Health inspection·August 15, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physicians for four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4) when their appointments for test and/or consultations were missed or not scheduled. These deficient practices resulted in Resident 1's surgery being delayed for five months and had the potential to result in a delay in treatment and services for Residents 2, 3, and 4. a. During a review of Resident 1's admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 1 required partial/moderate assistance (helper does less than half the effort) from facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician's Order dated 3/11/2025, the Physician's Order indicated a micro laryngoscopy (a minimally invasive surgical procedure to diagnose and treat various conditions affecting the vocal cords and larynx (voice box) for vocal cord lesion removal was scheduled for Resident 1 on 3/21/2025. During a review of Resident 1's Physician's Order dated 4/10/2025, the Physician's Order indicated an appointment for a cardiac stress test on 4/21/2025 at 7:30 a.m. During a review of Resident 1's Nurses Progress Note dated 6/12/2025, the Nurses Progress Note indicated Resident 1's physician informed Registered Nurse (RN) 1, that Resident 1 needed a micro laryngoscopy for vocal cord lesion removal as soon as possible and Resident 1 had missed two cardiac stress test appointments. The Nurses Progress Note indicated RN 1 would inform the social worker to make another cardiac stress test appointment. During a review of Resident 1's Physician's Progress Note dated 8/1/2025, the Physician's Progress Note indicated Resident 1 should have had a cardiac clearance (a medical evaluation performed by a cardiologist [a doctor who specializes in diagnosing and treating diseases of the heart and blood vessels]) to assess Resident 1's heart health and determine if it was safe for Resident 1 undergo a planned medical procedure, but the cardiac stress test appointments were overlooked by facility. The Physician's Progress Note indicated facility staff were working on scheduling a cardiac stress test and cardiac clearance for Resident 1's surgery (3/21/2025). During a telephone interview on 8/19/2025 at 1:53 p.m., Resident 1's physician stated he called the facility in 6/2025 (exact date unknown), to inquire about and reschedule Resident 1's surgery because Resident 1's surgery had been delayed because he missed his cardiac stress test and cardiac clearance. b. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hydronephrosis with renal and ureteral calculous obstruction (swelling of the kidneys due to a blockage in the urinary tract Page 1 of 8 055032 055032 08/15/2025 The Earlwood 20820 Earl Street Torrance, CA 90503

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few caused by a kidney stone) and degenerative disc disease (a condition where the spinal discs wear down over time due to aging and daily stress). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact, and Resident 2 required supervision or touch assistance (providing verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from facility staff to complete his activities of daily living ADLs. During a review of Resident 2's Physician's Order dated 2/13/2025, the Physician's Order indicated Resident 2 required a follow up appointment with urology (a branch of medicine concerned with the function and disorders of the urinary system) for kidney stones. During a review of Resident 2's Physician's Order dated 5/21/2025, the Physician's Order indicated Resident 2 required a follow up appointment with a neurosurgeon (a medical doctor who diagnoses and treats conditions that affect the nervous system including the brain, spinal cord, and nerves) due to degenerative disc disease During a review of Resident 2's Medical Records, there was no documentation to indicate that Resident 2's urology and neurosurgeon appointments had been scheduled or that Resident 2 had gone to the appointments. c. During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis Parkinson's Disease (a progressive disease of the nervous system marked by tremors, muscular rigidity, and slow, imprecise movements). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was moderately impaired, and Resident 3 required partial/moderate assistance from facility staff to complete his ADLs. During a review of Resident 3's Physician's Order dated 6/02/2025, the Physician's Order indicated Resident 3 had a neurology appointment for 6/11/2025. During a review of Resident 3's Medical Record, there was no documentation to indicated that Resident 3's neurology appointment had been scheduled or that Resident 3 had gone to the appointment. d. During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with the diagnoses including acute kidney failure (a sudden and rapid decline in kidney function) and benign prostatic hyperplasia ([BPH] a condition in which the prostate gland grows larger than normal, but the growth is not caused by cancer). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was intact, and Resident 4 required partial/moderate assistance from facility staff to complete his activities of daily living ADLs. During a review of Resident 4's Physician's Order dated 5/29/2025, the Physician's Order indicated Resident 4 had a urology appointment scheduled for 7/7/2025. During a review of Resident 4's Medical Records, there was no documentation to indicated that Resident 4's urology appointment had been scheduled or that Resident 4 had gone to the appointment. During an interview on 8/14/2025 at 10:49 a.m., the Director of Staff Development (DSD) stated, after reviewing Residents 1, 2, 3 and 4's medical record, there was no documentation to indicate an appointment was scheduled to follow up with Resident 2's urologist or neurosurgeon. The DSD stated there was no documentation to indicate Resident 3 and 4 completed their scheduled appointments. The DSD stated there was no documentation to indicate Resident 1, 2, 3 and 4's physicians were notified regarding their missed and/or unscheduled appointments. The DSD stated the resident's physicians should be notified regarding the status of the resident's appointments because the resident's treatment plan could be affected based on the results of the appointments and/or evaluation. During a telephone interview on 8/15/2025 at 11:57 a.m., the resident's physicians stated he did not recall being notified that Residents 1, 2, 3 and 4's appointments were missed and/or had not been scheduled. During an interview on 8/15/2025 at 12:34 p.m., the Director of Nursing (DON) stated physicians should be notified when appointments were missed and/or consultations were not scheduled as ordered because could cause a delay in treatment. During a review of the facility's policy and procedure (P/P) titled 055032 Page 2 of 8 055032 08/15/2025 The Earlwood 20820 Earl Street Torrance, CA 90503

F 0580 Change in Condition: Notification of dated 8/25/2021, the P/P indicated the facility should consult with the resident's physician and/or Nurse Practitioner (NP) where there is a need to alter treatment significantly. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055032 Page 3 of 8 055032 08/15/2025 The Earlwood 20820 Earl Street Torrance, CA 90503

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4), who had orders in place for test and/or consultations, had those orders implemented. These deficient practices resulted in Resident 1's surgery being delayed for five months and had the potential to result in a delay in treatment and services for Residents 2, 3, 4.a. During a review of Resident 1's admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 1 required partial/moderate assistance (helper does less than half the effort) from facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician's Order dated 3/11/2025, the Physician's Order indicated a micro laryngoscopy (a minimally invasive surgical procedure to diagnose and treat various conditions affecting the vocal cords and larynx (voice box) for vocal cord lesion removal was scheduled for 3/21/2025. During a review of Resident 1's Physician's Order dated 4/10/2025, the Physician's Order indicated an appointment for a cardiac stress test on 4/21/2025 at 7:30 a.m. During a review of Resident 1's Nurses Progress Note dated 6/12/2025, the Nurses Progress Note indicated Resident 1's physician informed Registered Nurse (RN) 1, that Resident 1 needed a micro laryngoscopy for vocal cord lesion removal as soon as possible and Resident 1 had missed two cardiac stress test appointments. The Nurses Progress Note indicated RN 1 would inform the social worker to make another cardiac stress test appointment. During a review of Resident 1's Physician's Progress Note dated 8/1/2025, the Physician's Progress Note indicated Resident 1 should have had a cardiac clearance (a medical evaluation performed by a cardiologist (a doctor who specializes in diagnosing and treating diseases of the heart and blood vessels) to assess his heart health and determine if it was safe to undergo a planned medical procedure) but appointments were overlooked by facility. The Physician's Progress Note indicated facility staff were working on scheduling a cardiac stress test and a cardiac clearance for surgery. During a telephone interview on 8/19/2025 at 1:53 p.m., Resident1's physician stated he called the facility in 6/2025 (exact date unknown) because Resident 1's surgery had been delayed because Resident 1 missed his cardiac stress test and cardiac clearance. b. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of hydronephrosis with renal and ureteral calculous obstruction (swelling of the kidneys due to a blockage in the urinary tract caused by a kidney stone) and degenerative disc disease (a condition where the spinal discs wear down over time due to aging and daily stress). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact, and Resident 2 required supervision or touch assistance (providing verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from facility staff to complete his activities of daily living ADLs. During a review of Resident 2's Physician's Order dated 2/13/2025, the Physician's Order indicated Resident 2 required a follow up appointment with urology (a branch of medicine concerned with the function and disorders of the urinary system) for kidney stones. During a review of Resident 2's Physician's Order dated 5/21/2025, the physician order indicated Resident 2 required a follow up appointment with a neurosurgeon (a medical doctor who diagnoses and treats conditions that affect the nervous system including the Residents Affected - Some 055032 Page 4 of 8 055032 08/15/2025 The Earlwood 20820 Earl Street Torrance, CA 90503

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some brain, spinal cord, and nerves) due to degenerative disc disease During a review of Resident 2's Medical Records, there was no documentation to indicate that Resident 2's urology and neurosurgeon appointments had been scheduled or that Resident 2 had gone to the appointments. c. During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis Parkinson's Disease (a progressive disease of the nervous system marked by tremors, muscular rigidity, and slow, imprecise movements). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was moderately impaired, and Resident 3 required partial/moderate assistance from facility staff to complete activities his of daily living ADLs. During a review of Resident 3's Physician's Order dated 6/02/2025, the Physician's Order indicated Resident 3 had a neurology appointment for 6/11/2025. During a review of Resident 3's Medical Record, there was no documentation to indicated that Resident 3's neurology appointment had been scheduled or that Resident 3 had gone to the appointment. d. During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with the diagnoses including acute kidney failure (a sudden and rapid decline in kidney function) and benign prostatic hyperplasia ([BPH] a condition in which the prostate gland grows larger than normal, but the growth is not caused by cancer). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was intact, and Resident 4 required partial/moderate assistance from facility staff to complete his activities of daily living ADLs. During a review of Resident 4's Physician's Order dated 5/29/2025, the Physician's Order indicated Resident 4 had a urology appointment scheduled for 7/7/2025. During a review of Resident 4's Medical Records, there was no documentation to indicated that Resident 4's urology appointment had been scheduled or that Resident 4 had gone to the appointment. During an interview on 8/14/2025 at 10:49 a.m., the Director of Staff Development (DSD) stated, after reviewing Residents 1, 2, 3 and 4's medical record, there was no documentation to indicate an appointment was scheduled to follow up with Resident 2's urologist or neurosurgeon. The DSD stated there was no documentation to indicate Resident 3 and 4 completed their scheduled appointments. The DSD stated there was no documentation to indicate Resident 1, 2, 3 and 4's physicians were notified regarding their missed and/or unscheduled appointments. The DSD stated the resident's physicians should be notified regarding the status of the resident's appointments because the resident's treatment plan could be affected based on the results of the appointments and/or evaluation. During an interview on 8/14/2025 at 12:17 p.m. and 3:50 p.m. with the Social Services Director (SSD), the SSD stated previously she oversaw arranging and scheduling appointments and transportation for residents when there was an order for an consultation or test. The SSD stated the previous system was not working because she was not scheduling the appointments in a timely manner, it would take her about 2 weeks to schedule the appointments. The SSD stated she was not aware of Resident 1, Resident 3, and Resident 4 appointments, so she did not make the arrangements for transportation. The SSD stated she was not aware of Resident 2's physician orders for follow-up appointments, so she did not make any appointments for Resident 2. During an interview on 8/14/2025 at 2:21 p.m. with the Director of Nursing (DON), the DON stated there was miscommunication between nursing and social services regarding appointments and consultations. The DON stated previously there was no system to communicate the appointments and transportation arrangements between nursing and social services staff which resulted in missed appointments and consultations. During a review of the facility's Job Description titled Registered Nurse (RN) dated 5/2022, the Job Description indicated the RN's duties and responsibilities included initiating requests for consultations or referrals as requested. During a review of the facility's Job Description titled Licensed Practical (Vocational) Nurse (LPN)/(LVN) dated 055032 Page 5 of 8 055032 08/15/2025 The Earlwood 20820 Earl Street Torrance, CA 90503

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5/2022, the Job Description indicated the LVN's duties and responsibilities included providing nursing services to residents in accordance with scope of practice, facility policies and professional standards of care. During a review of the facility's Policy and Procedure (P/P) titled Physician Orders dated 3/22/2022, the P/P indicated whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order. The P/P indicated an order pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline. 055032 Page 6 of 8 055032 08/15/2025 The Earlwood 20820 Earl Street Torrance, CA 90503

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a consultation outside of the facility with a cardiologist (a doctor who specializes in the heart and blood vessels) on 3/24/2025, returned to the facility with progress notes and instructions for care that were available for review in Resident 1's medical record. This deficient practice resulted in a delay in scheduling Resident 1's micro laryngoscopy (a minimally invasive surgical procedure to diagnose and treat various conditions affecting the vocal cords and larynx ([voice box]) for vocal cord lesion removal and had the potential for complications occurring based on that delay in surgery.During a review of Resident 1's admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 1 required partial/moderate assistance (helper does less than half the effort) from facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician's Order dated 3/11/2025, the Physician's Order indicated a micro laryngoscopy for vocal cord lesion removal was scheduled for 3/21/2025. During a review of Resident 1's Physician's Order dated 3/19/2025, the Physician's Order indicated Resident 1 had an appointment to see a cardiologist for a cardiology clearance (an evaluation performed by a cardiologist to determine if a patient's heart is healthy enough to undergo a planned surgical procedure) on 3/24/2025. During a review of Resident 1's Medical Records, there was no documentation to indicate consultation note and/or care instructions following Resident 1's cardiologist appointment on 3/24/2025. During an interview on 8/14/2025 at 1:14 p.m., the Social Services Director (SSD) stated she could not recall if Resident 1 went to his cardiology appointment on 3/24/2025. Later the same day the SSD called the cardiologist office to obtain the cardiology progress notes from Resident 1's cardiology appointment on 3/24/2025. During a review of Resident 1's cardiology Progress Notes dated 3/24/2025, the cardiology Progress Notes indicated they were faxed to the facility on 8/14/2025 at 4:23 p.m. During an interview on 8/14/2025 at 1:54 p.m., the Director of Staff Development (DSD) stated when residents leave the facility for doctor appointments, the physician usually transfers the residents back to the facility with orders in a packet, the visit notes take a couple of days to complete. The DSD stated if the resident returns to the facility without orders or instructions for care, the licensed nurses should follow up with the physician who provided the care to obtain those instructions because the facility should know what was discussed during the appointment and what the instructions for care were. During an interview on 8/14/2025 at 2:12 p.m., the Director of Nursing (DON), after reviewing Resident 1's medical record, stated the progress note from Resident 1's cardiology visit on 3/24/2025 was not available in Resident 1's medical record. The DON stated she was made aware that Resident 1 had an appointment on 3/24/2025 but she did not see the note from the cardiologist, assumed Resident 1 had not been seen by the cardiologist and made another appointment to see the cardiologist on 8/13/2025. The DON stated if Resident 1's cardiologist progress notes from his 3/24/2025 appointment had been available for review in Resident 1's medical record, she would have called Resident 1's surgeon (MD 2) to schedule Resident 1's surgery and there would have been no delay. The DON stated if Resident 1 did not have care instructions/notes with him when he returned to the facility 055032 Page 7 of 8 055032 08/15/2025 The Earlwood 20820 Earl Street Torrance, CA 90503

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from his appointment, the nursing staff should have called the physician's office to obtain the instructions for care, and if after 24 hours the documents were not received, medical records should have been made aware so they could have followed up. During a review of the facility's Policy and Procedure (P/P) titled Location and Storage of Medical Records dated 12/2006, the P/P indicated all current medical records are filed in the Medical Records Department and maintained by the Medical Records Clerk. During a review of the facility's undated P/P titled Appointments the P/P indicated any orders and follow up appointment are to be documented in the electronic record and the MD progress notes to be included in the resident's 055032 Page 8 of 8