Harbor Post Acute Care Center
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
During an interview on 10/7/2025, at 3:33 p.m., the Director of Nursing (DON) stated that a COC was required for any significant change in a resident's condition. The DON stated that a COC should have been initiated for Resident 1's elevated uric acid level to allow staff to closely monitor for improvement or deterioration in the resident's status.
During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will record in
the resident's medical record information relative to changes in the resident's medical/mental condition or status.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/07/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Post Acute Care Center
21521 S. Vermont Avenue Torrance, CA 90502
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm
During a review of the facility's P&P titled, Weight Assessment and Intervention, undated, the P&P indicated, Resident weights are monitored for undesirable or unintended weight loss or gain. Individualized care plans shall address the identified cause of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/07/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Post Acute Care Center
21521 S. Vermont Avenue Torrance, CA 90502
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0745
F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
b. During a concurrent interview and record review conducted on 10/03/2025 at 11:24 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated she could not recall why Resident 1 missed a scheduled urology appointment on 11/04/2024, as there was no documentation available to explain the absence. LVN 1 explained that upon receiving the appointment order from general acute care hospital (GACH), LVN 1 entered the order into the facility's system and provided a copy to the Social Services department. LVN 1 stated that Social Services was responsible for arranging transportation for residents' medical appointments.
During a concurrent interview and record review on 10/03/2025 at 12:07 p.m. with Social Services Designee (SSD 1), SSD 1 stated that she was responsible for arranging transportation for Resident 1's urology appointment scheduled for 11/04/2024. SSD 1 stated that she had the appointment order on file but did not know why the resident missed the appointment. SSD 1 stated there were no notes or documentation indicating whether Resident 1 attended the appointment or why transportation did not occur.
SSD 1 further explained that her assistant was responsible for contacting the transportation provider but was also unaware of what happened. SSD 1 acknowledged the lack of documentation and stated that the facility has since implemented a tracking system to log all residents scheduled for outside appointments to prevent future occurrences.
During an interview and record review on 10/03/2025 at 12:31 p.m. with the Social Services Assistant (SSA), SSA stated that she had texted the transportation company using her personal phone regarding Resident 1's scheduled urology appointment on 11/04/2024. SSA stated that she had no notes or records to verify the contact. SSA acknowledged the absence of documentation and reported that the facility has implemented a new process for documenting and communicating all resident appointments to ensure accountability and prevent future missed appointments.
During an interview on 10/03/2025 at 2:13 p.m. with Registered Nurse Supervisor 1 (RNS1), RNS1 stated that she was working on 11/04/2024, the date of Resident 1's scheduled urology appointment but did not know why the resident missed the appointment. RNS 1 confirmed that staff had reviewed Resident 1's chart and were unable to locate any documentation explaining the missed appointment. RNS 1 stated it was important to document all actions in the resident's medical record and stated that, moving forward, the facility has implemented three separate tracking systems to monitor resident appointments.
During an interview and record review on 10/07/2025 at 2:23 p.m. with the Director of Nursing (DON), the DON stated that she had interviewed all staff members involved in coordinating appointments, including the social services team, but no one could explain why Resident 1's appointment was missed. The DON stated that she has since conducted multiple in-service training courses and revised the facility's appointment coordination process to ensure all responsible parties were involved and accountable. The DON stated she felt bad over Resident 1's missed appointment.
During a review of the facility's dated 12/2016. policy and procedure titled, Resident Rights, indicated The rights include residents right to be notified of his or her condition and of any changes in his or her condition.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
HARBOR POST ACUTE CARE CENTER in TORRANCE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TORRANCE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HARBOR POST ACUTE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.