Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Torrance Memorial Med Ctr Snf/dp during CMS and state inspections, most recent first.
A resident with a history including ORIF, stroke, and brain dysfunction had O2 saturation drop to 90% on room air, but staff did not document physician notification or a COC at that time. RN staff and the DON stated the low O2 sat required immediate physician notification, and later notes documented lethargy, coughing, rales, fever, mental status changes, new hypoxia, and a rapid response for worsening respiratory distress and agitation, with transfer to the GACH.
Inadequate Competency for 1:1 Sitter Care: An LVN assigned as a 1:1 sitter for a resident with suicidal ideations did not demonstrate awareness of the reason for the sitter order. The resident’s record included a sitter order, and staff interviews showed the LVN described the assignment as related to falls and confusion, while the resident’s daughter and RN stated the sitter was needed because the resident wanted to hurt himself and die. The DON also stated the LVN should have known what to watch for to keep the resident safe.
An RN preparing medications for a resident with impaired cognition and dependence with ADLs picked up a dirty trashcan and returned to the med pass without changing gloves or performing hand hygiene. In a separate event, a visitor assisted a resident with a hip fracture and an unhealed surgical incision with high-contact care without wearing appropriate PPE, despite an EBP order and facility policy requiring visitors to follow isolation protocol.
The facility failed to properly store food and maintain the required dishwasher temperature, potentially compromising food safety. An unlabeled, undated bag of pepperonis with freezer burns was found, and the dishwasher's temperature was below the required 150°F. Staff acknowledged the importance of these standards to prevent bacterial growth.
A resident with multiple health issues experienced nausea, vomiting, and refusal to eat, but the facility failed to notify the physician or document the change in condition. Staff interviews confirmed the oversight, which contradicted the facility's policy requiring physician notification for changes in condition.
A resident with hypertension was administered Amlodipine and Lisinopril without checking their blood pressure immediately prior, relying instead on a reading taken over an hour earlier. The RN stated that the facility allowed using earlier vital signs for medication administration, but the DON confirmed no policy supported this practice, risking hypotension and falls.
A resident was administered clindamycin for cellulitis without meeting the necessary criteria for a skin infection. The resident's medical records showed no fever, elevated white blood cells, or drainage, and no culture was performed before the antibiotic was given. The facility's policy required a clear indication for each drug, but the pharmacist did not clarify the diagnosis with the physician or discontinue the medication, leading to the deficiency.
A resident received an unnecessary antibiotic for a skin tear without meeting the facility's criteria for a skin infection. The resident was prescribed clindamycin for cellulitis without a prior culture, and the Infection Preventionist confirmed the resident did not meet NHSN criteria. The Director of Nursing acknowledged the risk of side effects and antibiotic resistance due to this oversight.
The facility did not post daily nurse staffing information in a visible and prominent place, as required. Observations revealed no visible staffing information at key locations, and interviews with staff confirmed the absence of such postings. The DON acknowledged the oversight, noting that staffing hours should be visible to comply with regulations.
Failure to Notify Physician of Resident’s Low Oxygen Saturation and Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for Resident 35 when the resident’s oxygen saturation dropped to 90% on room air. Resident 35 was admitted with diagnoses including left femoral ORIF, stroke, and non-traumatic brain dysfunction, and the MDS indicated the resident had some difficulty with daily decision making and required extensive assistance from nursing staff for multiple activities of daily living, including eating, oral hygiene, toileting, dressing, showering, sitting, standing, lying down, and transferring. During interviews, RN 1 stated the resident’s oxygen saturation of 90% was low, that the doctor should have been notified, and that a change of condition should have been documented; RN 1 also stated there was no documentation that the doctor was notified. RN 2 stated licensed nurses are supposed to notify the doctor if a resident is distressed or having trouble breathing and that a COC should have been documented. The DON stated that when the resident’s oxygen dropped to 90%, physician notification for intervention needed to be done at the time of the change of condition and documented in the Nursing Progress Notes. The physician progress notes later documented lethargy, coughing, rales, fever, mental status changes, and new hypoxia, and the resident subsequently had a rapid response for worsening respiratory distress and agitation, with RR 42, BP 195/87, O2 saturation 84% on room air, and transfer to the GACH.
Inadequate Competency for 1:1 Sitter Care
Penalty
Summary
The facility failed to ensure LVN 1 was competent in providing 1:1 sitter care for Resident 38, who had an order for a sitter to observe him for suicidal ideations. Resident 38’s record showed he was admitted to the facility, had intact cognition on the MDS dated 3/13/2026, and was dependent with ADLs. His physician orders dated 3/13/2026 included the sitter order, and his H&P dated 3/15/2026 listed diagnoses of AFIB, a paraspinal mass, and HTN. During a concurrent observation and interview on 3/14/2026, LVN 1 was observed sitting at Resident 38’s bedside and stated she was a 1:1 sitter because he was a high-fall risk, confused, and tried to get out of bed without calling. However, Resident 38’s daughter stated he had a 1:1 sitter because he told her he wanted to hurt himself and die if given the chance. RN 2 and the DON both stated LVN 1 should have known why Resident 38 needed a 1:1 sitter so she would know what to watch for and prevent him from harming himself. The facility policy for sitter support personnel stated the sitter should obtain a patient condition report before engaging in care activities and report changes in mental status or physical status immediately to the primary nurse.
Infection Control Practices Not Followed During Medication Pass and Visitor Care
Penalty
Summary
Infection prevention and control practices were not maintained during a medication pass for a resident admitted with intracerebral hemorrhage and acute respiratory failure, whose MDS indicated moderately impaired cognition and dependence with ADLs. During observation, an RN prepared the resident’s medications while wearing gloves, picked up the trashcan, and then returned to medication preparation without changing gloves or performing hand hygiene. The RN stated she should have washed her hands and changed her gloves after touching the trashcan to prevent cross-contamination and infection. The IPN and DON also stated the RN should have washed her hands and changed gloves after touching the trashcan while passing medications. In a separate event, Enhanced Barrier Precautions were not followed for a resident with a hip fracture, hypertension, and an order for EBP isolation for an unhealed surgical incision. During observation, the resident’s visitor assisted the resident to sit up in bed and transfer to a chair without wearing appropriate PPE. The DSD stated the caregiver should have been wearing PPE while providing care, and the IPN and DON stated visitors should wear PPE for high-contact care and to prevent the spread of infection. Facility policies stated gloves should be removed after contact with a patient and/or surrounding environment, visitors are to be educated on appropriate PPE use for residents in isolation, and visitors must adhere to the isolation protocol.
Food Safety and Dishwashing Temperature Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and dishwashing practices, which could compromise food safety and quality. During an observation, an open, unlabeled, and undated bag of pepperonis with freezer burns was found in Freezer #14. This indicates a failure to adhere to the facility's policy of labeling and dating food items to ensure the use of first-in, first-out procedures. The Lead Food Service Supervision (LFSS) confirmed that food with freezer burn should be discarded due to poor presentation and taste. Additionally, the facility did not maintain the required temperature for the dishwasher wash cycle. The temperature was observed to range from 144 to 146 degrees Fahrenheit, below the facility's policy requirement of 150 degrees Fahrenheit or greater to effectively kill germs and bacteria. The Dishwasher (DW) 1 and LFSS both acknowledged the importance of maintaining the correct temperature to prevent bacterial growth, and the manager was notified to address the issue. These deficiencies could potentially expose residents to compromised food quality and foodborne illnesses.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician and document a change in condition for a resident who experienced nausea, vomiting, and refusal to eat. The resident, who had a history of breast cancer, metastatic disease to the bone, atrial fibrillation, a stage 3 pressure ulcer, and hypothyroidism, was admitted to the facility and was dependent on staff for various daily activities. On a specific day, the resident had an episode of vomiting after lunch, and the family member refused anti-nausea medication. The resident's meal intake records showed a pattern of eating only breakfast and lunch, with a refusal to eat lunch on the day following the vomiting episode. Interviews with facility staff revealed that the physician was not notified of the resident's change in condition, and the change was not documented in the resident's records. The Director of Staff Development and the Director of Nursing both acknowledged the importance of notifying the physician for medical intervention and documenting changes in condition to prevent delays in treatment. The facility's policy required nursing staff to notify the attending physician of any change in condition, but this protocol was not followed in this instance.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for Resident 12 by not ensuring vital signs were obtained before administering medications that can affect blood pressure. Resident 12, who was admitted with diagnoses including hypertension, diabetes, and aphasia, had a blood pressure reading of 101/53 and a heart rate of 64 beats per minute taken at 7:07 a.m. However, during a medication administration observation at 8:40 a.m., RN1 administered Amlodipine and Lisinopril to Resident 12 without taking the resident's blood pressure at that time. RN1 stated that she typically used the blood pressure and heart rate readings taken by Certified Nursing Assistants from 6:30 a.m. to 7:00 a.m. when administering medications that could lower blood pressure. She mentioned that the facility had informed her it was acceptable to use vital signs taken two hours prior to medication administration. The Director of Nursing confirmed that there was no policy or defined time frame indicating it was acceptable to use earlier vital signs as a basis for administering cardiac medications. This practice could potentially lead to hypotension, dizziness, and falls if the resident's blood pressure is not checked immediately before administering the medication.
Unnecessary Antibiotic Administration for a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from receiving an unnecessary antibiotic. The resident, who was admitted to the facility with a skin tear on the lower leg, was prescribed clindamycin for cellulitis without meeting the necessary criteria for a skin infection. The resident's medical records indicated no fever, elevated white blood cells, or drainage from the skin tear, and no culture was performed before administering the antibiotic. The facility's Infection Preventionist acknowledged that the resident did not meet the NHSN criteria for a skin infection and that this should have been discussed with the physician. The facility's policy required a weekly drug regimen review to ensure that each drug had a clear indication. However, the pharmacist did not clarify the diagnosis with the physician or take measures to discontinue the medication, as required by the facility's protocol. The Director of Nursing confirmed that the resident had the potential to develop side effects and antibiotic resistance due to the unnecessary administration of antibiotics. This oversight in following the facility's policy and procedure led to the deficiency.
Unnecessary Antibiotic Administration for Skin Tear
Penalty
Summary
The facility failed to ensure that a resident was free from receiving an unnecessary antibiotic for a skin tear. The resident, who was admitted with a skin tear of the lower leg, pressure injury, and cerebrovascular accident with left lower leg weakness, was prescribed clindamycin for cellulitis of the right leg. However, no culture was performed before administering the antibiotic, and the resident did not exhibit symptoms such as fever, elevated white blood cells, or drainage from the skin tear that would justify the use of antibiotics according to the facility's policy. The Infection Preventionist (IP) acknowledged that the resident did not meet the NHSN criteria for a skin infection, which should have been discussed with the physician. The Director of Nursing (DON) also recognized the potential for the resident to develop side effects and antibiotic resistance due to the unnecessary administration of antibiotics. The facility's policy on antibiotic stewardship emphasizes the importance of mitigating overutilization of anti-infectives, which was not adhered to in this case.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily in a visible and prominent place, as required by regulations. On January 19, 2025, during observations at 11:30 a.m., no staffing information was visible at station 1, station 2, the lobby, or upon entrance to the unit. Interviews conducted on the same day revealed that RN 1 confirmed the absence of visibly posted staffing information for residents and visitors. The Director of Staff Development acknowledged that while a staffing information form was posted at station 1, it was not facing outward for visibility. The Director of Nursing admitted that the nurse staffing hours were not posted for residents and visitors to see, although they should be to comply with regulations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Torrance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beachside Post Acute | 0.8 mi | ★★★★★ | 10 | 0 |
| Del Amo Gardens Care Center | 1.4 mi | ★★★★★ | 14 | 0 |
| Lomita Post-acute Care Center | 1.9 mi | ★★★★★ | 29 | 0 |
| Torrance Care Center West, Inc | 2.1 mi | ★★★★★ | 7 | 0 |
| Providence Little Co Of Mary Transitional Care Ctr | 2.2 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.