Health inspection·November 20, 2025

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was seen by an oral surgeon (Dental specialist that performs surgery on mouth jaw and face).This deficient practice had the potential for Resident 1 to have gum disease, tooth loss and an overall poor quality of life.Findings:During a review of Resident 1's admission Record (Face sheet) dated 11/20/ 2025, the face sheet indicated that Resident 1was admitted on [DATE] and readmitted on [DATE] with the diagnosis including Bechet's disease (autoimmune disease-causing inflammation of blood vessels), depression ( a mood disorder affecting how a person thinks, feels and acts) and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History & Physical (H&P) dated 1/17/2025, the H&P indicated, Resident 1 was alert and oriented.During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/17/2025, the MDS indicated Resident 1's cognition was intact. The MDS also indicated Resident 1needs substantial/maximal assistance (helper who does most of the work) with activities of daily living (ADL's- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 1's Dental Progress Note dated 7/1/2025, the Dental Progress Note indicated Resident 1's treatment recommendations, were to follow-up with an oral surgeon for referral for scaling and root planing (SRP-deep cleaning procedure for gum disease).During a concurrent observation and interview on 11/20/2025 at 8:30 a.m. with Resident 1 in Resident 1's room. Resident 1's teeth showed signs of decay (rot from bacteria). Resident 1 stated he would like to see a dentist.During an interview on 11/20/2025 at 11:43 a.m. with the Social Services Director (SSD), the SSD stated she was made aware by Resident 1's sister that Resident 1 needed to see an oral surgeon. The SSD stated Resident 1 did have a recommendation to see an oral surgeon on 7/1/2025. The SSD stated the dentist recommendation should have been done right away. The SSD stated the facility failed Resident 1.During an interview on 11/20/2025 at 3:49 p.m. with the Administrator (ADM), The ADM stated she expects the staff to follow up on the dentist's recommendations within 72 hours after receiving the recommendation. The ADM stated there was a delay in care for Resident 1.During a review of the facility's Policy and Procedure (P&P) titled Appointments the P&P indicated that this policy and procedure document outlines the support a facility provides to residents in accessing specialty healthcare services to enhance their health and wellbeing. The P&P indicated the facility will help residents contact specialty providers as needed, based on health recommendations. The P&P indicated the facility will assist in scheduling appointments and arranging necessary transportation for residents to ensure they can attend their appointments. Residents Affected - Few Page 1 of 3 055032 055032 11/20/2025 The Earlwood 20820 Earl Street Torrance, CA 90503

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food preferences were honored for one of three sampled residents, (Resident1).This deficient practice violated Resident 1's rights and had the potential for malnutrition and weight loss.Findings:During a review of Resident 1's admission Record (Face sheet) dated 11/20/25, the face sheet indicated that Resident 1was admitted to the facility on [DATE] and readmitted on [DATE]with the diagnosis including Bechet's disease (autoimmune disease-causing inflammation of blood vessels), depression ( a mood disorder affecting how a person thinks, feels and acts) and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History & Physical (H&P) dated 1/17/2025, the H&P indicated, Resident 1 alert and oriented.During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/17/2025, the MDS indicated Resident 1's cognition was intact. The MDS also indicated Resident 1needs substantial/maximal assistance (helper does most of the work) with activities of daily living (ADL's- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 1's Dietary assessment dated [DATE] the Dietary Assessment indicated that Resident 1's food dislikes were cranberry juice, alfredo sauce, broccoli, bell peppers, eggs, fish, tuna, greens, macaroni and cheese, mashed potatoes, hot cereal, peas, salad dressing and spinach.During a review of Resident 1's Dietary Meal Ticket dated 11/20/2025, the meal ticket indicated Resident 1 had no food dislikes.During a telephone interview on 11/20/2025 at 9:46 a.m. with Resident 1's representative, Resident 1's representative stated Resident 1 is a very picky eater and if he does not like the food, he will not eat it.During an observation on 11/20/2025 at 12:19 p.m. in the dining room, Resident 1's food tray was observed having cranberry juice, chicken stroganoff, and broccoli.During a concurrent interview and record review on 11/20/2025 at 2:31 p.m. with the Dietary Supervisor (DS), Resident 1's Dietary assessment dated [DATE] was reviewed. The DS stated once the resident's food dislikes are entered into the computer, the system then selects the food the residents can eat. The DS stated he had entered Resident 1's food dislikes wrong into the computer system and that's why Resident 1 had received cranberry juice, chicken stroganoff and broccoli on his lunch tray on 11/20/2025. The DS stated Resident 1 should not have received those foods because they were all foods Resident 1 disliked. The DS stated the facility does not put the resident's food dislikes on their meal tickets and that he felt the residents' food dislikes should be put on their meal ticket, so the staff will know what the resident does not like to eat. The DS stated when residents are not served food, they like to eat there is a potential for the residents to have weight loss.During an interview on 11/20/2025 at 3:29 p.m. with the Director of Nursing (DON), the DON stated that she agreed the resident's food dislikes should be put on the resident's meal ticket because the residents will be served foods they don't like to eat, if staff are not aware. The DON stated it is the residents right to be served foods they like to eat. The DON stated they did not honor Resident 1's food preferences.During an interview on 11/20/2025 at 3:45 p.m. with the Administrator (ADM), the ADM stated the resident's food preferences must be honored and it is the residents' right to be served the foods they like to eat. The ADM stated that not having the residents' food dislikes on their meal ticket, there is a possibility that the residents would be served foods they don't like to eat.During a review of the facility's Policy and Procedure (P&P), titled Resident Food Preferences, the P&P indicated, the Dietary Manager will complete a Dietary Profile for residents to reflect current food preferences and nutritional needs upon admission, readmission, quarterly, annually or as needed.The P&P indicated the Dietary Department will 055032 Page 2 of 3 055032 11/20/2025 The Earlwood 20820 Earl Street Torrance, CA 90503

F 0806 provide residents with meals consistent with their preferences, as indicated on their tray card and if the preferred item is not available, a suitable substitute should be provided. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055032 Page 3 of 3