Vermont Healthcare Center

status on the Minimum Data Set (MDS) for one of five sampled residents (Resident 26).This failure

treatment.Findings:During a review of Resident 26's admission Record, the admission Record indicated Resident 26 was admitted to the facility on [DATE] to with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), schizoaffective disorder, (a mental illness that can affect thoughts, mood, and behavior) , depression( serious mood disorder characterized by persistent sadness, loss of interest and low energy) and hypertension(HTN-high blood pressure).During a review of Resident 26's Dietary assessment dated [DATE], the Dietary Assessment indicated Resident 26 was edentulous (a person has lost all or some of their natural teeth) and had no difficulty in chewing and swallowing food.During a review of Resident 26's Minimum Data Set (MDS- a resident assessment tool) dated 3/7/2026, the MDS indicated Resident 26 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills.

The MDS indicated Resident 26 required setup or clean-up assistance with oral hygiene, dressing and personal hygiene.

The MDS indicated Resident 26 had natural teeth.During a review of Resident 26's Care Plan titled, Dental Care, initiated on 4/23/2026, the Care Plan indicated Resident 26 is edentulous and at risk for inadequate nutrition and alteration in comfort.

The Care Plan's interventions included notifying the physician about pain issues and monitoring food intake, appetite and weight.During a concurrent observation and interview on 4/21/2026 at 3:28 p.m. with Resident 26, Resident 26 had no natural teeth. Resident 26 stated she did not like dentures because they hurt and would like to have dental implants.During a concurrent interview and record review on 4/23/2026 at 8:46 a.m. with Minimum Data Set Nurse (MDSN) 1, Resident 26's MDS assessment dated [DATE] and Dietary assessment dated [DATE] were reviewed. MDSN 1 stated MDS assessment was not coded correctly regarding Resident 26's oral (mouth) and dental (referring to teeth and oral care) status. MDSN 1 stated accurate assessment of Resident 26's dental status is important because it can affect the care of the resident by not providing the right level of care.During an interview on 4/24/2026 at 3:15 p.m. with the Director of Nursing (DON), the DON stated accurate assessment will ensure appropriate plan of care will be implemented for the resident.

The DON stated care plan for the resident will be affected if the MDS assessment is inaccurate.During a review of facility's policy and procedure (P&P) titled, Policy on Accurate Assessment- Minimum Data Set, dated 2024, the P&P indicated MDS assessments should reflect resident's actual condition, supported by clinical documentation in the medical record, completed within time frames and false, misleading and unsupported documentation is strictly prohibited.

The P&P indicated MDS Coordinator will review assessments for accuracy and completeness.

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Vermont Avenue Torrance, CA 90502

for services as needed.

interview and record review, facility documentation, and staff interview, the facility failed to ensure

Level II evaluation for one of four sampled residents (Resident 14) identified through PASRR Level I screening as needing further evaluation for Serious Mental Illness (SMI).This deficient practice placing the Resident 14 at risk for unmet mental health needs and noncompliance with federal PASRR requirements of competition of level II by the facility.Findings:During a review of Resident 's admission Record, the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included paranoid schizoaffective (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), and anxiety disorder (excessive, persistent, and uncontrollable fear, worry, or dread that interferes with daily life).During a review of Resident 14's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/26/2026, the MDS indicated, Resident 14 had moderate cognitive (ability to think, understand, learn, and remember) impairment.

The MDS indicated, Resident 14 required maximal assistance (helper does more than half the effort) from staff with eating, oral hygiene, and upper body dressing.During a concurrent interview and record review on 4/24/2026 at 12:43 p.m. with Minimum Data Set Nurse 1(MDSN 1), Preadmission Screening and Resident Review (PASRR) level I screening dated 05/02/2025 was reviewed.

The form indicated SMI level II Mental Health Evaluation was required.

Notice of Evaluation for Level II screening completion dated 05/07/2025 indicate level II assessment was not completed due to facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level II screening. As a result of the facility's lack of response, the PASRR Level II case was subsequently closed without completion of the required evaluation.MDSN1 stated the PASRR Level I screening for Resident 14, dated 05/02/2025, showed a positive result for Serious Mental Illness (SMI), which required a PASRR Level II mental health evaluation prior to or upon admission in accordance with federal regulations. MDSN 1 stated the facility failed to follow up on the PASRR Level II because no staff member took ownership of the task; responsibility fell between the nurses and medical records staff, and the process was overlooked.

MDSN1 stated that moving forward, the facility will establish a process to prevent this issue from recurring.

During an interview, on 4/24/2026 at 2:28 pm with the Director of Nursing (DON), the DON stated residents identified through PASRR Level I screening as requiring Level II evaluation must receive timely follow-up to ensure compliance and appropriate care planning.

The DON stated failure to respond to PASRR communications may result in delays or failure to complete required evaluations.

The DON stated moving forward, she will have a process of assigning certain staff for PASSR.During a Review of facility's policy and procedure titled Preadmission Screening and Resident Review (PASRR) undated indicated Referral :if the level I screen is positive for SMI or (intellectual Disability) ID referral is made to the State Mental Health or Intellectual Disability Authority.

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Vermont Avenue Torrance, CA 90502

actions that can be measured.

observation, interview and record review the facility failed to develop and implement comprehensive

level II evaluation for residents 14.This deficient practice placed the residents at risk for unmet needs and lack of appropriate coordination of care and services.Findings:During a review of Resident 's admission Record, the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included paranoid schizoaffective (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), and anxiety disorder (excessive, persistent, and uncontrollable fear, worry, or dread that interferes with daily life).During a review of Resident 14's Minimum Data Set ([MDS] a resident assessment tool), dated 1/26/2026, the MDS indicated, Resident 14 had moderate cognitive (ability to think, understand, learn, and remember) impairment.

The MDS indicated, Resident 14 required maximal assistance (helper does more than half the effort) from staff with eating, oral hygiene, and upper body dressing.During a concurrent interview and record review on 04/24/2026 at 1:14 p.m. with Minimum Data Set Nurse 1 (MDSN1), the records showed Resident 14 screened positive on the PASRR Level I, indicating the need for a PASRR Level II evaluation due to mental illness. Resident 14's review of electronic health record (EHR)contained no evidence of an individualized, interdisciplinary care plan addressing Resident 14's identified mental health or specialized service needs as required. MDSN 1 stated she believed the care plan had been completed; however, upon reviewing Resident 14's EHR no care plan could be found. MDSN 1 stated the facility had not developed or implemented a comprehensive care plan at this time.During an interview on 4/24/2026 at 2:28 p.m. with the Director of Nursing (DON), the DON stated the care plan was missing because the facility failed to complete the PASRR Level II.

The DON stated the process lacked clear staff assignment, which led to the followˆup being missed.

The DON stated that moving forward, she will implement a process to assign responsibility and ensure all required care plans are completed in a timely manner.During a review of facility's policy and procedure (P&P) titled Preadmission Screening and Resident Review (PASRR) undated indicated Referral: if the Level II evaluation recommends Specialized Services, these must be integrated into the resident's comprehensive care plan within 14 days of admission.Cross reference F-F644

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During the care, CNA 1 supported the resident's left side and buttock with one hand while using the other hand to clean him, change the incontinent brief, and replace linens underneath him for approximately 10 minutes. Resident 37 was observed coughing intermittently throughout the resident personal care. CNA 1 stated Resident 37 was typically provided incontinent care by two staff members; however, because the other staff member was busy, she performed the care alone.During a concurrent interview and record review on 4/23/2026 at 10: 15 a.m. with Registered Nurse Supervisor (RNS) 1, Resident 37's Task List Report, dated 4/23/26, was reviewed. RNS 1 stated turning and providing incontinent care to the residents who had tracheostomy, G-tube, and foley catheter were weight bearing tasks. RNS 1 stated Resident 37 was totally dependent and required at least two-person assistance for turning and incontinent care to prevent falls, any accidents or any injury for both the resident and the staff.During an interview on 4/24/2026 at 3: 38 p.m. with the Director of Nursing (DON), the DON stated staff should provide incontinent care with at least two to three staff members for Resident 37, as indicated in the Task List Report, to prevent injury or accident.

The DON stated if staff were unsure of the required assistance level, they should ask the resisted nurse for instructions.During a review of the facility's policy and procedure (P&P) titled, Safe Resident Handling, Turning, and Repositioning Residents, dated 2024, the P&P indicated staff shall use sufficient staff assistances as reflected in the president's plan of care.During a review of the facility's P&P titled, Activities of Daily Living (ADL) Performance and Assistance, dated 2024, the P&P indicated staff should assist residents according to their assessed level (independent, supervision, limited assist, expensive assist, total assist) provide care in a safe and timely manner.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a review of Resident 184's Minimum Data Set (MDS a resident assessment tool) dated 04/22/2026 indicated Resident 184 with severe cognitive (ability to think, understand, learn, and remember) impairment in decision making.

The MDS indicated Resident 184 was dependent (helper does all the effort) in oral hygiene, toileting, shower/bath and substantial /maximal assistance (helper does more than half the effort) for upper/lower body dressing.During a concurrent observation and interview on 04/21/2026 at 10:50 a.m. with Resident 184 and Registered Nurse Supervisor (RNS 3), observed Resident 184 lying in bed with her mouth full of a brown, sticky substance coating the roof of her mouth, tongue, teeth, and lips. Resident 184 stated that her mouth had not been cleaned for a while and she did not know what was inside her mouth. Resident 184 opened her mouth to inspect it more closely.

While in the room, RNS 3 came in to assess the substance in the resident's mouth. RNS 3 stated it appeared to be brown crust, not chocolate. RNS 3 gathered supplies and immediately began providing mouth care while waiting for the assigned Certified Nursing Assistance (CNA). RNS 3 used a mouth swab to remove the dry, sticky brown substance and stated she would request the assigned CNA to complete the remaining oral care because it would take additional time and the resident needed to rest, as Resident 184 had requested.

During an interview on 04/21/2026 at 11:00 a.m., with CNA 4, CNA 4 stated it was her responsibility to perform mouth care on her residents because it reflects dignity and respect. CNA 4 stated she had Resident 184 on her assignment on 04/20/2026 and again on the day of the observation. CNA 4 stated she did not perform oral care because the resident had a mouth sore, and she was unsure whether the CNA or a licensed nurse should clean the resident's mouth. CNA 4 stated she should have verified with a licensed nurse any concerns instead of ignoring the situation. CNA 4 stated the resident should have still receive oral care and she would provide it immediately.During an interview on 04/23/2026 at 9:51 a.m. with Registered Nurse Supervisor 3 (RNS 3), RNS 3 stated CNAs were required to perform oral care on all residents because providing daily oral hygiene was an essential part of maintaining dignity and respect. RNS 3 stated she immediately assisted in cleaning the resident's mouth to remove the crusted brown substance and improve the resident's comfort. RNS 3 stated staff must ensure residents receive proper care and comfort to prevent further complications.

During an interview on 04/24/2026 at 2:27 p.m. with the Director of Nursing (DON), the DON stated CNAs were expected to understand the importance of oral care through constant huddles and in-service training.

The DON stated she was surprised oral care had not been completed, as providing oral hygiene reflects dignity and respect.

The DON stated CNAs should seek clarification whenever they were unsure whether a resident requires oral care.During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs) Supporting undated, the P&P indicated Residents who are unable to carry out activities of daily living independently will receive the service necessary to maintain good nutrition, grooming and personal and oral hygiene.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a concurrent observation and interview on 04/21/2026 at 12:27 p.m. with Resident 188, Resident 188 was observed in bed during lunchtime in a slouched position, sliding downward and unable to safely access her meal tray. Resident 188 stated Certified Nursing Assistant (CNA) 6 delivered her meal tray without repositioning her into an upright position. Resident 188 stated I don't want to report this, but I need to be repositioned.

During an interview on 04/21/2026 at 3:19 p.m. with CNA 6, CNA 6 stated she did not intentionally fail to reposition Resident 188. CNA 6 stated Resident 188 requires a twoˆperson assist to be repositioned and pulled up in bed because of the resident's size. CNA 6 stated she had stepped out to find help to reposition Resident 188 for her meal but became busy passing meal trays and forgot to return. CNA 6 stated failing to reposition the resident could cause choking and aspiration.

She stated that in the future she will obtain assistance before moving on to the next resident, so she does not forget or become distracted again.

During an interview on 04/23/2026 at 10:27 a.m. with Registered Nurse Supervisor 3 (RNS 3), RNS3 stated residents were required to be properly positioned upright at approximately 35 to 45 degrees during mealtimes to prevent choking and aspiration. RNS 3 stated CNAs must ensure residents were comfortable and correctly positioned when delivering meal trays and must reposition residents before leaving the room.

During an interview on 04/24/2026 at 2:28 p.m., with the Director of Nursing (DON), the DON stated staff must properly position all residents during mealtimes to reduce the risk of aspiration and choking.

During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs) Supporting undated, the P&P indicated Appropriate care and service will be provided for residents who are unable to carry out activities of daily living independently, will receive the service necessary to maintain good nutrition, grooming and personal and oral hygiene.

Including dining (meals and snacks).

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Vermont Avenue Torrance, CA 90502

catheter care, and appropriate care to prevent urinary tract infections.

observation, interview, and record review, the facility failed to ensure proper urinary catheter care by

sampled residents (Resident 37).This failure had the potential to cause urine backflow into the resident's bladder, increasing the risk for urinary tract infection (UTI- an infection in the bladder/urinary tract) and indwelling catheter-related complications.Findings:During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted on [DATE].

The admission Record indicated Resident 37 with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), benign prostatic hyperplasia (BPH, age-associated prostate gland enlargement that can cause urination difficulty) and retention of urine (difficulty emptying the bladder).During a review of Resident 37's History and Physical (H&P), dated 1/3/2026, the H&P indicated, the resident did not have the ability to understand and make decisions.

The H&P also indicated Resident 37 had a foley catheter (a flexible, thin tube inserted through the urethra into the bladder to drain urine into a collection bag).During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 37's cognitive (ability to think, understand, learn, and remember) skills for daily decision making were severely impaired.

The MDS indicated Resident 37 was dependent (helper does all the effort, or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff with oral hygiene, toileting hygiene, showering, personal hygiene, and rolling left and right.During a review of Resident 37's care plan, titled Indwelling foley catheter with risk of urinary tract infection (UTI- an infection in the bladder/urinary tract ), created 1/12/2026, the care plan's interventions included staff should keep drainage bag below bladder level and change bag as needed.During a concurrent observation and interview on 4/21/2026 at 10:21 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 37's room, a foley drainage bag was observed remaining on top of the bed while CNA 1 was providing personal care to the resident approximately for 10 minutes, and the drainage bag was filled with urine. CNA 1 stated she placed the foley drainage bag on top of the bed during personal care to prevent accidental pulling of the catheter/ drainage bag.

During an interview on 4/24/2026 at 3:38 p.m. with the Director of Nursing (DON), the DON stated the foley catheter drainage bag should be maintained below the level of the bladder to prevent backflow of urine into the resident's bladder and reduce the risk of urinary tract infection.During a review of the facility's policy and procedure (P&P) titled, Indwelling Urinary Catheter Care, dated 2024, the P&P indicated staff must always keep drainage bag below bladder level.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a review of the facility's policy and procedure (P&P) titled, Hydration and Nutrition Policy, dated 2024, the P&P indicated, To ensure that all residents receive adequate nutrition and hydration to maintain the highest practicable level of health, prevent malnutrition and dehydration, and support overall will-being.During a review of the facility's P&P titled, Hydration Management Policy, dated 2024, the P&P indicated, The facility shall assess, monitor, and manage each resident's fluid needs to maintain adequate hydration, while accommodating medical conditions, physician orders, and individual preferences.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

accuracy of labeling and dating of each feeding bag or formula container.

The P&P indicated label

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

(Resident 8) received appropriate monitoring and labeling of an intravenous (IV- giving medicine,

instantly) site who was on IV antibiotic (a medicine that fights infections caused by harmful bacteria) therapy.This failure had the potential to result in IV infiltration( when the IV catheter slips out of the vein, causing fluids or medication to leak into surrounding tissue), leading to pain, tissue injury, and increased risk of infection.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE].

The admission Record indicated Resident 8 with diagnoses including multiple sclerosis (a disease in which the immune system attacks the protective covering of the nerves causing nerve damage), respiratory failure (any condition that affects breathing function and results in lungs not functioning properly) and sepsis (a life threatening blood infection).During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 1/4/6/2026, the MDS indicated Resident 8's cognitive (ability to think, understand, learn, and remember) was severely impaired.

The MDS indicated Resident 8 was dependent (helper does all the effort) on staff with oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 8's Order Summary Report, dated 4/21/2006, the Order Summary Report indicateda.

Starting 4/18/2026, administer Vancomycin HCl Solution (antibiotic medication used to treat sever bacterial infections) one gram intravenously every 12 hours for ventilator-associated pneumonia (a lung infection that develops in a person who is on a ventilator) until 4/24/2026.b.

Starting 4/18/2026, monitor peripheral IV site for any signs and symptoms of infection and infiltration: None; Redness; Swelling; Pain; Warm to touch; Infiltration every day and night.During a review of Resident 8's Medication Administration Record (MAR), dated 4/21/2026, the MAR indicated Registered Nurse Supervisor (RNS) 2 started Vancomycin one gram via back of right hand IV access on 4/21/2026 at 8:51 a.m.During an observation on 4/21/2026 at 9:25 a.m. in Resident 8's room, observed Vancomycin 1 gram in a 250ˆmilliliter IV antibiotic infusion through Resident 8's leftˆhand IV access at 125 milliliters per hour (ml/hr-how much liquid flows in one hour).

The IV site dressing does not have label for insertion date, time, and staff initialsDuring an interview on 4/21/2026 at 9:45 a.m. with Registered Nurse Supervisor (RNS) 2 in Resident 8's room, RNS 2 stated the resident's IV site dressing lacked the required labeling. RNS 2 stated she had initiated the IV antibiotic infusion at 125 ml/hr approximately one hour before the observation and, upon reassessment, noted that the IV site had infiltrated, with redness and swelling present. RNS 2 acknowledged responsibility for managing the IV.

During an interview on 4/24/2026 at 3:38 p.m. with the Director of Nursing (DON), the DON stated staff must label the IV site dressing with the insertion date, time, and their initials to ensure proper rotation.

The DON stated staff should monitor the IV site after initiating IV medication, including reassessment approximately 15 minutes after starting the infusion, as part of standard practice.

The DON stated Vancomycin may cause phlebitis ( inflamed, swollen, and painful vein) as well as discomfort, infiltration, and vein damage, and therefore requires close monitoringDuring a review of the facility's policy and procedure (P&P) titled, Peripheral IV Catheter Insertion, dated 2001, the P&P indicated Staff should label on dressing of the IV insertion site including date and time of dressing placement, initials, gauge size, and length of catheter.During a review of the facility's P&P titled, Intravenous (IV) Medication Administration Policy, dated 2024, the P&P indicated Staff must assess IV site for signs of infiltration, phlebitis, or infection and monitor IV site throughout administration.During a review of the facility's P&P titled, Peripheral IV-line care and Removal, dated 2024, the P&P indicated Staff should assess IV site after medication administration to evaluate for redness, swelling, pain or tenderness, warmth or coolness, leakage, and signs of infiltration or phlebitis.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a concurrent observation and interview on 4/21/2026 at 11:05 a.m. with Resisted Nurse Supervisor (RNS) 3, in Resident 150's room, Resident 150 was observed receiving oxygen through a NC.

The NC tubing was observed without a date label indicating when the tubing was last changed. RNS 3 confirmed the oxygen flow rate was set at 3 L/min and the NC tubing lacked the required date label. RNS 3 stated staff are responsible for dating NC tubing upon replacement and changing tubing per facility protocol to promote infection control and ensure timely replacement.

During an interview on 4/24/2026 at 3:38 p.m. with the Director of Nursing (DON), the DON stated staff were expected to date NC tubing to promote infection prevention and ensure oxygen was administered in accordance with the physician's order for accurate oxygen delivery.During a review of the facility's policy and procedure (P&P), titled Oxygen Equipment and Tubing Change Policy, dated 2024, the P&P indicated staff should ensure oxygen flow rate matches physician order.During a review of the facility's P&P titled Oxygen Set-Up, dated 2024, the P&P indicated all oxygen tubing must be dated when initiated and when replaced to ensure timely changes and infection prevention compliance.

The P&P indicated oxygen tubing shall be dated when initiated or changed near oxygen source end of tubing or another visible location that does not obstruct function.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During a concurrent interview and record review on 4/23/2026 at 9:31 a.m. with License Vocational Nurse (LVN) 4, Resident 44's Medication Administration Record (MAR) dated April 2026 was reviewed.

The MAR indicated, fluid restriction due to CHF 1000 ml/24 hours. LVN 4 stated that a resident's fluid restriction status was communicated to staff through the MAR. LVN 4 stated the CNAs were responsible for reporting to the license staff the resident's fluid intake during their shifts, but they are not responsible for documenting the resident's fluid intake during their shifts. LVN 4 stated that the total daily fluid intake is calculated and documented by the license nurses. LVN 4 stated that signs and symptoms of fluid overload include edema, crackles 9abnormal breath sounds) , shortness of breath, and weight gain. LVN 4 stated that Resident 44 had exhibited bilateral upper and lower extremity edema, and crackles while breathing and has experienced weight gain. LVN 4 confirmed that she had not reported those signs and symptoms to the physician. LVN 4 stated she does not know why she did not report the signs and symptoms to the physician, and acknowledged that the signs and symptoms should be reported to the physician immediately to avoid further complications such as hospitalization.

During a concurrent interview and record review on 4/23/2026 at 10:20 a.m. with LVN 4, Resident 44's Medication Administration Record (MAR) dated April 2026 was reviewed, the MAR indicated the following:4/1/2026 Day shift 700 ml, Evening shift 700 ml, Night shift 100 ml= 1500 ml4/2/2026 Day 540 ml, Evening 400 ml, Night 100 ml= 1040 ml4/3/2026 Day 540 ml, Evening 540 ml, Night 100 ml= 1140 ml4/4/2026 Day 540 ml, Evening 540 ml, Night 540 ml= 1620 ml4/7/2026 Day 700 ml, Evening 700 ml, Night 100 ml= 1500 ml4/8/2026 Day 800 ml, Evening 600 ml, Night 100 ml= 1500 ml4/10/2026 Day 360 ml, Evening 900 ml, Night 100 ml= 1330 ml4/11/2026 Day 800 ml, Evening 240 ml, Night 240 ml= 1280 ml4/22/2026 Day 800 ml, Evening 800 ml, Night 800 ml= 2400 mlLVN 4 acknowledged Resident 44 had exceeded the prescribed fluid restriction and potential adverse outcomes of fluid overload include edema, shortness of breath, crackles, weight gain and hospitalization.

During an interview with the Director of Nursing (DON), the DON stated residents receiving dialysis were assessed upon admission and routinely thereafter for fluid balance, weight trends, and risk for fluid overload or dehydration.

The DON stated physician-ordered fluid restrictions are implemented into the care plan, dietary plan, nursing documentation, and includes tracking intake and output.

The DON stated nursing staff were responsible for monitoring daily weights, intake, and observing for signs of fluid imbalance.

The DON stated if noncompliance or failure to follow fluid restrictions was identified, staff should immediately notify the physician, reassess the resident, and update the care plan.

The DON stated interventions may include increased monitoring, staff education, resident/family education, and possibly adjusting the fluid restriction order.

The DON stated that failure to follow fluid restrictions can lead to serious complications including fluid overload, respiratory distress, congestive heart failure exacerbation, elevated blood pressure, hospitalization risk, and in severe cases death.During a review of the facility's policy and procedures (P&P) titled Fluid Restriction Management, dated 2024, the P&P indicated The facility will implement fluid restrictions only with a valid physician order or licensed provider order.

All staff will adhere to prescribed limits, monitor intake accurately, and educated residents and families regarding compliance.

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During the interview on 4/23/2026 at 4:58 p.m., with the Director of Nursing (DON), the DON stated for controlled medication administration, the licensed nurse should document the medication as yes in the eMAR but should not save the entry until the medication is fully administered.

The DON stated the nurse should document the medication on the controlled medication count sheet as soon as it is removed from the medication card, and after administering the medication, the nurse should then save the eMAR entry as administered.

The DON stated accurate documentation of controlled medications was essential to prevent misuse and drug diversion.

She stated it would be important to reassess the resident for neuropathic pain or signs of exacerbation due to the pregabalin count discrepancy identified on the controlled drug record (CDR).

During a review of the facility's P&P titled, Medication Timing of Administration Policy, dated 2024, the P&P indicated, 1.

Standard Administration Time Frames.

Routine medications shall be administered within a one-hour window before or after the scheduled time (e.g., 8:00 a.m., dose given between 7:00 a.m., and 9:00 a.m.).

Critical medications shall be administered at the exact time ordered or within a more restrictive window as defined below. 2.

Medications considered time-critical must be . within 60 minutes before or after the scheduled time, unless otherwise specified by the prescriber.

Examples include: Insulin (rapid-acting), anticoagulants (e.g., warfarin, heparin), antibiotics with specific dosing intervals, anti-seizure medications, medications with short half-lives or requiring consistent blood levels.

The P&P indicated, 5.

Missed or Late Doses. If a medication is not administered within the allowable time frame: The nurse shall assess the situation.if necessary.

The dose shall not be automatically .without an order, Documentation must include: Reason for delay or omission.actions taken.notifications made.During a review of the facility's P&P titled, Medication Administration, dated 2024, the P&P indicated, Medications shall be administered safely, accurately, and timely in accordance with physician orders, accepted standards of practice,.outcomes.During a review of the facility's P&P titled, Policy & Procedure: Documentation of Controlled Drugs/Medications, dated 2024, the P&P indicated, All controlled drugs/medications must be documented accurately, completely, and in a timely manner to ensure patient safety, regulatory compliance and prevention of diversion.

Documentation must reflect a clear, auditable trail from receipt.disposal.

The P&P indicated, 6.3 Administration Documentation.

Document administration immediately after giving the medication in the Medication Administration Record (MAR/eMAR).

Include: Date and time.signature/initials of administering staff. 6.4 Controlled Drug Register (CDR) Entries.

Maintain a separate page.for each medication and strength.

Record: running balance after each transaction.

Patient details for administered doses.

Staff signatures for all entries.

Entries must be.(no erasing).

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Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

Summary Report , dated 4/5/2026, the Order Summary Report indicated but not limited to the following physician orders: Seroquel oral tablet 50 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for mood instability manifested by (m/b) agitated outburst, non-pharmacological intervention (NPI): 1 = Re-assurance, 2 = Redirection, 3 = Relaxation technique, 4 = calming environment, 5 = gentle massage, 6 = Meaningful activities, 7 = Other, order date 3/23/2026, start date 3/24/2026.The facility did not provide Resident 10's active orders as of 4/22/2026 and/or 4/23/2026 as per request.During a review of Resident 10's MAR dated 4/1/2026 to 4/22/2026, the MAR indicated Seroquel oral tablet 50 mg was administered 44 times to Resident 10.During a review of Resident 10's MAR dated 3/1/2026 to 3/31/2026, the MAR indicated Seroquel oral tablet 50 mg was administered 48 times to Resident 10.During a review of Resident 10's MAR dated 2/1/2026 to 2/28/2026, the MAR indicated Seroquel oral tablet 25 mg was administered 51 times to Resident 10.During a concurrent interview and record review on 4/23/2026 at 3:29 p.m. with Licensed Vocational Nurse (LVN) 6, Resident 10's electronic medical records and physical chart notes were reviewed. LVN 6 stated Resident 10 was on Seroquel for angry outbursts related to agitation and episodes of wandering (walk around without any clear purpose or direction) at times and screaming. LVN 6 stated Resident 10 should have been evaluated by a psychiatrist for his illnesses. LVN 6 stated she could not find any psychiatrist notes.During the interview on 4/23/2026 at 5:19 p.m., with the Director of Nursing (DON), the DON stated after the consultant pharmacist submitted MRR recommendations, the DON reviewed them as soon as the following day and attempted to address them before the next review date.

The DON stated difficulty reviewing the volume of material, noting there were 600 pages and not enough time to review them all.

The DON stated residents were routinely seen by a psychiatrist at least quarterly.

The DON stated the psychiatric consult had not been uploaded into the facility's electronic health record system, but confirmed that a consult existed and would need to be located.

When asked about Resident 10, the DON stated they had requested the psychiatrist to see the resident.

The DON added that if a resident's medication list did not contain the correct diagnosis, they would ask the physician to reevaluate.During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review (MRR) Policy, dated 2024, the P&P indicated, A licensed pharmacist shall conduct . (MRR) for each resident at least monthly.

Identified irregularities shall be reported to the attending physician and Director of Nursing (DON) with prompt follow-up and resolution.

The P&P indicated, Scope of Review: the MRR shall include, but is not limited to: Medication appropriateness (indication, dose, duration).

The P&P indicated, Physician Response: The attending physician must: Review and respond to reported irregularities; Indicate agreement, disagreement or alternative action; Responses must be documented in the medical record.

The P&P indicated, Timeliness of Action: Identified issues shall be addressed promptly; Urgent concerns.immediately.During a review of the facility's P&P titled, Psychotropic Medication Management Policy, dated 2024, the P&P indicated, Psychotropic medications shall be used only when clinically indicated, prescribed in accordance with accepted standards of practice, and monitored.safety.

The P&P indicated, General Requirements: Each psychotropic medication must have: a documented clinical indication/diagnosis.

056433 04/24/2026

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

shallow, leading to low blood oxygen levels and excessive carbon dioxide buildup [body is producing

hospitalizationDuring a review of facility's policy and procedure (P&P) titled, Monitoring Medication

to adverse drug effects in patients will ensure safe administration of medications.During a review of facility's P&P titled, Unnecessary Medication.

Dated 2024, the P&P indicated all staff and individuals involved in prescribing, administering medications should evaluate the medications for drug interactions, duplications and side effects.

056433 04/24/2026

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During the interview on 4/23/2026 at 4:50 p.m., with the DON, the DON stated the nurse should have flushed the gˆtube with 30 mL of water before and after administering psyllium husk, in accordance with the physician's order, to prevent clogging of the gˆtube.

During a review of the facility's P&P titled, Medication Timing of Administration Policy, dated 2024, the P&P indicated, 1.

Standard Administration Time Frames.

Routine medications shall be administered within a one-hour window before or after the scheduled time (e.g., 8:00 AM dose given between 7:00 AM and 9:00 AM).

Critical medications shall be administered at the exact time ordered or within a more restrictive window as defined below. 2.

Medications considered time-critical must be . within 60 minutes before or after the scheduled time, unless otherwise specified by the prescriber.

Examples include: Insulin (rapid-acting), Anticoagulants (e.g., warfarin, heparin), Antibiotics with specific dosing intervals, Anti-seizure medications, Medications with short half-lives or requiring consistent blood levels.

The P&P indicated, 5.

Missed or Late Doses. If a medication is not administered within the allowable time frame: The nurse shall assess the situation.if necessary.

The dose shall not be automatically .without an order, Documentation must include: Reason for delay or omission.actions taken.notifications made.During a review of the facility's P&P titled, Medication Administration, dated 2024, the P&P indicated, Medications shall be administered safely, accurately, and timely in accordance with physician orders, accepted standards of practice,.outcomes.During a review of the facility's P&P titled, Gastrostomy (g-tube) Medication Administration, dated 2024, the P&P indicated, Medications administered via G-tube shall be given safely and accurately, using proper technique to prevent tube occlusion, medication errors, and infection.

The P&P indicated, 3.

Administration Procedure- 1.

Stop feeding if applicable, 2.

Flush tube per protocol, 3.

Administer medications one at a time, 4.

Flush between medications, 5.

Flush after final medication, 6.

Resume feeding as ordered.(Cross-referenced with F-F755)

056433 04/24/2026

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

4/22/2026, there were 15 times when scheduled administration for levetiracetam oral solution 500

LVN 2, LVN 2 stated Resident 128's medications, including Keppra, were administered more than one

one hour before and no later than one hour after the scheduled administration time. LVN 2 stated the delayed administration could reduce the effectiveness of Keppra and place Resident 128 at risk for seizures and possible hospitalization.

During an interview on 4/23/2026 at 4:38 p.m. with the DON, the DON stated she conducted an in-service for the facility nurses regarding late administration of medications.

The DON stated there was a risk for adverse effects if the facility residents did not receive medications on time.

The DON stated the physician informed her (DON) that there would be a risk for seizures if the resident did not receive or if Keppra was omitted because it could cause low levels of Keppra.During a review of the facility's P&P titled, Medication Timing of Administration Policy, dated 2024, the P&P indicated, 1.

Standard Administration Time Frames.

Routine medications shall be administered within a one-hour window before or after the scheduled time (e.g., 8:00 AM dose given between 7:00 AM and 9:00 AM).

Critical medications shall be administered at the exact time ordered or within a more restrictive window as defined below. 2.

Medications considered time-critical must be . within 60 minutes before or after the scheduled time, unless otherwise specified by the prescriber.

Examples include: Insulin (rapid-acting), Anticoagulants (e.g., warfarin, heparin), Antibiotics with specific dosing intervals, Anti-seizure medications, Medications with short half-lives or requiring consistent blood levels.

The P&P indicated, 5.

Missed or Late Doses. If a medication is not administered within the allowable time frame: The nurse shall assess the situation.if necessary.

The dose shall not be automatically .without an order, Documentation must include: Reason for delay or omission.actions taken.notifications made.During a review of the facility's P&P titled, Medication Administration, dated 2024, the P&P indicated, Medications shall be administered safely, accurately, and timely in accordance with physician orders, accepted standards of practice,.outcomes.( Cross-reference with F-F759)

056433 04/24/2026

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

less participation in activities and would also negatively affect their mood.

During an interview on

effective if administered to residents and could increase the risk for hyperglycemia and

facility nurse should have verified with the pharmacy if they did not know how to store morphine sulfate oral solution.

The DON stated the pharmacy informed her (DON) that morphine could become too thick and might not be a comfortable consistency to administer to the resident when it was stored in refrigerator instead of at room temperature.During a review of the facility's P&P titled, Medication Storage Temperature Policy, dated 2024, the P&P indicated, To ensure all medications are stored under proper temperature conditions to maintain safety, stability, and effectiveness in compliance with regulatory requirements.

The P&P indicated, Room Temperature Requirements.

Medications labeled for controlled room temperature shall be stored between 68 F-77 F (20 C-25 C).

Manufacturer's labeling instructions shall always take precedence over standard ranges. 2.

Refrigerator Temperature Requirements.

Medications requiring refrigeration shall be stored between 36 F-46 F (2 C-8 C).During a review of the facility's P&P titled, Medication Storage and Labeling, dated 2024, the P&P indicated, All medications shall be.with physician orders, manufacturer instructions and regulatory requirements.

Medications must be maintained to ensure integrity, safety.personnel.

The P&P indicated, This policy means that medications must be: Properly labeled.Stored under appropriate conditions.Protected from contamination.unauthorized access.

The P&P indicated, Staff are expected to: Check for: Expired medications.Ensure multi-dose containers are dated when opened (if applicable).

The P&P indicated, To implement this policy.remove and properly dispose of: Expired medications, discontinued medications.During a review of the facility's P&P titled, Medication Labeling, dated 2024, the P&P indicated, Insulin.

Multi-dose vials or pens must be dated when opened, Discard per manufacturer guidelines.

056433 04/24/2026

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

During the concurrent observation, the Assistant Dietary Supervisor, who had a beard spanning the jawline and sideburns approximately 0.5-1.0 inches in length, was assisting AM [NAME] in the kitchen preparation area without wearing a beard net or restraint.During a concurrent interview on 4/22/ 2026, at 10:00 a.m., with the Dietary Supervisor (DS), when inquiring regarding the practice of wearing beard restraints DS stated, I have them wear it during service but not during prep. [NAME] restraints were not observed at the kitchen entrance where hair nets are routinely provided.

Upon inquiring about the location and accessibility of beard restraints DS went into her office located in the opposing corner of the main kitchen entrance, reached underneath a desk, and pulled out cardboard box which contained a clear plastic bag filled with beard nets.

During a follow-up interview with DS on 4/22/2026 at 2:15 p.m., DS stated that restraints should be treated in the same regard as hair nets to prevent hair from contacting food which can act as both physical and biological contaminant.

During a review of facility's policy and procedure (P&P) titled Personal Hygiene, Personnel Permitted and Appearance in Food and Nutrition Service Department (undated), the P&P indicated all employees must wear hair restraints to prevent the contamination of food, equipment, or utensils.

The P&P indicated beards, sideburns, and mustaches that are not closely cropped and neatly trimmed shall be covered.During a review of the 2022 FDA Food Code section 2-402.11, indicated that food employees shall wear hair coverings, including nets or beard restraints that are designed and worn to effectively keep hair from contacting exposed food, clean equipment and utensils.During a review of the Code of Federal Regulations, Title 21, Section 11.10 (b)(6), indicated Wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, or other effective hair restraints.

056433 04/24/2026

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502

in accordance with accepted professional standards.

interview and record review, the facility failed to ensure clinical weight records were complete and

six sampled residents (Resident 4) reviewed for nutritional status.

This failure placed the resident at risk for not receiving timely clinical evaluation and intervention.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE].

The admission Record indicated Resident 4 with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), dependence on respirator (ventilator- a machine for artificial breathing), and atrial fibrillation (irregular heart rate that can cause poor blood flow).During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 2/9/2026, the MDS indicated Resident 4's cognitive (ability to think, understand, learn, and remember) was intact.

The MDS indicated Resident 4 was dependent on staff with oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 4's Vital and Weight Summary, for the year 2026, the summary indicated following weights and reflected a total loss of 50.85% loss from 3/6/2026 to 3/30/2026:On 2/11/2026, Resident 4 weighed 200 pounds (lbs- a unit measure for weight).On 03/06/2026, Resident 4 weighed 199 lbs.On 03/30/2026, Resident 4 weighed 97.8 lbs.During a concurrent interview and record review on 04/23/2026 at 8:10 a.m. with Registered Nurse Supervisor (RNS) 1, Resident 4's Vital and Weight Summary, for the year of 2026 was reviewed. RNS 1 stated there was no documentation regarding the weight loss recorded on 3/30/2026, no recheck weight was obtained, and no follow-up was completed. RNS 1 stated the weight change represented a change of condition: however, no Change of Condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) assessment was completed, the attending physician was not notified, and no follow- up was initiated with the Registered Dietitian. RNS 1 also stated that sufficient time had elapsed to correct the weight if it had been a documentation error.During an interview on 4/23/2026 at 11:39 a.m. with RNS 1, RNS 1 stated the facility obtained Resident 4's weight on 4/23/2026, which was documented as 195 lbs.

During an interview on 4/24/2026 at 3:38 p.m. with the Director of Nursing (DON), the DON stated staff should have reassessed Resident 4's weight immediately to verify the accuracy of the documented measurement.

The DON stated that if the weight was confirmed to be accurate, a Change of Condition assessment should have been completed, and interventions should have been initiated and addressed promptly to ensure early intervention.During a review of the facility's policy and procedure (P&P), titled Weight Assessment and Intervention, dated 2024, the P&P indicated any weight change of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing.

Verbal notification must be confirmed in writing.

Inaccuracies will be corrected once confirmed by 2 licensed nurses.During a review of the facility's P&P, titled Charting and Documentation, dated 2024, the P&P indicated the documentation in the medical record will be complete, and accurate.During a review of the facility's P&P, titled Weight Change Protocol, undated, the P&P indicated early identification of a weight problem and possible cause(s) can minimize complications, assessment of residents experiencing weight changes should be completed in a timely manner.

The P&P also indicated residents will be weighed monthly and weekly for those deemed to be at high risk for weight changes or according to the facility's policies.

During an interview on 4/24/2026 at 3:00 pm with the Director of Nursing (DON), the DON stated the drainage bag should always be kept off the floor and below the bladder to prevent backflow and reduce the risk of infection.

The DON stated that the drainage bag should be secured to the bed frame.

The DON stated that if there is an order for a leg anchor the catheter tubing should be secured to the resident's leg to prevent pulling, trauma, and movement of the catheter.

The DON stated that this also helps to maintain proper positioning of the drainage bag.

The DON stated that the drainage bag lying directly on the floor and the catheter not secured with a leg anchor, was not acceptable and was not consistent with the facility's standard of care.

The DON stated that this could increase the risk of infection, including urinary tract infections, and could also lead to catheter dislodgement or trauma due to lack of securement.

During a review of the facility's policy and procedure (P&P) titled, Suprapubic Catheter Management dated 2024, the P&P indicated The facility ensures safe, sterile, and effective management of suprapubic catheters (SPCs) to reduce the risk of infection, maintain urinary drainage, and promote patient comfort and dignity.

056433 04/24/2026

Vermont Healthcare Center 22035 S.

Vermont Avenue Torrance, CA 90502