Torrance Care Center West, Inc

In the surveyor’s words

From the most serious findings on record at Torrance Care Center West, Inc, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 26, 2024

  Based on observation, interview, and record review, the facility failed to ensure 5 of 5 sampled residents (Residents 6, 117, 122, 141, and 157) who were smokers, had an environment free of accident hazards (risk), by failing to: 1. Implement guidance from the Resident Smoking Assessment Form which indicated all residents' smoking materials and paraphernalia must be safely stored by facility staff. 2. Ensure Residents 6, 141, 122, 157, and 117 were not in possession of smoking materials (cigarettes and lighters). 3. Provide supervision while smoking for Residents 141, 157, and 117 identified as unsafe smokers. 4. Follow its policy and procedure (P&P) titled, Accidents and Supervision, which indicated staff will observe and identify potential hazards in the environment. 5. […]

• Immediate jeopardy, isolatedF689Jan 19, 2021

  Based on observation, interview, and record review, the facility's nursing staff failed to ensure a resident was adequately supervised on a locked unit, the locked unit was secured, alarms activated, and residents were closely supervised to prevent an elopement (leaving without permission unsupervised) from occurring for one of three sampled residents (Resident A). Resident A, who had a behavior of walking a lot and pushing on doors was not being supervised and went missing from the locked unit on 1/14/2021 for over 20 hours in the middle of the night. […]

• Actual harm, isolatedF689Feb 11, 2026

  Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) who was diagnosed with Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) did not sustain a second degree burn (damage to the epidermis [top layer of the skin] and part of the dermis [underlying layer] causing painful, red, blistered, and swollen skin) to his right leg. On 12/28/2025, Certified Nursing Assistant (CNA) 1 placed a lunch tray containing a cup of hot water on Resident 1's overbed table (a mobile, height-adjustable table with a narrow, rectangular top designed to slide over a bed or chair) and the cup of hot water fell onto Resident 1's right leg. The facility failed to: 1. […]

• Actual harm, isolatedF600Jul 15, 2025

  Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and 3) were free from physical abuse when Resident 1, who had a history of schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (excessive worry and feelings of fear, dread, and uneasiness), and major depressive disorder ([MDD] a mood disorder that causes a persistent feeling of sadness and loss of interest), suddenly without any provocation, hit Resident 2 on the left side of his face and then proceeded to hit Resident 3 on the right side of his face causing Resident 3 to fall to the floor. Resident 1 was arrested by the local area police. […]

• No harm, potential for more than minimal, widespreadF576Aug 14, 2025

  Based on interview and record review the facility failed to ensure seven of seven sampled residents (Resident 25, Resident 29, Resident 41, Resident 58, Resident 59, Resident 96 and Resident 108) received their mail on Saturdays.This failure resulted in Resident 25, Resident 29, Resident 41, Resident 58, Resident 59, Resident 96 and Resident 108 rights violated to receive mail on Saturdays.Findings:1. During a review of Resident 25's admission Record (Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness… […]