Vermont Healthcare Center

screening process.

The admitting nurse notifies the social services department when a resident is

b.

Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought with intense paranoia, leading to false beliefs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and cerebral infarction (loss of blood flow to the brain).

During a review of Resident 48's Minimum Data Set ({MDS}- a resident assessment tool), dated 1/23/2025, the MDS indicated Resident 48 was moderately cognitively (ability to think, understand, learn, and remember) impaired and required substantial assistance with showering/bathing, dressing, and personal hygiene.

During an observation on 3/11/2025 at 9:48 a.m., Resident 48 yelled out that he wanted to die in the presence of Licensed Vocational Nurse (LVN) 4. LVN 4 stated she would notify her charge nurse immediately.

During an interview on 3/12/2025 at 11:37 a.m., with LVN 1, LVN 1 stated there is no care plan for Resident 48's verbalization of wanting to die but should be because Resident 48 could potentially commit suicide.

During an interview on 3/12/2025 at 3:11 p.m., with Registered Nurse Supervisor (RNS) 1, RNS stated a care plan is a guideline for the residents care with interventions for the staff to follow when providing care to the residents. RNS 1 stated Resident 48 should have a care plan for his verbalization of wanting to die so the staff are aware and the resident could be monitored more closely to prevent Resident 48 from potentially committing suicide.

During an interview on 3/14/2025 at 11:14 a.m., with the Director of Nursing (DON), the DON indicated Resident 48 should have a care plan for his verbalization of wanting to die because it is a guideline for how to care for the resident.

During a review of the facility's policy and procedure (P&P) titled, Care Plans- Comprehensive, undated, the P&P indicated, Each resident's comprehensive care plan is designed to: incorporate identified problem area, incorporate risk factors associated with identified problems, aid in preventing or reducing declines in the resident's functional status and/or functional levels; Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During an interview on 3/14/25 at 6:26 p.m., with the Director of Nursing (DON), the DON stated Resident 218 was alert and oriented to name, place, time and an IDT meeting should be done within 7 days after admission to the facility with the resident and family member.

The DON stated Resident 218 can get mad and depressed and may want to leave the facility early if care and services were not explained.

The DON stated Resident 218 needs to know what was going on with the care and services the facility was going to provide.

During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, date revised 3/2022, the P&P indicated, The IDT includes but is not limited to the resident's attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition services staff, to the extent practicable, the resident and/or the resident's representative, and other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident.

Care plan meetings are scheduled at the best time of the day for the resident and family when possible. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.

During a review of the facility's P&P titled, Care Plans-Comprehensive, undated, the P&P indicated, Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.

During a review of the facility's P&P titled, Facility Assessment, date revised 2/19/2025, the P&P indicated the IDT members were responsible for Person-centered care (PCC-an approach to healthcare that focuses on the individual patient's needs, preferences, and values) and for the , Education of resident and family/ resident representative about treatments and medications, documentation of resident treatment preferences, end- of-life care, and advance care planning.

During a review of the facility's P&P titled, Quality of Life Policy, undated, the P&P indicated, Residents shall be involved in care planning and have the right to refuse care in accordance with regulatory guidelines.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During an interview on 3/14/25 at 4:17 p.m. with Director of Nursing (DON), the DON stated CNAs were responsible for showering/bathing the residents.

The DON stated CNAs do skin inspections during scheduled shower and bed baths.

The DON stated residents are showered twice weekly and the CNAs use Skin Inspection Sheets to document once the resident was showered.

The DON stated if a resident does not have a Skin Inspection Sheet, it would be an indication that the resident did not receive a shower.

The DON stated it was residents right to receive showers and bed baths.

The DON stated bathing helps residents feels clean and refreshed, which can improve their overall comfort and well-being.

During a review of the facility's policy and procedure (P&P) titled, Bath, Shower/Tub, dated 2018, the P&P indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

During a review of the facility's P&P titled, Assistance with ADL Care, [undated], the P&P indicated, Provide assistance with activities of daily living depending on the level of assistance needed and the number of person (s) needed to assist resident.

During a review of the Certified Nursing Assistant (CNA) Job Description, [undated], the CNA Job Description indicated, Assist residents with bath functions (i.e., bed bath, tub or shower bath, etc.) as directed.

Cross reference F-F686

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

are directed towards assisting the residents in maintaining independence, dignity and well-being to

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During an interview on 3/14/25 at 4:17 p.m. with the Director of Nursing (DON), the DON stated the RN Supervisor (RNS) and TN were responsible for doing skin assessments upon a resident admission, weekly and as needed.

The DON stated CNAs were responsible for doing skin inspections when providing a shower and bed baths and report any findings to the charge nurse and TN.

The DON stated residents were showered twice weekly and the CNA's use Skin Inspection Sheets to document resident skin condition once the resident received a shower or bed bath.

The DON stated if a resident does not have a Skin Inspection Sheet completed, it would be an indication that the resident did not receive a shower and did not have a skin inspection done by the CNA's.

The DON stated it was imperative that residents receive showers and bed baths as this their right, and good hygiene practices, can help prevent or reduce the risk of pressure injury infection.

The DON stated residents that are total dependent need to be repositioned and turned every two hours, because it helps to maintain their skin integrity, improves circulation, and relieves pressure which could cause pressure injury.

During a review of the Certified Nursing Assistant (CNA) Job Description, [undated], the CNA Job Description indicated, Special Nursing Care Functions .Turn bedfast residents at least every two (2) hours.

During a review of facility's P&P titled Wound and Ulcer Protocol undated, the P&P indicated, CNA's will complete body checks on resident shower days and report findings to the charge nurses.

The P&P indicated the treatment nurse will ensure if the treatment plan is appropriate for the current status and if changes are needed , the treatment nurse will obtain needed treatment from the physician.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

Survey Report did not include Omni-cycle exercises on both arms.

The Documentation Survey Report

Resident 112 with ambulation using the FWW with AFO on the left leg was blank for the following

During a review of Resident 112's Documentation Survey Report for 1/2025, the Documentation Survey Report indicated for RNA to provide Resident 112 with ambulation using the FWW with AFO on the left leg, Omni-cycle exercises on both legs, [TRUNCATED]

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

and/or at least every seven days or if the integrity of the dressing is compromised (wet, loose or

least every shift.

Documentation in the medical record includes but is not limited to: Date and time, site assessment, Resident response to procedure, and resident teaching.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

including but not limited to shunt care.

Shunt care shall be provided by licensed nurse, upon orders

evaluate resident and notify physician immediately of any apparent complications from dialysis

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a review of the facility's P&P titled, Resident Mobility and Range of Motion, revised 7/2017,

services to maintain or improve mobility.

Cross reference F-F688.

• During a concurrent observation and interview on 3/12/25 at 11:47 a.m., with Licensed Vocational

Nurse (LVN 6) in the SAU, LVN 6 stated the SAU had 26 residents in house on 3/12/25 and 12 of 26 residents were assigned to LVN 6. LVN 6 stated 3 out of 12 assigned residents had not receive their morning medications at 11:47 a.m.

During an interview on 3/12/25 at 11:58 a.m., with LVN 6 outside of Resident 149's room, LVN 6 stated Resident 149[TRUNCATED]

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

The DON stated it was important because it indicates how many staff are providing care to the

indicated, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During an interview on 3/12/2025 at 2:01 p.m., with Resident 48, Resident 48 indicated he thinks about dying every day, even dreams about dying. Resident 48 stated he began thinking about dying when he was admitted to the facility and stated I wake up feeling like sh*t everyday and it goes downhill from there. I'm sick of it.

This is a miserable existence.

During an interview on 3/12/2025 at 3:11 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 indicated she was unaware of Resident 48's verbalization of wanting to die. RNS 1 stated this verbalization of wanting to die is suicidal ideation and Resident 48's doctor should be notified immediately. RNS 1 stated there was no COC, care plan, nursing notes, or monitoring for Resident 48's suicidal ideation but there should be to prevent Resident 48 from potentially committing suicide.

During an interview on 3/12/2025 at 4:57 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated she has heard Resident 48 verbalizing he wanted to die and reported it to her charge nurse.

During an interview on 3/14/2025 at 11:14 a.m., with the Director of Nursing (DON), the DON stated when Resident 48 verbalized he wanted to die, it should have been immediately reported to the doctor, a COC completed, care plan implemented, monitoring initiated, and the social worker notified immediately so an investigation could be done.

During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention, and Monitoring, undated, the P&P indicated, The facility will provide, and residents will receive behavioral health services as needed to attain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

The nursing staff will identify, document, and inform the physical about specific details regarding changes in an individual's mental status, behavior, and cognition, including onset, duration, intensity, and frequency of behavioral symptoms.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a concurrent observation and interview on 3/14/25 at 9:51 a.m., with RNS 4 outside of Resident 44's room, RNS 4 was preparing IV medication for Resident 44. RNS 4 stated Resident 44's Zosyn IV would be held due to the label did not match with Resident 44's physician order.

During an interview on 3/14/25 at 10:06 a.m., RNS 4 stated before administration, licensed nurse should check the label of the IV medication against the physician order. RNS 4 stated a complete order includes the type of fluid needed to reconstitute & mix with the medication.

During an interview on 3/14/25 at 10:20 a.m., RNS 4 stated Resident 44's IV medication administration record did not contain full order details. RNS 4 stated Resident 44's physician order indicated Zosyn 3.375 mg in Dextrose 50 ml, which did not match with the label and the medication in NS 100 ml sent from the pharmacy.

During an interview on 3/14/25 at 10:36 a.m., the DON stated the physician order stated in Dextrose, but the pharmacy sent NS.

The DON stated the pharmacy should communicate the change of fluid to mix with the medication.

The DON stated the pharmacy did not communicate the change.

During an interview on 3/14/25 at 12:59 p.m., the DON stated licensed nurses did not perform the 5 rights of medication administration (right medication, right resident, right dose, right time, right route of administration) for Resident 22 and 44.

The IV Zosyn in NS 100 ml did not match with the physician orders on file.

During a review of the facility policy and procedures, Medication Administration Policy (dated January 2022), indicated .

Medications are administered as prescribed .

• During a concurrent interview and record review, reviewed the emergency kit (E-Kit, contain a

small quantity of emergency drug supplies which can be dispensed when pharmacy services are not available) log. RNS 4 stated one of the pages indicated someone removed a 1000 ml D5/0.45% NS (IV fluid that contains a mixture of 5% dextrose and 0.45% sodium chloride in water for fluid replenishment) for Resident 22, but failed to fill in the date, time, quantity removed, and licensed nurse's initial.

During a review of the facility's policy and procedures (P&P) titled Emergency Pharmacy Services and E-Kits (dated August 2014), the P&P indicated . A record of the name, dose of the drug administered, . date, time of administration, and the signature of the person administering the dose shall be recorded in the emergency log book .

Cross reference F-F760

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During an interview on 3/14/2025, at 4:50 p.m. with RNS 4 , RNS 4 stated it is chemical restraint.

During an interview on 3/14/2025, at 6:16 p.m. with Director of Nursing (DON), DON stated Resident 112 was not seen by the psychiatrist because of his insurance. DON stated GDR assessment is important to ensure the psychotropic medicine is effective and lowest dose of the medicine can be used . DON stated monitoring psychotropic medicine use and resident's behavior in response to the medicine is important for patient's safety and for monitoring of side effect.

During a review of facility's policy and procedure(P&P) titled Psychotropic Medication Use, dated 7/2022 indicated anti-depressants are considered psychotropic medications, is subject to prescribing, monitoring, and review requirements specific to psychotropic modifications.

The P&P indicated residents on psychotropic medications received (coupled with non-pharmacological interventions) gradual dose reductions, unless clinically contraindicated to discontinue the medication.

During a review of facility's P&P titled, Behavioral Assessment.

Intervention and Monitoring, revised 3/2019, the P&P indicated antipsychotic medications are used to treat behavioral symptoms, and the IDT will monitor their indication, implement a gradual dose reduction, monitor their indication, side effects and complications related to psychotropic medications.

The P&P indicated interventions will be adjusted based on the impact on behavior and other symptom.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a review of Resident 22's Physician Order, dated 3/3/25 at 5:57 p.m., the Physician Order indicated Piperacillin Sodium-Tazobactam Sodium in dextrose (chemically identical to glucose or blood sugar, a form of parenteral solutions containing various concentrations of glucose in water intended for intravenous fluid replenishment, mix or compound with IV medications) 3-0.375 gm/50ml.

During a concurrent observation and interview on 3/13/25 at 11:19 a.m., with RNS 4 at Resident 22 bedside observed Resident receiving the infusion of Zosyn. RNS 4 stated the Zosyn label read piperacillin sodium and tazobactam sodium in 100 ml NS.

The volume and the type of fluid used were incorrect.

During a concurrent interview and record review on 3/13/25 at 11:30 a.m., reviewed Resident 22's Physician Order (dated 3/3/25). RNS 4 stated the order indicated Zosyn 3.375mg in Dextrose 50 ml.

RNS 4 stated Resident 22 received Zosyn in NS at 100 ml which did not match Resident 22's physician's order.

During an interview on 3/14/25 at 12:59 p.m., the DON stated licensed nurses did not perform the 5 rights of medication administration (right medication, right resident, right dose, right time, right route of administration) for Resident 22.

The IV Zosyn in NS 100 ml did not match with the physician orders on file.

The DON stated residents that had a certain condition can be sensitive with certain types of fluids that could cause negative effect to residents.

During a review of the facility policy and procedures, Medication Administration Policy (dated January 2022), indicated .

Medications are administered as prescribed .

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During an interview on 3/11/2025 at 3:04 p.m., with Resident 361, Resident 361 stated she does not always receive her thyroid medications in the morning.

During a concurrent interview and medication reconciliation record review on 3/12/2025 at 10:23 a.m., with Licensed Vocational Nurse (LVN) 1, reviewed Resident 361's Medication Administration Record ({MAR}- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) which indicated there were missed doses of Liothyronine on March 1, 2025, and March 6, 2025. LVN 1 stated she was assigned to Resident 361 on March 6, 2025, and not sure how she missed that medication.

Reviewed the Liothyronine bubble pack which indicated there were two doses missed. LVN 1 stated missing doses of thyroid medications can result in constipation and hypothyroidism.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration Policy, undated, the P&P indicated, Medications must be administered in accordance with the orders including any required time frame.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV,

accordance with the physician orders for two (2) of 2 sampled residents (Residents 22 and 44).

This failure had the potential of medication error.

Findings

During a concurrent observation, interview and record review on 3/13/25 at 11:19 a.m., Registered Nurse Supervisor (RNS 4) was in Resident 22's room at bedside and Resident 22 was receiving an IV medication.

The surveyor asked to see the label of the Resident 22's IV medication. RNS 4 stated the label on Resident 22 IV medication read piperacillin sodium and tazobactam sodium (antibiotic combination that treat certain infections, also known as Zosyn) 3.375 gram (gm, unit to measure mass) in 100 milliliter (ml, unit to measure volume) of 0.9% sodium solution (normal saline, NS, a mixture of water and salt, or sodium chloride, with a salt concentration of 0.9%; it is a form of IV fluids used for fluid replenishment and compound with IV medications).

During a review of Resident 22's Physician Order, dated 3/3/25 at 5:57 p.m., indicated Piperacillin Sodium-Tazobactam Sodium in dextrose (a form of parenteral solutions intended for intravenous fluid replenishment, mix or compound with IV medications) 3-0.375 gm/50ml.

Use 1 dose intravenously one time only for urinary tract infection (UTI, an infection of the urinary system) until 3/3/25 at 11:59 p.m., infuse at 25 cubic centimeters (CC, unit to measure volume) per hour for four hours intravenously every 8 hours for UTI until 03/15/2025 ,infuse at 25cc/hour for four hours.

During a concurrent observation and interview on 3/14/25 at 9:51 a.m., outside Resident 44's room, RN 4 was preparing an IV medication for Resident 44. RN 4 stated the medication was Zosyn 3.375 mg in 100 ml NS. RN 4 stated the label on Resident 44's Zosyn did not match with Resident 22's physician the order.

During a review of Resident 44's Physician Order dated on 3/7/25 timed at 4:33 p.m., the Physician Order indicated Zosyn Intravenous Solution 3-0.375 gm/50 ml (Piperacillin Sodium-Tazobactam Sodium in Dextrose) use one dose intravenously one time only for pneumonia (an infection in the lung) until 03/07/2025 and use one dose intravenously every 8 hours for pneumonia for 7 Days.

Cross Reference F-F755 and F-F760

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

not matter if Resident 10's insurance would not pay for her dentures it is the facility's responsibility

P&P indicated if dentures are damaged or lost, residents will be referred for dental services within three days. If the referral is not made within 3 days, documentation will be provided regarding what will be done to ensure that the resident is able to eat and drink adequately while awaiting the dental services, and the reason for the delay.

All dental services provided are recorded in the resident's medical record. A copy of the resident's dental record is provided to any facility to which the resident is transferred.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During an observation on 3/12/2025 at 11:14 a.m. in Resident 109's room, Resident 109's PT

applied the left knee splint and both PRAFOs on Resident 109's legs.

During a concurrent interview and record review on 3/15/2025 at 10:49 a.m. with the DOR, Resident 109's PT Treatment Notes were reviewed.

The DOR stated the PTs applied Resident 109's left knee and both PRAFO splints every treatment session.

The DOR reviewed Resident 109's PT Treatment Notes and stated the therapists did not indicate splints were applied during treatment sessions on 2/27/2025, 2/28/2025, 3/3/2025, 3/5/2025, 3/6/2025, and 3/10/2025.

During a concurrent interview and record review on 3/15/2025 at 12:44 p.m. with the DOR, Resident 109's OT Treatment Notes were reviewed.

The DOR reviewed Resident 109's OT Treatment Notes.

The DOR stated the therapists did not indicate splints were applied during treatment sessions on 2/27/2025, 3/3/2025, 3/5/2025, 3/6/2025, and 3/7/2025.

During an interview on 3/14/2025 at 11:21 a.m. with OTA 1 and PTA 1, PTA 1 stated Resident 109's splints to both arms and legs were applied every treatment session but was not included in the PT and OT documentation. PTA 1 stated the facility did not have any documented evidence Resident 109's splints were applied during PT and OT treatment sessions.

• During a review of Resident 109's SLP Evaluation and Plan of Treatment, dated 2/28/2025, the

SLP Evaluation indicated Resident 109 had impaired receptive language skills (ability to understand and comprehend spoken language), impaired expressive language (ability to communicate thoughts, feelings, and needs through verbal or nonverbal means, including words, gestures, writing, and facial expressions), and impaired cognitive-communicative skills (mental processes and abilities we use to effectively communicate and process information, including attention, memory, and problem-solving).

The SLP Plan of Treatment included speech, language, voice, and communication, three times per week for four weeks.

During a concurrent interview and record review on 3/13/2025 at 12:59 p.m. with the DOR, the SLP Evaluation, dated 2/28/2025, and SLP documentation was reviewed.

The DOR stated the treatment plan included SLP intervention three times per week for four weeks.

The DOR reviewed Resident 109's SLP electronic documentation and was unable to locate any treatment notes.

The DOR stated the facility did not have any documented evidence Resident 109 was seen for SLP treatment.

During a telephone interview on 3/14/2025 at 11:50 a.m. with Speech Language Pathologist 1 (SLP 1), SLP 1 stated he attempted to provide treatment to Resident 109 at the end February and on the weekend (unspecified date). SLP 1 stated Resident 109 was not alert enough during the attempts to participate in treatment. SLP 1 stated he did not write any notes documenting the attempts for SLP treatment because the therapists did not have access to complete a note with the facility's electronic documentation system. SLP 1 stated he also did not write a hand-written note in Resident 109's clinical record regarding attempts to provide treatment.

During a review of the facility's undated policy and procedure (P&P) titled, Medical Records Accuracy Policy, the P&P indicated the facility maintained medical records that are complete and accurately documented.

The P&P indicated the medical record must accurately reflect the resident's treatments.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey indicated the following repeat deficiencies: activities of daily living care provided for dependent residents, increase and prevent the decrease in range of motion and mobility, pharmacy services, procedures and pharmacist records, free of medication error rates five percent or more, and labeling and storage of drugs and biologicals.

During an interview on 3/14/25 at 6:39 p.m., with the Administrator (ADM), the ADM stated deficiencies were identified from the previous recertification survey.

The ADM stated the facility will identify and work on the deficiencies.

The ADM stated the facility must have accountability and the staff need to know how their actions affect the residents.

During a review of the facility's policy and procedure (P&P) titled, Quality Assurance & Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) Committee, dated 8/2017, the P&P indicated, The QAPI Committee responsibilities include identifying and responding to quality deficiencies throughout the facility and oversight of the QAPI program when fully implemented, develop and implement corrective action and monitor performance goals or targets are achieved and revising corrective action when necessary.

The duties of the QAPI Committee include but are not limited to routine monitoring of the following for all residents nursing care, including medication administration, prevention of pressure ulcers, dehydration and malnutrition, nutritional status and weight loss or gain, accidents and injuries, unexpected deaths, changes in mental or psychological status, and unplanned hospitalizations.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During an observation on 3/12/2025 at 12:06 p.m. in the hallway, Resident 143 was sitting in a wheelchair with RNA 5's cloth gait belt around the waist. Resident 143 stood up from the wheelchair and walked using the FWW while RNA 5 held onto the gait belt. Resident 143's family member pushed the wheelchair behind Resident 143.

During an observation on 3/12/2025 at 12:18 p.m. in Resident 143's room, RNA 5 wiped the FWW using disinfectant wipes, rolled up the cloth gait belt, and placed the rolled gait belt in the side pocket of RNA 5's pants.

During an observation on 3/12/2025 at 12:44 p.m. in Resident 134's room, RNA 5 removed the rolled gait belt from the side pocket of RNA's pants and placed it around Resident 134's waist. Resident 134 stood up, walked outside of the room, and walked down the facility's hallways using the FWW while RNA 5 held onto the cloth gait belt.

During a concurrent observation and interview on 3/12/2025 at 12:56 p.m. with RNA 5, the gait belt was made of thickly woven cotton fabric. RNA 5 stated the disinfecting wipes were used to wipe down the FWW and the gait belt.

During an observation on 3/12/2025 at 2:07 p.m. in the hallway, Resident 16 was sitting in a wheelchair with a [NAME]-colored cloth gait belt around the waist.

Restorative Nursing Aide 2 (RNA 2) and RNA 3 were standing on both sides of Resident 16 and physically assisted Resident 16 to transfer from sitting to standing while holding onto the FWW.

During a concurrent interview and record review on 3/14/2025 at 9:41 a.m. with the Infection Prevention Nurse (IPN), the IPN viewed a picture of the gait belts used with Resident 143, 134, and 16 and reviewed the manufacturer's recommendations of the disinfecting wipes.

The IPN stated the gait belts were made of cotton, which were porous surfaces.

The IPN reviewed the manufacturer recommendations of the disinfecting wipes and stated the disinfecting wipes should be used on hard, nonporous surfaces.

The IPN stated the disinfecting wipes were ineffective on the cloth gait belts.

The IPN stated there was a potential for transmission of infection without proper disinfection of cloth gait belts between residents' use.

During a review of the undated manufacturer's recommendations of the disinfecting wipes, the manufacturer's recommendations indicated it was a violation of Federal law to use the product inconsistent with its labeling.

The manufacturer's recommendations indicated the disinfecting wipes were for use on hard, non-porous surfaces of non-critical medical devices.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During an interview on 3/14/2025, at 6:33 p.m. with Director of Nursing (DON), DON stated using two antibiotics could be an unnecessary medicine which could be harmful to the health condition of the resident because antibiotic resistance, MDRO and C-diff could occur.

During a review of facility's policy and procedure (P&P) titled, Antibiotic Stewardship revised 12/2016, the P&P indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program to ensure antibiotic usage of the residents are monitored.

The P&P indicated laboratory results, and the current clinical situation of the resident will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued when a culture and sensitivity (C &S- diagnostic test used to identify bacteria or fungi causing infections and determine which antibiotics are effective) is ordered.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a concurrent observation and interview on 3/13/2025 on 7:36 a.m., in the laundry room with the Maintenance Supervisor (MS), it was observed three of three washer temperature gauges were not functioning properly.

The MS stated the temperature gauges so not always work and he uses a thermometer to check the sink water temperature to monitor the washer temperatures.

The MS demonstrated how he checked the temperatures by taking the thermometer, turned on the sink across from the washers, sticking the thermometer under the water, and recorded the reading on the boiler temperature log.

The MS stated the washer temperature gauges are not accurate and that is why he uses the sink water temperatures stating they use the same water pipeline.

The MS stated he reported this issue to the previous Administrator but not to the current one.

During a concurrent observation and interview on 3/13/2025 on 8:16 a.m., with the Laundry Aide (LA) 1, LA 1 stated the washer temperature gauges have not been functional for several weeks, but he has not reported it to anyone. LA 1 demonstrated how he checks the washer temperature by using a thermometer and checking the sink water. LA 1 stated the washer water temperature should be at 160 degrees Fahrenheit (F- scale for measuring temperature) to kill bacteria and prevent the spread of infection which can lead to an outbreak from the contamination of the linens.

During a concurrent observation and interview on 3/13/2025 at 8:33 a.m., with LA 2, LA 2 stated he is unsure how long the temperature gauges have not been functional, but he did not report it to anyone.

During an interview on 3/14/2025 at 11:14 a.m. with the Director of Nursing (DON), the DON stated checking the washer temperatures via the sink is incorrect and the individual washer temperature gauges should be functioning properly.

The DON stated its crucial that the washer water temperatures are accurate to prevent infections, outbreaks, and potential illnesses for the residents.

During a review of the facility's policy and procedure (P&P) titled, Departmental (Environmental Services)- Laundry and Linen, revised 2/2014, the P&P indicated, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linens.

For high-temperature processing, wash linen in water that is at least 160 degrees Fahrenheit, for a minimum of 25 minutes.

During a review of the Maintenance Supervisor (MS) Job Description, the MS Job Description indicated the MS primary functions and responsibilities of this position are as follows: identify, report to administration, and schedule repair of any equipment malfunction.

056433 03/14/2025

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During an interview on 3/14/2025, at 4:47 p.m. with Registered Nurse Supervisor (RNS4), RNS 4

should be operational and working.

During an interview on 3/14/2025, at 6:13 p.m. with Director of Nursing (DON), DON stated the residents would not be able to get the care they needed and could lead to a negative outcome like fall if their call lights are not working.

During a review of facility's policy and procedure (P&P) titled Call System, Resident dated 9/2022, the P&P indicated the resident call system is routinely maintained and tested by the maintenance department.

The P&P indicated the resident call system always remains functional, and each resident is provided with a means to call staff for assistance through a communication system that directly calls a staff member.

During a review of facility's Job Description and Performance Standards of a Maintenance Supervisor, the Job Description and Performance Standards of Maintenance Supervisor indicated the Maintenance Supervisor will develop and implement a monitoring system for the maintenance department and make recommendations to assure compliance with federal, state and local requirements.

During a review of Resident 20's Minimum Data Set ({MDS}- a resident assessment tool) dated 1/3/2025, the MDS indicated Resident 20's cognition (ability to think, understand, learn, and remember) was intact and was dependent (helper does all the effort) with toileting and bathing.

During a review of Resident 20's care plan initiated 12/26/2024, the care plan indicated Resident 20 has a communication deficit, hearing impaired with goals that included.

During a review of Resident 20's Psychosocial Note, dated 1/28/2025 at 2:29 p.m., the Psychosocial Note indicated Resident 20 went to the Social Services Director (SSD) and reported her hearing aids were missing.

During an interview on 3/11/2025 at 10:26 a.m., with Resident 20, Resident 20 stated her hearing aides were missing and feels irritated because others must repeat themselves when speaking with her. Resident 20 stated she told the staff, but no one followed up and she would like to have hearing aids.

During a concurrent interview and record review on 3/14/2025 at 7:50 a.m., with the SSD, the SSD stated he spoke with Resident 20 about her hearing aids but did not follow up.

The SSD stated he should have followed up with Resident 20's hearing aids and made an appointment for her to be seen.

During an interview on 3/14/2025 at 11:14 a.m., with the Director of Nursing (DON), the DON stated hearing aides are important to have because not having them can affect the delivery of care and makes it hard for the resident to communicate.

During an interview on 3/14/2025 at 1:19 p.m., with the Administrator (ADM), the ADM stated a resident not having their hearing aides can affect their dignity and it would benefit Resident 20 to have them so others would not have to constantly repeat themselves when speaking to her.

056433

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056433 B.

Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a concurrent observation and interview on 3/12/25 at 11:47 a.m., with Licensed Vocational Nurse (LVN 6) in the SAU, LVN 6 stated the SAU had 26 residents in house on 3/12/25 and 12 of 26 residents were assigned to LVN 6. LVN 6 stated 3 out of 12 assigned residents had not receive their morning medications at 11:47 a.m.

During an interview on 3/12/25 at 11:58 a.m., with LVN 6 outside of Resident [TRUNCATED]

056433

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056433 B.

Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a review of Resident 361's Minimum Data Set (MDS- a resident assessment tool) dated 3/4/2025, the MDS indicated Resident 361's cognition (ability to think, understand, learn, and remember) was intact and required substantial/maximal assistance (helper does more than half the effort) with toileting, bathing, and dressing.

During a review of Resident 361's Physician Order Summary Report, the Physician Order Summary included, but not limited to the following medications:

056433

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056433 B.

Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a review of Resident 10's ({MDS}- a resident assessment tool) the MDS dated [DATE], indicated Resident 10 is cognitively intact.

The MDS also indicated, Resident 10 needs substantial assistance (helper does more than half the work) with activities of daily living (ADL's - activities such as toileting, bathing and dressing, a person performs daily).

During review of Resident 10's Order summary Report, dated 3/14/25, the order summary report indicated, Resident 10 was on a finely chopped mechanical soft texture, thin consistency until her dentures are available.

The order summary report also indicated Resident 10 had orders for dental evaluation and follow up treatment.

During a review of Resident 10's care plan titled Dental Care dated 3/10/2022 last revised 8/13/2024 indicated Resident 10 had the potential for decreased food intake related to dental problem, Resident 10 has all natural teeth missing with full upper and lower dentures and is at risk for difficulty chewing and weight loss.

Intervention to monitor dental condition & refer for dental evaluation if indicated.

During an observation and interview on 3/11/2025 at 10:10 a.m. in Resident 10's room, Resident 10 was missing her bottom dentures. Resident 10 stated I don't like the way food tastes without my bottom dentures.

During a concurrent interview on 3/14/2025 at 7:50 a.m. and record review of Residents 10's dental records with the Social Services Director (SSD) , The SSD stated that Resident 10 was seen by the dentist on 2/3/2025 for evaluation for full upper and lower dentures.

The SSD stated from what he could see there was no follow up appointment.

The facility must provide Resident 10 with bottom dentures.

The SSD stated Resident 10's quality of life can be affected with missing teeth.

056433

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056433 B.

Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502