Other·October 22, 2020

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 the investigation of one complaint during an abbreviated standard survey. Complaint number: CA00698799. Representing the Department: Health Facilities Evaluator Nurse 36292 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written for complaint number CA00698799.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 10/05/2020 §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 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: NDCH11 Facility ID: CA910000091 If continuation sheet 1 of 5 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: _______________ 055952 (X3) DATE SURVEY COMPLETED 09/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TORRANCE CARE CENTER WEST, INC. 4333 Torrance Blvd Torrance, CA 90503 (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 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 interview and record review, the facility failed to ensure that an incident of an elopement was promptly reported to the Department of Public Health (DPH) in accordence to the the facility's policy and procedure, for one of three sampled residents (Resident 1). This deficient practice increased the potential to result in serious harm. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on 7/2/20 and readmitted on 7/25/20 after eloping from the facility. Resident 1's diagnoses included diabetes mellitus with hyperglycemia (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hydrocephalus (a condition in which fluid accumulates in the brain, typically in young children, enlarging the head and sometimes causing brain damage), hypertensive heart disease without heart failure (refers to heart problems that occur because of high blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NDCH11 Facility ID: CA910000091 If continuation sheet 2 of 5 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: _______________ 055952 (X3) DATE SURVEY COMPLETED 09/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TORRANCE CARE CENTER WEST, INC. 4333 Torrance Blvd Torrance, CA 90503 (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 pressure that is present over a long time). A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 7/11/2020 indicated Resident 1 understand, clear comprehension. MDS indicated Resident 1 needs extensive one person assist for toileting, dressing, and personal hygiene. A review of the physician's orders dated 7/25/20 at 2:15 a.m., indicated Resident 1 was readmitted, and to continue previous orders, no new orders made. A review of Resident 1's physician's history and physical examination on 7/3/20 indicated that Resident 1 has the capacity to understand and make decisions. A review of Resident 1's Background Investigation, indicated on 7/24/20 around 4:30 p.m., Resident 1 was talking to a nursing staff that Resident 1 wanted to go to the general acute care hospital (GACH), as he states feeling weak. Staff prepared for transfer of Resident 1, calling physician, transportation, GACH, Resident 1 left without notice or signing out. On the same day, 7/24/20 Resident 1 was observed sitting in the back patio around 4:30 p.m., and by 5 p.m. dinner, Resident 1 could not be located in the facility. The residents physician, law enforcement and responsible person were notified. On 7/24/20 at 7:45 p.m., GACH called and stated that Resident 1 is the hospital in stable condition and will return shortly. A review of Resident 1's nurse's notes dated 7/24/20 at p.m., indicated Resident complained of "being weak and something else." Vital signs taken. Blood pressure was 131/78, Pulse 76, Respiration 20, Temperature 98.1, O2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NDCH11 Facility ID: CA910000091 If continuation sheet 3 of 5 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: _______________ 055952 (X3) DATE SURVEY COMPLETED 09/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TORRANCE CARE CENTER WEST, INC. 4333 Torrance Blvd Torrance, CA 90503 (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 saturation 96% room air. Physician made aware with order to transfer to GACH, responsible party made aware, called for transportation. A review of Resident 1's nurse's notes dated 7/25/20 11p.m.- 7a.m. shift (time unspecified) Resident 1 was received via gurney, alert, and responsive to stimuli. Breathing is even and unlabored. Noted with periods of confusion. No complaint of pain. On 72 hours monitoring. Vital signs taken. Blood pressure 126/78, Pulse 84, Respiration 18, Temperature 97.8, denies pain. On 7/29/2020 at 9 a.m., Resident 1 was observed in bed sleeping. On 7/29/2020 at 10:30 a.m., during an interview, the DON stated she was made aware of the on Resident 1 elopement by the GACH. The DON stated an investigation was conducted and it was found that Resident 1 left the facility without signing out. DON stated Resident 1 is self-responsible for medical decisions. DON stated that the facility should have reported the elopement to the department. A review of the facility's undated policy titled, "Elopement," indicated that if Resident 1 was not located , notify the Administrator and the Director of Nursing Services, Resident 1 's legal representative, the Attending Physician, law enforcement officials, the Department of Public Health. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NDCH11 Facility ID: CA910000091 If continuation sheet 4 of 5 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: _______________ 055952 (X3) DATE SURVEY COMPLETED 09/24/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TORRANCE CARE CENTER WEST, INC. 4333 Torrance Blvd Torrance, CA 90503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: NDCH11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA910000091 (X5) COMPLETE DATE If continuation sheet 5 of 5