Heritage Rehabilitation Center
Inspection Findings
F-Tag F688
F-F688
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 28851
Residents Affected - Some Based on observations, interviews, and record review, the facility failed to:
1.Ensure to keep a separate log of uses from the emergency medication supplies.
2.Ensure the licensed nurses would document inventory count (cycle count) of narcotics (medication used to moderate to severe pain) stored in the Cubex (an automated dispensing cabinet with a computer-controlled system that stores and dispense medications) at change of shift. Twenty-four of 124 shifts did not have nurses' signatures, and the existing signatures of the remaining 100 shifts had identical signatures for the performing and witnessing nurses.
3.Ensure there were administration record of narcotic medications for three (3) of 30 sampled residents (Residents 5, 43, 239).
4.Ensure the facility's consent policy is outdated and did not match with current regulations.
These deficient practices had the potential for loss of accountability, medication errors, issues in residents' rights, and/or diversions or theft of medications.
Findings:
1. During a concurrent observation, interview, and record review on 6/11/2024 at 11:43a.m., with Assistant Director of Nursing (ADON) in the medication storage room at the nursing station A, there was an Emergency Kit ([EKIT] an emergency drug supply) logbook. Reviewed the logbook and the Emergency Drug Supply Log Sheet with the ADON, the ADON stated licensed nurses document medication taken from the EKIT and the Cubex on the Emergency Drug Supply Log Sheet.
During a review of the Cubex pharmacy transactions on 5/30/2024 indicated, there was a tablet of alprazolam (used to treat anxiety) 0.25 milligrams ([mg] a unit to measure mass) issued for Resident 5 on 5/30/2024 at 3:59 p.m.
During a review of Resident 5's physician orders indicated an order dated 5/30/2024 at 2:28 p.m. for alprazolam 0.25 mg, give 1 tablet by mouth every eight (8) hours as needed for anxiety.
During an interview on 6/11/2024 at 11:45 p.m., ADON stated this issuance of alprazolam was not recorded
in the Emergency Drug Supply Log Sheet.
During a review of the facility's policy and procedures (P&P), (undated), indicated . Cubex .Emergency STAT orders may be retrieved pursuant to the order of a prescriber for emergency or immediate administration to a resident of the facility . The CUBEX System keeps a complete and accurate record of all users accessing the cabinet .
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0755 During a review of the facility's P&P, Emergency Equipment, Supplies and Medications (E-KIT) (undated), indicated . Separated records of use shall be maintained for drugs administered from the supply. Such Level of Harm - Minimal harm or records shall include the name and dose of the drug administered, name of the patient, the date and time of potential for actual harm administration and the signature of the person administering the dose .
Residents Affected - Some 2. During an interview on 6/11/2024 at 11:45 p.m., with ADON stated the registered nurse (RN) of the incoming shift would perform the Cubex cycle count (a method of checks and balances by which the facility confirms physical inventory counts match their inventory records) with the outgoing RN of every shift.
During a concurrent interview and record review on 6/11/2024 12:01 p.m. with RN 2 reviewed Cubex controlled substance count with shift change sheet, RN 2 stated she performed the cycle count of Cubex this morning with the outgoing RN, however, she stated she forgot to sign in the shift count sheet.
During a review of the cycle count sheet, there are two columns, tilted Nurse 1 and Nurse 2, under each shift. A further review of the cycle count records indicated there were 24 of 124 total shifts did not have nurses' signatures between 5/1/24 to 6/11/2024 morning; 100 of the 124 shifts had identical signatures for both incoming and outgoing nurses.
During an interview on 6/11/2024 at 12:11 p.m., the Director of Nursing (DON) stated two RNs perform the Cubex cycle count at each shift and there were three shifts per day. DON referred to the cycle count sheet and stated one of the columns would be signed by the outgoing nurse, the other column by the incoming nurse. DON confirmed the signatures of both columns looked identical for the shifts that had signatures, and there were multiple shifts without signatures. DON stated the RNs did not sign the sheet correctly. Also, DON stated some forgot to sign as they completed the count.
During an interview on 6/11/2024 at 4 p.m., the DON stated she could not locate the Cubex cycle count policy.
3. During a review of Resident 5's physician orders indicated an order dated 5/30/2024 at 2:28 p.m., for alprazolam 0.25 mg, give 1 tablet by mouth every 8 hours as needed for anxiety.
During a review of the Cubex transactions on 5/30/2024 indicated, there was a tablet of alprazolam 0.25 mg issued for Resident 5 on 5/30/2024 at 3:59 PM.
During an interview on 6/12/2024 at 11:20 a.m., reviewed Resident 5's electronic medication administration
record (eMAR) of May 2024. The DON stated the administering nurse did not record the administration of Resident 5's alprazolam on 5/30/2024.
During an observation on 6/12/2024 at 2:22 p.m. at the medication cart labeled Station B1 (7-3 shift (morning shift), 3-11 shift (afternoon shift), the licensed vocation nurse (LVN 7) presented a bubble pack (form of tamper-evident packaging of medication) of hydrocodone-acetaminophen (potent narcotic for the treatment of pain) 5-325 mg for Resident 43.
During a review of Resident 43's physician order of hydrocodone-acetaminophen 5-325 mg (dated 5/30/2024 at 6:44 PM) indicated to give 1 tablet by mouth every 6 hours as needed for severe pain.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0755 During a review of the Narcotic and Hypnotic Record for Resident 43's hydrocodone-acetaminophen 5-325 mg indicated there were three doses issued in June 2024: one dose on 6/1/2024 at 9:13 AM, 6/8/2024 at 2 p. Level of Harm - Minimal harm or m., and one dose on 6/11/2024 at 2:19 p.m. potential for actual harm
During a concurrent interview and record review on 6/12/2024 at 2:35 p.m. with the DON, reviewed Resident Residents Affected - Some 43's eMAR. The DON stated there was no documentation in MAR for two of three doses shown on narcotic record; the doses on 6/8/2024 at 2 p.m., and on 6/11/24 at 2:19 p.m., did not have a matching administration
record in the resident's eMAR.
During an observation on 6/12/2024 at 2:55 p.m. at the nursing station A medication cart, the licensed vocational nurse (LVN 5) presented a bubble pack of Norco 10/325 mg for Resident 239.
During a review of Resident 239's physician order of Norco 10-325 mg dated 6/7/2024 at 12:13 p.m. indicated to give 1 tablet by mouth every 8 hours as needed for moderate to severe pain.
During a review of the Narcotic and Hypnotic Record for Resident 239's Norco 10-325 mg indicated there was one dose issued on 6/1/2024 at 9:13 a.m.
Norco narcotic record 6/12/24 at 6 AM.
During a concurrent interview and record review on 6/12/2024 at 3:03 p.m., with the DON, reviewed Resident 239's eMAR. The DON stated there was no documentation in the eMAR for the following doses as indicated
on the Narcotic Record: 6/7/2024 at 6 a.m., and 6/12/2024 at 6 a.m. The DON stated the administering nurses did not document the administrations of these two doses.
During a review of the facility's P&P titled Oral Medication Administration (undated) indicated, . Return to the Medication Cart and document medication administration with initials in appropriate spaces on the MAR.
4. During an interview on 6/12/2024 at 9:54 a.m., the ADON stated the prescriber obtained informed consents for residents' psychotropic uses; when facility got the order, nurses contact resident and/or family member to inform them of such order and verify if they had given consent to receive the psychotropic medications.
During a review of the facility's P&P, Consent Requirements For Psychotherapeutic Medications (undated), indicated . There is no requirement to obtain a new consent when a dosage change is made . The facility and nurses are neither responsible to determine that all risks are enumerated and disclosed .The facility is not responsible for obtaining a signature .
During an interview on 6/12/2024 at 10:10 a.m., ADON acknowledged the facility P &P did not match the current regulatory requirements.
During a telephone interview on 6/12/2024 at 3:27 p.m. the facility consultant pharmacist stated the facility was aware of the outdated consent policy and they were in the process of updating the policy.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 28851 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure the label of a bubble pack (unit-dose card that packages doses of medication within small, clear, or light-resistant plastic bubbles) reflected the current dosage, and/or a change in dosage, for one (1) of 30 sampled residents (Resident 239).
This deficient practice had the potential for medication error.
Findings:
During an observation on 6/12/2024 at 2:55 p.m. at the nursing station A medication cart, the Licensed Vocational Nurse (LVN 5) presented a bubble pack belonged to Resident 239. The pharmacy label on the bubble read: hydrocodone-acetaminophen (potent narcotic for the treatment of pain) 10-325 milligrams ([mg] unit to measure mass), take one tablet by mouth every eight hours for pain management.
During a review of Resident 239's physician orders indicated Norco 10-325 mg, give 1 tablet by mouth every 6 hours as needed (PRN) for moderate to severe pain (pain level 6-10), ordered on 6/7/2024 at 12:13 p.m.
During an interview on 6/12/2024 at 3:03 p.m., the Director of Nursing (DON) stated Resident 239's routine order of Norco had been discontinued and replaced by a PRN order. The DON stated when there was a change of dosage and the remainder tablets can be used, the nurse should contact the pharmacy and obtain
a change of dose sticker to be placed on the bubble pack. -+
During a review of the facility's policy and procedures (P&P) titled Guidelines for Medication Administration (undated) indicated, . If a discrepancy exists, . consult the appropriate resource(s) such as the pharmacist . If label directions are incorrect, the medication nurse is responsible for affixing a direction change sticker. If the Medication Administration Record and the medication labeling do not match, the medication nurse should investigate the discrepancy .
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 41699
Residents Affected - Some Based on interview and record review, the facility's Quality Assessment and Assurance ([QAA] a group which develops and implements appropriate plans of action to correct identified quality deficiencies) committee and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality
in nursing homes while involving residents and families) committee failed to:
1. Ensure on-going assessment and reevaluation of physical restraints' continuous use were conducted.
2. Identify, assess, and implement interventions on residents with severe weight loss.
3. Identify, assess, and implement interventions on residents with pain during wound care treatment.
4. Ensure Restorative Nurse Aide services were implemented to residents as ordered.
These deficient practices placed the residents at risk for not receiving the quality-of-care treatment necessary to adequately meet their highest practicable well-being and placed the residents.
Findings:
During an interview with the Administrator, Quality Assurance Nurse and the Director of Nursing (DON) on 6/13/2024 at 3:09 p.m., the DON stated not being able to identify systemic issues identified even before the survey. The QA Nurse and the DON, both stated QAA was supposed to identify systemic issues and address it. The Administrator acknowledged the facility had opportunities for improvement of all mentioned deficient practices.
During a record review of the facility's policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) Program revised 3/2020, the policy indicated This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. To provide a means to measure current and potential indicators for outcomes of care and quality of life. To provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. To reinforce and build upon effective systems and processes related to the delivery of quality car and services. To establish systems through which to monitor and evaluate corrective actions.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0880 Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49145 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain and observe infection Residents Affected - Many control practices by failing to:
1. Ensure Certified Nursing Assistant (CNA) 1 and 2, performed hand hygiene in between residents when passing lunch trays.
2. Ensure Restorative Nursing Aide 1 (RNA 1) use the appropriate cleaning agent to effectively clean and disinfect a cloth gait belt (safety device worn around the waist that can be used help safely transfer a person from one surface to another or while walking) after completing RNA walking exercises with Resident 96.
These deficient practices had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection.
3.Ensure Resident 3's nephrostomy tube (a drainage tube placed into the kidney to drain urine directly from
the kidney) drainage should be below the level of the kidneys.
This deficient practice had the potential for backflow of urine that can lead to infection.
Findings:
1.During an observation on 6/13/2024 at 12:40 p.m., in the hallway, Certified Nursing Assistant (CNA) 1 and 2, were observed not performing hand hygiene while passing meal trays to the residents.
During an interview on 6/13/2024 at 12:50 p.m., with CNA 1, CNA 1 stated she did not perform hand hygiene between residents while passing out their lunch trays. CNA 1 stated she should be performing hand hygiene when passing trays to prevent the spread of infection.
During an interview on 6/13/2024 at 12:50 p.m., with CNA 2, CNA 2 stated she was rushing when passing out the lunch trays and forgot to perform hand hygiene. CNA 2 stated she should have performed hand hygiene because it was important in the prevention of spreading germs and infection to the residents.
During an interview on 6/13/2024 at 1:04 p.m., with the Infection Prevention Nurse (IP), the IP Nurse stated
the staff should be performing hand hygiene when passing lunch trays to prevent the spread of infection which could potentially cause the residents to get sick.
During a record review of the facility's policy and procedure (P&P), titled Handwashing/Hand Hygiene, revised August 2019, indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitor.
45382
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0880 2. During a review of Resident 96's Admission Record indicated Resident 96 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including spinal stenosis (condition that occurs when the Level of Harm - Minimal harm or spaces in the spine narrow and put pressure on the spinal cord and nerve roots), metabolic encephalopathy potential for actual harm (brain dysfunction caused by a chemical imbalance in the blood), and high white blood cell (part of the body responsible for protecting the body from infection) count. Residents Affected - Many
During an observation and interview on 6/11/2024 at 9:21 a.m., with RNA 1 in the hallway, RNA 1 was observed completing walking exercises with Resident 96. Resident 96 was walking down the hallway using a walker (type of mobility aid with wide base of support) and had a cloth gait belt around the waist. RNA 1 assisted Resident 96 to walk down the hall into an activity room and assisted Resident 96 onto a bicycle machine for further exercises. Once Resident 96 was seated on the bicycle machine, RNA 1 removed the cloth gait belt from Resident 96's waist, walked to the dining room, and sprayed the cloth gait belt on both sides with liquid in a clear spray bottle labeled 70% isopropyl alcohol. RNA 1 stated cloth gait belts were made of fabric and used either 70% isopropyl alcohol or bleach wipes to disinfect cloth gait belts in between resident use. RNA 1 stated it was important to properly clean and disinfect cloth gait belts before and after resident use to prevent the spread of infection.
During an interview on 6/11/2024 at 11:46 a.m., the Administrator (ADM) stated the 70% isopropyl spray could be used as a disinfectant for many surfaces throughout the facility but was unsure if it was the appropriate cleaning agent to be used to disinfect porous (having small spaces or holes through which liquid or air may pass) materials such as fabric.
During an interview and record review on 6/12/2024 at 11:14 a.m., the Infection Preventionist nurse (IP) stated cloth gait belts were cleaned and disinfected using either the 70% isopropyl alcohol spray or the bleach germicidal wipes (disinfecting wipes) before and after resident use. The IP stated cloth gait belts were made of fabric, a porous material. The IP reviewed the manufacturer instructions for both the 70% isopropyl alcohol and the bleach germicidal wipes. The IP confirmed manufacturer instructions for the isopropyl alcohol spray indicated the alcohol spray could only be used on the skin for minor cuts or burns or on hard, non-porous surfaces and was ineffective on porous materials such as fabric. The IP confirmed the bleach germicidal wipes were to be used on non-porous, hard surfaces only and could not be used on fabric per manufacturer's instructions. The IP stated the isopropyl alcohol spray and bleach germicidal wipes were ineffective cleaning agents because cloth gait belts were made of porous materials. The IP stated the only way to properly clean and disinfect cloth gait belts was to launder them after each resident use. The IP stated it was important to clean and disinfect shared equipment properly to prevent the spread of infection and avoid cross contamination.
During an interview on 6/13/2024 at 1:55 p.m., the Director of Nursing (DON) stated shared resident equipment such as gait belts must be cleaned and disinfected in between resident use. The DON stated it was important shared resident equipment was cleaned and disinfected appropriately and according to manufacturer's guidelines to prevent the spread of infection.
During a review of the facility's undated policy and procedure (P&P), titled, Infection Control, the P&P indicated staff were to select equipment that could be easily cleaned and disinfected. The P&P indicated, do not use fabric-based equipment (e.g., chairs, stuffed toys, furry toys, transfer belts) if it will likely be contaminated with body fluids.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0880 During a review of the facility's P&P, revised 10/2018, titled, Cleaning and Disinfection of Resident-Care Items and Equipment, indicated Resident care equipment, including reusable items and durable medical Level of Harm - Minimal harm or equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention potential for actual harm (CDC) recommendations for disinfection and the Occupational Safety and Health Administration
Residents Affected - Many (OSHA) Bloodborne Pathogens Standard. The P&P further indicated reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions.
41699
3. During a review of Resident 3's Admission Order, the Admission Record indicated Resident 3 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including paraplegia (paralysis that affects your legs, but not your arms), and unspecified epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures [involuntary muscle movements])
During a review of Resident 3's Minimum Data Sheet (MDS- a comprehensive assessment and care planning tool) dated 5/10/2024 indicated Resident 3 had moderate cognitive impairment (ability to learn, understand, and make decisions) and requires maximum assistance for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene.
During an observation on 06/10/2024 at 10:48 a.m.,11:45 a.m., 12:47 p.m., and 2:10 p.m., observed Resident 3 nephrostomy tube bag on top of the bed next to the resident parallel to his body.
During an interview on 6/11/2024 at 2:50 p.m., the Director of Staff Development (DSD) stated nephrostomy tube drainage must be below the Resident 3's kidney to prevent reflux (flow backwards) of the urine to prevent infection.
During an interview on 6/13/2024 at 8:54 a.m., the Licensed Vocational Nurse (LVN 4) stated when nephrostomy tube bag was in the same level of the kidney urine does not flow by gravity and can create urine backflow and might lead to infection.
During a review of facility's P&P titled Nephrostomy Tube, Care of(undated), indicated Drainage should be below the level of the kidneys.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 43 056308
F-Tag F725
F-F725
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0692 Provide enough food/fluids to maintain a resident's health.
Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45981
Residents Affected - Few Based on interview, and record review, the facility failed to prevent the resident's unplanned severe weight loss (a weight loss greater than 5 % in one month, greater that 7.5% in three months and greater than 10 %
in 6 months) of nine (9) pounds ([lbs.] 9.57 percent [%] in one month for one of two sampled residents (Resident 129). The facility failed to:
1. Ensure the Registered Dietician's ([RD] a health professional who has a special training in diet and nutrition) recommendation to increase Resident 129's enteral (form of nutrition that is delivered into the digestive system as liquid) feeding from 250 milliliter ([ml] unit of measurement) four times per day to 250 ml five times per day totaling 1500 calories ([kCal] energy people get from the food and drink they consume, and the energy they use in physical activity) were followed and provided.
2.Ensure staff monitored Resident 129's weight and reported the resident's five pounds weigh loss to Resident 129's physician and RD in accordance with the care plan titled Risk for Malnutrition (lack of significant nutrients [substance used in the body to function] leading to physical decline).
3. Ensure the facility's staff informed the RD when Resident 129 had a 9.57 % weight loss from 4/29/2024 through 6/1/2024 for RD to evaluate and make necessary recommendations on Resident 129's enteral feeding formula to provide Resident 129 with a sufficient amount of calories and nutrients to prevent Resident 129's severe weight loss of 9.57 % in 34 days in accordance with the facility's policy and procedure (P&P) titled, Nutrition (Impaired/Unplanned Weight Loss-Clinical Protocol.
4. Ensure licensed staff followed facility's P&P titled, Weight Assessment and Intervention and immediately notified the Dietician in writing of Resident 129's weight loss of 5% or more since the last weight assessment
on 4/29/2024.
5. Ensure the RD completed Resident 129's full nutritional assessment upon admission to the facility on [DATE REDACTED] and monitor Resident 129's weight and caloric intake, who was receiving tube feeding nutrition, and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of tube feedings per facility's P & P.
These deficient practiced resulted in Resident 129's severe weight loss of 9.57 % in 34 days and placed Resident 129 at risk for malnutrition, dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake), skin break down, having feelings of depression and hopelessness.
Findings:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0692 During a review of Resident 129's Admission Record, indicated Resident 129 was admitted to the facility on [DATE REDACTED], with diagnoses including amyotrophic lateral sclerosis ( a nervous system disease that affects nerve Level of Harm - Actual harm cells in the brain and spinal cord), dysphagia (difficulty of swallowing), gastrostomy tube ([GT] a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition), deep tissue injury Residents Affected - Few ([DTI] purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) to a sacral (tailbone) area, and muscle wasting (loss of muscle tissue).
During a review of Resident 129's History and Physical (H&P), dated 4/28/2024, the H&P indicated, Resident 129 did not have decision making capacity.
During a review of Resident 129's Minimum Data Set ([MDS], a standardized assessment and care screening tool]) dated 5/1/2024, the MDS indicated Resident 129 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated Resident 129 height was five feet (unit of measurement) and three inches (unit of measurement) and weighed 94 pounds ([lbs.] unit of weight). The MDS indicated Resident 129 was receiving nutrition via GT.
During a review of Resident 129's Weights and Vitals Summary from 4/29/2024 to 6/1/2024, the Weights and Vitals Summary indicated the following resident's weekly weight:
1. On 4/29/2024 - 94 pounds.
2. On 5/5/2024- 93.4 pounds.
3. On 5/12/2024- 87 pounds (7.0 pounds [7.45%] weight loss).
4. On 5/19/2024- 87.4 pounds (6.6 pounds [7.02%] weight loss).
5. On 5/26/2024- 85.4 pounds (8.6 pounds [9.15 %] weight loss).
6. On 6/1/2024- 85 pounds (9.0 pounds [9.57 %] weight loss).
During an interview on 6/12/2024 at 10:30 a.m., the License Vocational Nurse (LVN 5) stated when Resident 129 had a weight loss of nine (9) pounds from 4/29/2024 to 6/1/2024, a change of condition (COC) documentation should have been done, Resident 129's physician and RD should have been informed and an Interdisciplinary team ([IDT]- group of healthcare professional s working together to plan the care needed for each residents) meeting should be held immediately in order to address the resident's weight loss and recommend interventions to prevent further resident's weight loss. LVN 5 stated Resident 129 was getting weighed weekly due to a weight loss. LVN 5 stated she did not report Resident 129's severe weight loss of 9 pounds (9.57 %) to RD and the physician. LVN 5 stated severe weight loss should be reported immediately to Resident 129's physician and RD because Resident 129 could lose more weight that can lead to hospitalization due to malnutrition.
During a review of Resident 129's care plan titled, Risk for Malnutrition, dated 4/28/2024 indicated a goal for Resident 129 was not to have significant weight loss of five lbs. in one month (5 % in one month, 7.5 % in 3 months, 10 % in 6 months). The care plan interventions included to monitor the resident's weight and report five lbs. weight loss to the physician and RD promptly and notify the physician of significant weight change and refer to dietician.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0692 During a review of Resident 129's Care Plan titled GT feeding, dated 4/28/2024 indicated a goal for Resident 129 was to maintain adequate nutrition and hydration (fluid intake) status and to have a stable weight with no Level of Harm - Actual harm signs and symptoms of malnutrition or dehydration.
Residents Affected - Few During a review of RD's Nutrition/Dietary Progress Note dated 4/28/2024 and timed at 6:55 p.m., the Nutrition/Dietary Progress Note indicated Resident 129 was receiving 250 ml of enteral feeding with formula Fibersource 1.2 four times daily. Resident 129 body mass index ([BMI] measure body weight to height and whether a resident has a healthy weight) was 17.9 (BMI between 18.5 and 24.9 -underweight, BMI healthy range -between 25 and 29.9, and BMI between 30 and 39.9- overweight). The RD's Nutrition/Dietary Progress Note indicated RD's recommendation to change GT enteral feeding formula to 250 ml five times a day to provide Resident 129 with 1250 ml (1500 kcal) daily. The RD's Nutrition/Dietary Progress Note indicated the RD's full assessment of Resident 129 nutritional needs will follow.
During a review of Resident 129's Nutritional Review Screening, dated 4/29/2024 completed by Dietary Supervisor (DS) indicated based on Resident 129's usual body weight (UBW) of 115 lbs. the resident's estimated daily need for calories were 1495-1709 kcal. The Nutritional Review Screening indicated recommendation including change enteral feeding to 250 ml five times daily to provide 1250 ml equal to 1500 kcal, 67 grams of protein, 1512 ml of free water (fluids with no salt content), and Multivitamins (dietary supplement containing all or most of the vitamins) with Minerals.
During a review of Resident 129's Medication Administration Record (MAR) dated 5/2024, the MAR indicated
the Enteral Feeding Order for Fibersource HN 1.2 four times a day as follows: 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime).
During a review of Resident 129's Physician Order Summary dated 5/2024, indicated Enteral Feeding Order for Fibersource HN 1.2 four times a day as follows: 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime).
During a review of Resident 129's MAR for the month 5/2024 indicated Resident 129 only received 250 ml of Fibersource for lunch instead of 500 ml as ordered:
1. From 5/3/2024 to 5/13/2024 (10 days) - Fibersource 250 ml.
2. On 5/14/2024- Fibersource 300 ml.
3. From 5/18/2024 to 5/20/2024 (there days)- Fibersource 250 ml.
4. On 5/27/2024- Fibersource 250 ml.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0692 During a concurrent interview and record review on 6/12/2024 at 11:05 a.m., the Director of Nursing (DON) stated residents (in general) with weight loss will trigger for weekly weight variance review (report generated Level of Harm - Actual harm to determine how much weight a resident has lost and recommendations to prevent further weight loss) and
a weekly weight variance meeting to discuss the plan of care for a residents (in general). The DON stated Residents Affected - Few Resident 129 was triggered for a weight variance weekly review meetings because the resident was at high risk for weight loss. The DON stated weekly weight variance meeting allows the facility to monitor Resident 129's weight and allows the facility to ensure that implemented interventions were successful. The DON stated weekly weight variance meeting also allows to evaluate if other interventions could be implemented to prevent further weight loss. The DON stated the weekly weight variance meetings were documented on the Progress Notes by nursing and the RD. After a review of Resident 129's Nurses Progress Notes and RD Progress Notes the DON stated, there was no documentation from nursing and the RD for the weekly variance meetings to address the resident's weight loss. The DON stated, if there was no documentation it means it was not done. After the DON reviewed Resident 129's Initial Nutritional Assessment, the DON confirmed the last documentation from the RD was the initial mini nutritional assessment (nutrition screening and assessment tool that can identify residents who are malnourished or at risk of malnutrition) done on 4/29/2024. The DON stated 9.57 % weight loss was considered a severe weight loss and required weekly monitoring by the facility. The DON stated the RD should have monitor Resident 129 to ensure the resident did not lose additional weight. The DON stated the staff communicates with the RD via text message regarding the weekly weight variance meetings. The DON stated it was the licensed nurses responsibility to ensure Resident 129's weight loss was communicated to the resident's physician and RD in order to prevent negative outcomes such as severe weight loss and dehydration. The DON stated when residents (in general) do not receive adequate nutrition they could have negative effects such as skin break down and malnutrition.
During a concurrent interview and record review on 6/12/2024 at 1:30 p.m. with RD, the RD stated she was responsible for nutritional assessments of residents on admission and quarterly assessment which includes evaluating and addressing residents' (in general) high risk for weight loss. RD stated residents (in general) who were on GT feedings should be weighed weekly and a weekly variance meeting should be held to discuss interventions to prevent weight loss. The RD stated she does not attend the weight variance meeting; the licensed staff communicates with her via text message about any weight loss and other concerns discussed during the weight variance meeting. The RD stated she follows up with residents (in general) that have weight loss weekly. The RD stated she has done Resident 129's mini nutritional assessment on 4/29/2024 and a full assessment of Resident 129 nutritional status and needs should have been done as well. The RD confirmed that Resident 129's full assessment had not been done since the resident's admission to the facility on [DATE REDACTED]. After RD reviewed her weekly progress notes, for Resident 129, she stated there was no weekly documentation for Resident 129's weight loss. Resident 129's Nutrition/Dietary Progress, dated 4/28/2024, indicated recommendation to change GT feeding to 250 ml five times daily to provide 1250 ml equivalent of 1500 kcal. with full assessment to follow. Reviewed Resident 129's MAR date 5/2024, the MAR indicated Enteral Feed Order four times a day Fibersource HN 1.2 250 ml (Breakfast), 500 ml (Lunch), 250 ml (Dinner), 250 ml (Bedtime). The RD stated Resident 129's enteral feeding order for 250 ml four times a day was not providing enough calories to Resident 129 and confirmed
the facility's staff did not follow with her recommendation to increase the feeding to 250 ml five times a day.
The RD stated Resident 129 did not receive the estimated needs of 1511 to 1727 kcal a day. The RD stated 9.57 % weight loss in 34 days was considered a severe weight loss and the facility's staff should have reported it immediately to Resident 129's physician and her. The RD stated Resident 129 could have become malnourished which would cause further skin breakdown from not receiving enough calories and protein per day.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0692 During a concurrent interview and record review on 6/12/2024 at 2:09 p.m., with LVN 1, LVN 1 stated during weekly weight variance meetings residents (in general) weight loss was discussed. LVN 1 stated any Level of Harm - Actual harm recommendations from the weekly weight variance meetings were communicated to the RD via text message and documented on the Nurses Progress Notes. LVN 1 reviewed Resident 129's Nurses Progress Residents Affected - Few Notes and stated there was no documentation RD was notified about Resident 129's severe weight loss. LVN 1 confirmed that there was no documentation for Resident 129's weekly weight variance meeting and it was not held since Resident 129's admission on 4/27/2024. LVN 1 stated if it was not documented it means
it was not done. LVN 1 stated 9.57 % weight loss in 34 days was considered a severe and had the potential to cause a negative outcome for Resident 129's health.
During an interview on 6/12/2024 at 2:23 p.m., the Dietary Supervisor (DS) stated she attends the weekly weight variance meetings. The DS stated she communicates with RD on Mondays regarding the weekly weight variance meeting. The DS stated there was no weight variance meeting held for Resident 129's severe weight loss of 9.57 % in 34 days from 4/27/2024 to 6/1/2024. The DS stated it was important to monitor Resident 129's weight to ensure that the interventions were effective in order to prevent further weight loss. The DS stated Resident 129's severe weight loss put the resident at risk for dehydration, malnutrition, skin breakdown and hospitalization . The DS stated nursing staff document the weekly weight variance meetings in a resident's (in general) Progress Notes. The DS stated 9.57% of weight loss in 34 days was considered a severe weight loss.
During a review of the facility's P&P titled, Weight Assessment and Intervention dated 9/2008, indicated, Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will review the unit weight record by the 15th of the month for follow individual weight trends over time.
During a review of the facility's P&P titled, Enteral Nutrition, dated 11/2018, the P&P indicated, The dietician with input from the provider and nurses: estimate calorie, protein, nutrients, and fluid needs. Determine whether the resident's current intake is adequate to meet his or her nutritional needs. The dietician monitors residents who are receiving enteral nutrition and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of enteral feedings.
During a review of the facility's P&P titled, Nutritional Assessment, [undated], indicated, The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that place the resident at risk for impaired nutrition.
During a review of the facility's P&P titled, Nutrition Impaired/Unplanned Weight Loss-Clinical Protocol, [undated], indicated, The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include evaluating the care plan to determine if the interventions are being implement and whether they are effective
in attaining the established nutritional and weight goals.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0697 Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45269
Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure the resident, who had a Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joints}, and bones caused by prolonged pressure on the skin) to sacrum (tailbone area), did not experience unnecessary pain and suffering during pressure ulcer treatment and repositioning for one of five sampled residents (Resident 73). The facility failed to:
1. Ensure the Registered Nurse (RN 6) provided Resident 73 with effective pain relieve when Resident 73 loudly screamed and moaned during the sacral pressure ulcer treatment.
2. Evaluate the pain relieve effectiveness of Tylenol (pain medication) 325 milligrams ([mg]-a unit of measurement) two tablets given to Resident 73's as ordered prior to pressure ulcer treatment before the start of pressure ulcer treatment.
3. Notify Resident 73's physician (MD 1) of Resident 73's pain management with Tylenol was unsuccessful when Resident 73 continue to moan and scream during the pressure ulcer treatment on 6/10/2024 and 6/13/2024.
4. Ensure RN 6 identified frequency, location, quality, onset, and manner of pain when Resident 73's experienced pain, in accordance with the resident's Care Plan titled, Potential for altered comfort which maybe evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacral area, bilateral knee osteoarthritis (degenerative joint disease) and pancreatic mass (tumor that forms in the cells of pancreas) dated 4/20/2023.
These failures resulted in Resident 73's to experience severe, unrelieved, and uncontrolled pain manifested by loud screaming and moaning during pressure ulcer treatment and personal care on 6/10/2024 and 6/13/2024.
Findings:
During an observation and concurrent interview on 6/10/2024, at 10:09 a.m., Resident 73 was observed screaming, groaning, and moaning with facial grimaces (facial expression usually suggesting pain or disgust). Concurrently, during an interview, Resident 73 nodded the head Yes and grimaced when asked if
she was having pain.
During an interview on 6/10/2024, at 10:09 a.m. with Resident 62 (Resident 73's roommate) Resident 62 stated Resident 73 was constantly groaning and moaning especially when staff was cleaning or doing personal care. Resident 62 stated staff members were aware of Resident 73's moaning and screaming.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0697 During an observation of RN 6 preparation for Resident 73's sacral pressure ulcer treatment on 6/10/2024, at 10:30 a.m., in Resident 73's room, Resident 73's physician (MD 1) entered the resident 's room and informed Level of Harm - Actual harm RN 6 he (MD 1) will put an order for Norco (narcotic [used to treat moderate to severe pain] pain medication) to administer prior to pressure ulcer treatment as Resident 73 was observed moaning and screaming. RN 6 Residents Affected - Few replied to MD 1 that Resident 73 does not need Norco as Resident 73 will receive Lidocaine spray (anesthetic topical [applied to the skin] spray) prior to the pressure ulcer treatment.
During an observation Resident 73's pressure ulcer treatment on 6/10/2024, at 10:32 a.m., Resident 73 was observed screaming and moaning when RN 6 positioned Resident 73 on her back with head of the bed in a flat position. RN 6 left Resident 73's room and ask another staff member to assist during pressure ulcer treatment. RN 6 came back with the Director of Staff Development (DSD). RN 6 and DSD turned Resident 73 to her right side. Resident 73 continuously moaned and screamed. RN 6 was observed to spray Resident 73's sacral Stage 4 pressure ulcer surrounding area with Lidocaine spray before the start of treatment. Resident 73 screamed and moaned louder when RN 6 cleaned the reddened surrounding area of Stage 4 sacral pressure ulcer with Hibiclens (liquid antibacterial cleanser) and applied Collagen powder (wound dressing that is applied topically) to the pressure ulcer. RN 6 completed the pressure ulcer treatment despite Resident 73's moaning and screaming.
During a review of Resident 73's Admission Record, the Admission Record indicated Resident 73 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), osteoarthritis of both knee (degenerative joint disease), a Stage 4 pressure ulcer to the sacral region, and attention/ concentration deficit.
During a review of Resident 73's History and Physical (H& P) dated 5/9/2024, indicated Resident 73 was not able to express needs, communicate, not to follow commands and talked in full sentences. Resident 73 had no decisions making capacity.
During a review of Resident 73's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 5/1/2024, indicated Resident 73 was dependent on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated Resident 73 had a Stage 4 pressure ulcer on the sacrum (sacral area).
During a review of Resident 73's Physician's Order dated 6/10/2024, the Physician's Order indicated the order for Lidocaine spray to apply to the resident's sacral area topically every day for pain management
during sacral pressure ulcer treatment.
During a review of Resident 73's Physician Order dated 4/20/2024, the Physician order indicated to cleanse sacral wound with Hibiclens, pat dry, apply Collagen powder to the pressure ulcer base then apply Hydrofera Blue (special dressing type) then cover with Allevyn (dressing) every day (7 a.m.to 3 p.m.) Monday, Wednesday, and Friday.
During an interview on 6/10/2024, at 10:45 a.m., and subsequent interview on 6/10/2024, at 11:22 am., with RN 6, RN 6 stated the Lidocaine spray was the only medicine he used to help with Resident 73's pain during pressure ulcer treatment.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0697 During a concurrent interview and record review on 6/12/2024 at 9:36 a.m., with DSD, the DSD stated for residents, who are not able to verbalize pain, the facility was using the facial pain scale tool (a picture with of Level of Harm - Actual harm different facial expressions referencing different pain level to help a resident effectively communicate the severity of their physical pain) to assess pain level. The DSD stated Resident 73 screamed loudly when RN Residents Affected - Few 6 cleansed Resident 73's pressure ulcer with Hibiclens and when the Collagen powder was applied to the resident's Stage 4 sacral pressure ulcer. The DSD stated when Resident 73 screamed loudly during the pressure ulcer treatment, RN 6 should have stopped the treatment, assessed Resident 73 pain level, including the non-verbal cues like facial grimacing, notified the physician, and provide Resident 73 pain medication. The DSD reviewed Resident 73's Medication Administration Record (MAR) and stated Resident 73 received Tylenol 325 mg two tablets on 6/10/2024, at 10:07 a.m., prior to pressure ulcer treatment for pain level 3 out of 10 on a pain scale rating from zero to ten (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). The DSD stated based on Resident 73 screaming and moaning
during sacral pressure ulcer treatment Tylenol given at 10:07 a.m. was not effective to alleviate Resident 73's pain. The DSD stated Resident 73 experienced excruciating (extremely painful, causing intense suffering) pain and discomfort during the pressure ulcer treatment which was unnecessary pain. The DSD stated RN 6 should have asked the physician for a stronger pain medication after the resident screamed
during sacral pressure ulcer treatment on 6/10/2024.
During an interview on 6/12/2024, at 3:31 p.m., with Treatment Nurse (TN 1), the TN 1 stated she coordinated Resident 73's pressure ulcer treatment with the charge nurse in order to give pain medication to
the resident before pressure ulcer treatment. TN 1 stated for residents, who could not verbalize pain and its severity, the staff used non-verbal indication of pain like screaming, moaning, or crying, and facial grimace. TN 1 stated Resident 73 screamed and moaned during pressure ulcer treatment, and it was an indication the resident was in excruciating pain. TN 1 stated Lidocaine spray was used topically and only applied on the skin and would not be enough to help with the pain during treatment. TN 1 stated if the resident screamed and moaned during pressure ulcer treatment RN 6 should have stopped the treatment, call the physician because the Lidocaine spray was not effective in managing Resident 73's pain. TN 1 stated Resident 73 should be assessed for pain before and during pressure ulcer treatment. TN 1 stated Resident 73's unrelieved pain could affect her health and comfort if her pain was not managed effectively.
During an interview and record review on 6/12/2024 at 4:08 p.m., RN 6 stated when Resident 73 screamed from pain during the pressure ulcer treatment, he should stopped the treatment and notified the Resident 73's MD 1. RN 6 stated on 6/10/2024, MD 1 came to the resident's room and told him (RN 6) about ordering Norco for pain because of the moaning and crying, and confirmed he told MD 1 Resident 73 did not need Norco because the Lidocaine spray was being applied to the pressure ulcer. RN 6 stated Resident 73's family did not want the resident to have any strong pain medication. RN 6 confirmed thru record review of Interdisciplinary Team Meeting ([IDT]-a healthcare team members and resident / family representative collaborate, solve problems, plan, and coordinate care of the resident) Notes and Care Plan there was no documentation of Resident 73's family not wanting strong pain medication to be given to Resident 73 during pressure ulcer treatment. RN 6 stated Resident 73 was suffering from pain during a sacral pressure ulcer treatment manifested by the resident's screaming and moaning. RN 6 stated Resident 73 continued to suffer from pain because her pain was not addressed and managed during the pressure ulcer treatment on 6/10/2024. RN 6 stated Tylenol's pain relieve effectiveness was not evaluated prior to begin the treatment.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0697 During an observation on 6/13/2024, at 10:54 a.m., with TN 1 and Certified Nursing Assistant (CNA 5) in Resident 73's room, Resident 73 was observed starting moaning during repositioning. Resident 73 observed Level of Harm - Actual harm moaned louder as the TN 1 started to clean the surrounding skin area of the sacral pressure ulcer and applying the Collagen powder on the pressure ulcer. TN 1 observed to pause the pressure ulcer treatment Residents Affected - Few and started reassuring the resident and massaging the resident's skin. TN 1 was observed to resume the treatment when Resident 73 stopped moaning.
During an interview on 6/13/2024, at 12:45 p.m. the TN 1 stated Resident 73 moaned during pressure ulcer treatment due to pain. TN 1 stated the resident had dementia and it was hard to tell when the resident was in pain, but the presence of pain should still be addressed by staff by using the resident's facial clues, grimacing, moaning and jerky movement during treatment.
During an interview on 6/13/2024, 2:04 p.m., CNA 5 stated every time she would clean and change Resident 73 after a bowel movement, the resident would moan and cry. CNA 5 stated Resident 73 would also moan
during pressure ulcer treatment.
During a review of Resident 73's Care Plan titled Potential for altered comfort evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacrum, bilateral knee osteoarthritis and pancreatic mass (tumor that forms in the cells of pancreas), dated 4/20/2023, the goal for Resident 73 was to be comfortable.
The Care Plan's interventions included to identify frequency, location, quality, onset, and manner of expressed pain and administer medication as ordered.
During a review of Resident 73's Care Plan titled, Resident has a Stage 4 sacral pressure ulcer on admission, initiated on 10/30/2023 indicated one of the interventions was to assess pain and discomfort at site of the altered skin area.
During a concurrent interview and record review of Resident 73's Physician Order on 6/13/2024, at 3:31 p.m. with Director of Nursing (DON), the DON confirmed the physician order for Tylenol 325 mg two tablets for pain relief did not include the pain parameters, however, Resident 73 had an order to monitor the intensity of pain using numerical pain rating scale. The DON stated pain level was not assessed properly and Resident 73's pain was not managed effectively during pressure ulcer treatment. The DON stated Resident 73 should be assessed for pain during and after pressure ulcer treatment. The DON stated if the resident was experiencing pain by screaming and moaning, the pressure ulcer treatment should be stop, the staff should have assessed the resident for pain, addressed the pain if pain was present, called Resident 73's physician to notify about the presence of pain. The DON stated Resident 73 had experienced undue suffering which could have been prevented if the resident was assessed properly for pain management.
During a review of facility's policy and procedure (P&P) titled Pain Assessment and Management, undated,
the P&P indicated to observe the resident during rest and movement for physiologic and behavioral (non-verbal) signs of pain. The P& P indicated possible behavioral signs of pain are verbal expressions such as groaning, crying, screaming, facial expressions such as grimacing, frowning, behavior such as resisting care, irritability, or depression. The P&P indicated to review resident's treatment record to identify any situations or interventions where an increase in the resident's pain may be anticipated such as treatment like wound care or dressing changes.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0697 During a review of facility's P&P titled Pressure Ulcer Treatment, undated, the P&P indicated to review the resident's care plan to assess for any special needs of the resident. The P&P indicated for residents who had Level of Harm - Actual harm a Stage 4 Pressure Injury one of the guidelines was to manage pain during wound care.
Residents Affected - Few According to a review the article titled The Symptoms of Pain with Pressure Ulcer: A Review of the Literature, dated 5/2008 on website for Wound Care Leading Management and Prevention, pain is an issue
in persons with pressure ulcers, measuring and managing pain will become more important for effective care with an aging population at risk for pressure ulcer development.
https://www.hmpgloballearningnetwork. com/site/wmp/content/the-symptom-pain-with-pressure-ulcers-a-review-literature
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 45382
Residents Affected - Some Based on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services.
This deficient practice had the potential for 95 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint) and mobility (ability to move).
Findings:
During a review of the Order Listing Report of RNA orders for 6/2024 indicated 95 residents had physician's orders for RNA to provide either assistance with sit-to-stand transfers, ROM exercises to the arms, ROM exercises to the legs, application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and / or increase range of motion), ambulation (walking), stair climbing exercises, or exercises on the arm bicycle (stationary piece of equipment using a cycling motion for the arms to provide
a cardiovascular and strength workout).
During a review of the facility's Nursing Staffing Assignment and Sign in Sheets for the month of May 2024 indicated the following total number of RNAs present for the day (7 a.m. to 3 p.m. shift and 6:30 a.m. to 3 p. m. shift):
Wednesday, 5/1/2024: Four (4) RNAs
Thursday, 5/2/2024: Three (3) RNAs
Friday, 5/3/2024: 4 RNAs
Saturday, 5/4/2024: Two (2) RNAs
Sunday, 5/5/2024: 2 RNAs
Monday, 5/6/2024: 3 RNAs
Tuesday, 5/7/2024: 4 RNAs
Wednesday, 5/8/2024: 3 RNAs
Thursday, 5/9/2024: 3 RNAs
Friday, 5/10/2024: 3 RNAs
Saturday, 5/11/2024: 3 RNAs
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0725 Sunday, 5/12/2024: 2 RNAs
Level of Harm - Minimal harm or Monday, 5/13/2024: 3 RNAs potential for actual harm Tuesday, 5/14/2024: 3 RNAs Residents Affected - Some Wednesday, 5/15/2024: 4 RNAs
Thursday, 5/16/2024: 3 RNAs
Friday, 5/17/2024: 4 RNAs
Saturday, 5/18/2024: 2 RNAs
Sunday, 5/19/2024: 2 RNAs
Monday, 5/20/2024: 4 RNAs
Tuesday, 5/21/2024: 4 RNAs
Wednesday, 5/22/2024: 2 RNAs
Thursday, 5/23/2024: 4 RNA
Friday, 5/24/2024: 4 RNAs
Saturday, 5/25/2024: 3 RNAs
Sunday, 5/26/2024: 2 RNA
Monday, 5/27/2024: 4 RNA
Tuesday, 5/28/2024: 3 RNAs
Wednesday, 5/29/2024: 3 RNAs
Thursday, 5/30/2024: Five (5) RNAs
Friday, 5/31/2024: 4 RNAs
During a review of the facility's Nursing Staffing Assignment and Sign in Sheets for the month of June 2024 indicated the following total number of RNAs present for the day (7 a.m. to 3 p.m. shift and 6:30 a.m. to 3 p. m. shift):
Saturday, 6/1/2024: 4 RNAs
Sunday, 6/2/2024: 3 RNAs
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0725 Monday, 6/3/2024: 4 RNAs
Level of Harm - Minimal harm or Tuesday, 6/4/2024: 2 RNAs potential for actual harm Wednesday, 6/5/2024: 2 RNAs Residents Affected - Some Thursday, 6/6/2024: 3 RNAs
Friday, 6/7/2024: 4 RNAs
Saturday, 6/8/2024: 3 RNAs
Sunday, 6/9/2024: 3 RNAs
Monday, 6/10/2024: 3 RNAs
Tuesday, 6/11/2024: 3 RNAs
During an interview on 6/11/2024 at 11:12 a.m., Restorative Nursing Aide 1 (RNA 1) stated she tried to provide RNA services to about 15 to 20 residents per day. RNA 1 stated RNA services included assisting residents with exercises, ROM, ambulation, feeding assistance, stationary bike exercises, application of splints, assisting Certified Nursing Assistants (CNA) with daily care, mechanical lift transfers (a mechanical piece of equipment that allows a person to be transferred from one surface to another), and weights (performed upon admission, daily, weekly, and monthly). RNA 1 stated many residents in the facility would not be seen for RNA treatment due to lack of staffing.
During an interview 6/11/2024 at 3:16 p.m., RNA 4 stated the RNAs were unable to provide RNA services to all the residents on their daily schedule as ordered due to lack of time and staffing. RNA 4 stated the RNAs
in the facility had a lot of tasks assigned to them daily and were often asked to assist the other CNAs with their daily care in addition to their current workload. RNA 4 stated if an RNA called out sick or got re-assigned for the day as a CNA, the RNA who was covering their shift would have double or triple their daily workload. RNA 4 stated the facility needed more RNAs to ensure all residents on the RNA program were seen as scheduled.
During an interview on 6/13/2024 at 8:50 a.m., Restorative Nursing Aide 3 (RNA 3) stated the RNA staff were unable to provide services to all the residents who had RNA orders due to short staffing, particularly on weekends. RNA 3 stated she was re-assigned to perform CNA duties about one time a week and was asked to assist the other CNAs with their tasks daily in addition to her current daily workload. RNA 3 stated if an RNA was re-assigned as a CNA for the day or called out sick, the RNA who was covering for the day would have double or triple the workload and would be unable to provide RNA services to the residents as ordered.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 43 056308 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056308 B. Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 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 0725 During a concurrent interview and record review on 6/13/2024 at 1:02 p.m., the Director of Staff Development (DSD) reviewed the Nursing Staffing Assignment and Sign in Sheets for the months of May Level of Harm - Minimal harm or 2024 and June 2024. The DSD stated the facility required a minimum of 4 RNAs on the floor daily to ensure potential for actual harm all residents with RNA orders received RNA services as ordered. The DSD confirmed the RNA program was insufficiently staffed for the months of May 2024 and June 2024 - particularly on the weekends. The DSD Residents Affected - Some stated many residents who required RNA services per physician's order were not receiving RNA services due to lack of RNA staff. The DSD stated there was potential for residents to experience a decline in function if RNA was not being provided as ordered.
During an interview on 6/13/2024 at 1:55 p.m., the DON stated the purpose of the RNA program was to maintain and/or improve a resident's current level of function and prevent declines in ROM and functional mobility. The DON stated missed RNA treatments could potentially cause a resident to experience a decline
in overall function and mobility.
During a review of the facility's undated Policy and Procedure (P&P), titled Staffing, the P&P indicated the facility provided adequate staffing on each shift to ensure the resident's needs and services were met.
CROSS REFERENCE TO