum and Resident A reported him to the Director of Nursing (DON). CNA 1 stated the DON asked him to apologize to the resident, which CNA1 stated that he apologized to Resident A. During an interview on 4/26/18, at 11:20 a.m., CNA 2 stated there were two occasions in year 2017, when Resident A had a large bowel movement. CNA 2 stated Resident A was alert and oriented to name, place, date and time, mostly continent (having control of the elimination of urine and feces) of his bowel and incontinent (not having control of the elimination of urine or feces) of urine. CNA 2 further stated when Resident A had a large bowel movement, the resident had so much FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 7 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE feces that she and CNA 1 had to clean inside Resident A's rectum so that he would not develop a rash. CNA 2 stated about two weeks ago she saw the ADON and CNA 1 go into a room with the DSD and assumed at that time the allegation was acknowledged. CNA 2 stated she found out about Resident A" recent allegation from CNA 1. CNA 2 further stated no one has her about Resident A's recent allegation and she was not aware there was a previous allegation in 2017, regarding Resident A and CNA 1. During an interview on 4/26/18, at 11:40 a.m., the Administrator stated he knew there was an allegation made by Resident A at sometime back in 2017. The Administrator stated last week the ADON reported to him there were allegations of abuse made by Resident A and Resident B. The Administrator stated he was not sure how the DON handled the allegation of abuse made in 2017, but, after the current allegation was made the ADON interviewed Resident A, Resident B and CNA 1. The Administrator stated according to the DON there was no "wrong doing." During an interview on 4/26/18 at 4:10 p.m., the ADON stated sometime back in 2017, during a stand up meeting, the DON stated that during care, Resident A complained about CNA 1 cleaning the resident too far. The ADON stated when Resident A made a similar allegation he did not explore the details of the allegation because he was aware the allegation had been made by Resident A previously. The ADON stated although he could not locate an incident report or any documentation he assumed the allegation had been investigated and handled by the DON. The ADON stated when Resident B overheard Resident A making FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 8 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE an accusation, the ADON thought Resident B was just repeating what Resident A comments. The ADON stated LVN 1 reported the current allegations on a Monday and the residents were not interview until Wednesday because the he was busy with other things. A review of a document dated on 4/16/18, and signed by CNA 1 indicated, CNA 1 had not been assigned to Resident A in the last few weeks and did not provide carenor changed Resident A. CNA 1's signed statement indicated CNA 1's only assignment with Resident A is for Restorative Nursing Assistant (RNA). CNA 1's signed statement did not indicate documentation of the events surrounding the allegation made from 2017. A review of Resident A's interview questions dated on 4/18/18, and conducted by the ADON indicated the following: Question (Q) - Can you verify with me when the incident happened? Answer (A) - I said about two weeks ago but now that you ask, I think I was more like a month ago Q - A Month ago, so this is a different incident from the previously reported and settle incident last year where you had a discussion with he DON, DSD and the CNA? A - Wait, that was last year already? Q - As far as the DSD reported it was last year. How many time did it happen? A - Yes that was last year, it happened one time only and he has never been my CNA since. Q - So what was the incident you reported to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 9 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE your charge nurse? A- It was that incident last year Q - Right now do you feel threatened with him present in the building A - No ADON - Just to let you know if and whenever you feel threatened or you feel not treated right, tell somebody; your nurse, me, the administrator or anybody you feel safe reporting Resident A - Ok, thank you A review of Resident B's interview questions dated on 4/18/18, conducted by the ADON, indicated the following: Q - Can you elaborate on the incident you reported to the LVN 1 A - At one time CNA 1 stuck his finger up my ass while he was cleaning me Q - When did this happen A - Oh maybe a month or so right around when it also happened to my roommate Q - That was last year, you mean it happened again? A - Was it a year ago already? Q - You had another incident? A - No that was the only time. He said it was an accident Q - Was he ever assigned to you to clean you up after that? A - I don't think so Q - Do you feel threatened or unsafe when he is around FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 10 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A - No During a review of Resident A and Resident B interviews indicated there was no documented evidence of a detailed description of what happened to the residents. The interviews only indicated the incident occurred in 2017 and both residents felt safe. There was no other documented evidence of interviews from other residents who received care from CNA 1, there was no evidence of a statement from CNA 2 who was with CNA 1 when he provided care to Resident A. There was no evidence of a conclusion of the current investigation and no documented evidence of an investigation for the allegation made in 2017. During an interview on 4/26/18, at 3:13 p.m., LVN 1 stated Resident A informed the Director of Staff Development (DSD) not to assign CNA 1 to him because during care, CNA 1 shoved his finger up his "ass". Resident A stated when he reported the incident the DON, the DON just laughed and smirked at him. LVN 1 stated she tried to report the allegations to the ADON but before she could tell him what Resident A alleged, the ADON blurted out what had happened and stated that he already knew because he overheard the allegation. LVN 1 stated she was asked by the ADON to make a report regarding the allegation, when she went to interview Resident A, he told her to talk to Resident B. LVN 1 stated during an interview with Resident B, Resident B stated the same thing that happened to Resident A happened to him, he was not sure of the date. LVN 1 stated she took the report to the ADON with the new accusation from Resident B and the ADON told her the incident had been resolved as an accident with the DON, CNA 1 and Resident A and that Resident B was just repeating what FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 11 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident A said. LVN 1 stated the Administrator was also present when she told both, the Administrator and the ADON she did not think they were taking the allegations seriously. LVN 1 stated the Administrator and the ADON assured her they were taking the allegations seriously and it had been resolved as an accident. LVN 1stated she went back to Resident A and B's rooms and they told her she was the only one who had spoken to them regarding the allegations. LVN 1 asked the ADON and the Administrator how were they taking Resident A and B seriously if they had not even spoken to the them, that was when the ADON conducted an interview with Resident A and B. During an interview on 5/8/18 at 9 a.m., the DON stated he could vaguely recall the incident involving Resident A, was not sure when the incident occurred, and did not have any notes regarding Resident A's allegation. During an interview on 5/8/18, at 1:10 p.m., Resident A stated he had a bowel movement on himself and needed to be cleaned. Resident A stated when CNA 1 cleaned him, he was not sure which position to lie in, however the resident felt CNA 1's finger go inside of his rectum. Resident A stated he was not sure how far the CNA's finger went inside his rectum, but, knew it went in far enough to make the resident uncomfortable. Resident A further stated he did not believe this was an accident because CNA 1 stated "Sorry, but I have to get you clean." Resident A stated at the time of the incident, a few months ago, he just wanted an apology but never got one. Resident A stated he reported CNA 1 this time to LVN 1 because he felt CNA 1 could be doing the same thing to residents' who could not speak for themselves. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 12 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident B's Admission Records indicated the resident was admitted to the facility on 2/28/17, with diagnoses that included muscle wasting atrophy, generalized muscle weakness and lack of coordination. A review of the MDS dated 3/14/18, indicated Resident B cognitive skills for daily decisionmaking were intact and required extensive assistance with one person physical assist for toilet use and personal hygiene but was continent of both bowel and bladder functions. During an interview on 5/28/18 at 1:32 p.m., Resident B stated during care and while being cleaned, CNA 1's finger went inside of his rectum. Resident B was not sure of the date when the incident happened, but when he overheard Resident A talking to LVN 1 about what CNA 1 did to him, Resident B decided to file a report. Resident B stated he did not feel it was an accident and CNA 1 put his finger inside of his rectum because that was something CNA 1 did to clean him which made Resident B uncomfortable. A review of the facility's policy and procedure dated 8/2/04 and titled "Abuse Program", indicated that all or any allegations of abuse shall be reported to the DPH within 24 hours.

F609 Reporting of Alleged Violations FORM CMS-2567(02-99) Previous Versions Obsolete

F609 Event ID: 5KVM11 08/03/2018 Facility ID: CA910000048 If continuation sheet 13 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.12(c)(1)(4) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility's administrative staff failed to report allegations of abuse made by two residents (A and B) to the Department of Public Health (DPH). This deficient practice placed the Resident A,B and other residents at risk for further abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 14 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: A review of Resident A's Admission Records indicated the resident was re-admitted to the facility on 4/1/16, with diagnoses that included muscle wasting and atrophy (partial or complete wasting away of a part of the body), generalized muscle weakness, lack of coordination, abnormal posture and multiple sclerosis (a progressive disease involving damage to the nerve cells in the brain and spinal cord, symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue). A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 3/17/18, indicated Resident A's cognition skills for daily decision making were intact, required extensive assistance with one person physical assist for toilet use, personal hygiene, was frequently incontinent (involuntary voiding of urine and stool) during urination and occasionally incontinent during bowel movements. During an interview on 4/26/18, at 10:20 a.m., the Assistant Director of Nursing (ADON) stated he was informed by Licensed Vocational Nurse 1 (LVN 1) alleging that while receiving care, CNA 1's finger touched Resident A's anal area. The ADON stated he conducted an interview with CNA 1 and during the interview CNA 1 acknowledged Resident A's allegations that CNA 1 placed his finger inside of the resident's rectum. The ADON stated during an interview, Resident A stated the incident occurred a week ago, however, the ADON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 15 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated he was aware that Resident A reported the same allegation previously, at sometime in 2017. The ADON stated during an interview, Resident A indicated this was the first time CNA 1 placed his finger in the resident's rectum. The ADON stated he assumed Resident A's previous allegation against CNA 1 made in 2017, was the same as the current allegation. The ADON stated during an interview with Resident A, Resident B (Resident A's roommate) stated the same thing happened to him as well with CNA 1 but was not sure of the date of which the incident occurred. The ADON stated during an interview with CNA 1, CNA 1 stated he had not been assigned to Resident A during the time of the resident's current accusation, however, acknowledged the incident that occurred a year ago when Resident A accused him of putting his finger in the resident's rectum. The ADON stated the Director of Nurses (DON) and the Director of Staff Development (DSD) addressed the incident with CNA 1, however the DSD stated she did not have any notes regarding the allegation that was reported last year. The Administrator stated the allegation of abuse should have been reported to the DPH when it was first acknowledged back in 2017. During an interview on 4/26/18 at 10:50 a.m., CNA 1 stated around 10/2017 or 11/2017, he was called into work on the 11 p.m.- 7 a.m., shift. CNA 1 stated Resident A had a large, bowel movement that was dry. CNA 1 stated he and CNA 2 had to clean around and inside Resident 1's anal area. CNA 1 stated his finger slightly entered Resident A" rectum and Resident A reported him to the Director of Nursing (DON). CNA 1 stated the DON asked him to apologize to the resident, which CNA1 stated that he apologized to Resident A. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 16 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 4/26/18, at 11:20 a.m., CNA 2 stated there were two occasions in year 2017, when Resident A had a large bowel movement. CNA 2 stated Resident A was alert and oriented to name, place, date and time, mostly continent (having control of the elimination of urine and feces) of his bowel and incontinent (not having control of the elimination of urine or feces) of urine. CNA 2 further stated when Resident A had a large bowel movement, the resident had so much feces that she and CNA 1 had to clean inside Resident A's rectum so that he would not develop a rash. CNA 2 stated about two weeks ago she saw the ADON and CNA 1 go into a room with the DSD and assumed at that time the allegation was acknowledged. CNA 2 stated she found out about Resident A" recent allegation from CNA 1. CNA 2 further stated no one has her about Resident A's recent allegation and she was not aware there was a previous allegation in 2017, regarding Resident A and CNA 1. During an interview on 4/26/18, at 11:40 a.m., the Administrator stated he knew there was an allegation made by Resident A at some time back in 2017. The Administrator stated last week the ADON reported to him there were allegations of abuse made by Resident A and Resident B. The Administrator stated he was not sure how the DON handled the allegation of abuse made in 2017, but, after the current allegation was made the ADON interviewed Resident A, Resident B and CNA 1. The Administrator stated according to the DON there was no "wrong doing." During an interview on 4/26/18 at 4:10 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 17 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the ADON stated sometime back in 2017, during a stand up meeting, the DON stated that during care, Resident A complained about CNA 1 cleaning the resident too far. The ADON stated when Resident A made a similar allegation he did not explore the details of the allegation because he was aware the allegation had been made by Resident A previously. The ADON stated although he could not locate an incident report or any documentation he assumed the allegation had been investigated and handled by the DON. The ADON stated when Resident B overheard Resident A making an accusation, the ADON thought Resident B was just repeating what Resident A comments. The ADON stated LVN 1 reported the current allegations on a Monday and the residents were not interview until Wednesday because the he was busy with other things. During an interview on 5/8/18 at 9 a.m., the DON stated he could vaguely recall the incident involving Resident A, was not sure when the incident occurred, and did not have any notes regarding Resident A's allegation. During an interview on 5/8/18, at 1:10 p.m., Resident A stated he had a bowel movement on himself and needed to be cleaned. Resident A stated when CNA 1 cleaned him, he was not sure which position to lie in, however the resident felt CNA 1's finger go inside of his rectum. Resident A stated he was not sure how far the CNA's finger went inside his rectum, but, knew it went in far enough to make the resident uncomfortable. Resident A further stated he did not believe this was an accident because CNA 1 stated "Sorry, but I have to get you clean." Resident A stated at the time of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 18 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056308 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERITAGE REHABILITATION CENTER 21414 S Vermont Ave Torrance, CA 90502 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE incident, a few months ago, he just wanted an apology but never got one. Resident A stated he reported CNA 1 this time to LVN 1 because he felt CNA 1 could be doing the same thing to residents' who could not speak for themselves. A review of Resident B's Admission Records indicated the resident was admitted to the facility on 2/28/17, with diagnoses that included muscle wasting atrophy, generalized muscle weakness and lack of coordination. A review of the MDS dated 3/14/18, indicated Resident B cognitive skills for daily decisionmaking were intact and required extensive assistance with one person physical assist for toilet use and personal hygiene but was continent of both bowel and bladder functions. During an interview on 5/28/18 at 1:32 p.m., Resident B stated during care and while being cleaned, CNA 1's finger went inside of his rectum. Resident B was not sure of the date when the incident happened, but when he overheard Resident A talking to LVN 1 about what CNA 1 did to him, Resident B decided to file a report. Resident B stated he did not feel it was an accident and CNA 1 put his finger inside of his rectum because that was something CNA 1 did to clean him which made Resident B uncomfortable. A review of the facility's policy and procedure dated 8/2/04 and titled "Abuse Program", indicated that all or any allegations of abuse shall be reported to the DPH within 24 hours FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KVM11 Facility ID: CA910000048 If continuation sheet 19 of 19