Other·August 30, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Health during a complaint investigation. Complaint number CA00640154 Representing the Department of Health: Health Facilities Evaluator Nurse ID: 38551 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. There was one deficiency issued for complaint number CA00640154.

F697 SS=G Pain Management CFR(s): 483.25(k)

F697 08/30/2019 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RKXQ11 Facility ID: CA910000036 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055032 (X3) DATE SURVEY COMPLETED 08/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE EARLWOOD 20820 Earl St Torrance, CA 90503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow its policies on pain management and physician notification for one of three sampled residents (Resident 1), who was experiencing severe back pain by not: 1. Notifying the facility's Medical Director, once Resident 1's primary physician was not responding for pain management for Resident 1, as per the facility's policy. 2. Medicating Resident 1 for severe back pain once the resident requested for pain medication as prescribed by the physician on 5/31/19. These deficient practices resulted in Resident 1 having uncontrolled pain of ten (10) on a pain scale one (1) to 10 (10 being the worse pain) from 6 p.m., till 11:33 p.m., a total of five and a half (5 1/2) hours. As a result, Resident 1 had to be transferred back to the general acute care hospital (GACH) for pain management only. Resident 1 stated he felt helpless as the licensed nurses would not help to ease his pain. Findings: A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on 5/31/19. Resident 1's diagnoses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RKXQ11 Facility ID: CA910000036 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055032 (X3) DATE SURVEY COMPLETED 08/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE EARLWOOD 20820 Earl St Torrance, CA 90503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE included low back pain, muscle weakness, Stage II (partial thickness loss of the dermis [a layer of skin between the epidermis and subcutaneous tissues], presenting as a shallow open ulcer with a red pink wound bed, without slough [dead tissue]) sacral (a large, triangular bone at the base of the spine) pressure ulcer (localized injury to the skin and/or underlying tissue due to pressure), stimulant dependence (continuous use of drugs such as cocaine that can cause mental discomfort ), paraplegia (paralysis [inability to move] of the legs and lower body), intra-spinal abscess (a collection of pus that has built up within the tissue of the body) and granuloma (a small area of inflammation [a part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants]). A review of Resident 1's Physician's Orders, dated 5/31/19 and timed at 7:32 p.m., indicated Resident 1 was to receive two (2) tablets of acetaminophen ([Tylenol]) a mild pain reliever) 325 milligrams (mg) by mouth (PO) every (q) four (4) hours as needed (PRN) for mild pain; one (1) tablet of Morphine Sulfate (narcotic medication used for treatment of moderate to severe pain) 30 mg PO q 12 hours for pain management; one (1) tablet of Hydromorphone ([Dilaudid] strong narcotic pain reliever similar to morphine) 4 mg q 3 hours prn mild pain; and two (2) tablets PO q three (3) hours PRN for moderate pain. A review of Resident 1's "Progress Note," dated 5/31/19 and timed at 6 p.m., indicated Resident 1 was admitted to the facility, unable to reposition in bed and/or transfer himself to and from the bed. According to the progress note, Resident 1 complained of severe back FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RKXQ11 Facility ID: CA910000036 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055032 (X3) DATE SURVEY COMPLETED 08/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE EARLWOOD 20820 Earl St Torrance, CA 90503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pain of 10 on a pain scale of 1-10 and 10 being the worse pain. A review of Resident 1's "Nursing Home to Hospital Transfer Form," dated 5/31/19, indicated Resident 1 had uncontrolled pain and was transferred, per the nurse's judgement and the facility's policy, to a GACH on 5/31/19 at 11:40 p.m. A review of a "Prehospital Care Report Summary," from an Ambulance Service, dated 5/31/19 and timed at 11:33 p.m., indicated Resident 1 was alert and experiencing severe back pain of 10 on a pain scale (0-10), as per the emergency medical technicians ([EMTs] a person who is specially trained and certified to administer basic emergency services) assessment. Resident 1 was transferred to the GACH by the EMTs. A review of an "Emergency Department (ED) Arrival Information form," dated 6/1/19, indicated Resident 1 arrived at the ED at 11:57 p.m. on 5/31/19 to receive medication for the uncontrolled back pain. The form indicated Resident 1 had a laminectomy (surgical operation to remove one or more small bones in the back to relieve pressure on the nerves or spinal cord) on 5/16/19. The ED Information form indicated Resident 1 did not receive pain medications at the facility because the resident's pain prescriptions was not "filled." According to this form, Resident 1 was treated and medicated for pain in the ED and sent back to the facility on 6/1/19. According to the ED note, Resident 1 received Dilaudid one 4 mg tablet by mouth with decreased pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RKXQ11 Facility ID: CA910000036 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055032 (X3) DATE SURVEY COMPLETED 08/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE EARLWOOD 20820 Earl St Torrance, CA 90503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's facility Nurse's Progress Note, dated 6/1/19 and timed at 1:32 a.m., indicated Resident 1 was readmitted to the facility from the GACH in severe pain. The nurse's progress note indicated Resident 1 refused to take Tylenol while the nurse waited for the other stronger pain medications to be approved by the resident's primary physician. The nurse's progress note indicated the pharmacist (a person who is professionally qualified to prepare and dispense medication) was made aware and stated that due to high volume of calls, the attending physician had not yet approved for the nurses to get narcotic medications from the facility's automated medications dispensing unit (Omnicell). According to the nurse's note, Resident 1's family member (FM 1) was very upset and requested for Resident 1 to be transferred back to the GACH for pain management. Resident 1 was transferred to the GACH per FM 1's request. On 6/14/19 at 3:10 p.m., during an interview, FM 1 stated Resident 1 was admitted to the facility on 5/31/19 at 6:30 p.m. and had to be transferred to an ED at 12 a.m., which was approximately five hours after being transferred to the facility from the GACH. FM 1 stated Resident 1 was crying in much pain and the facility did not have any pain medications to give the resident. FM 1 stated that she asked the nurse to send Resident 1 back to the GACH for prompt treatment because the resident had just had back surgery and needed pain medications. On 6/18/19 at 8:44 a.m., during a concurrent observation and interview, Resident 1 was observed in bed complaining of pain. Resident 1 stated that a Licensed Vocational Nurse (LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RKXQ11 Facility ID: CA910000036 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055032 (X3) DATE SURVEY COMPLETED 08/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE EARLWOOD 20820 Earl St Torrance, CA 90503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2) was notified at 7 a.m., that he was in pain, but no one has come to medicate him "as usual." Resident 1 stated he decided not to bother them anymore, because the nurses would do what they wanted regardless. Resident 1 stated that he felt helpless, especially since he could not walk and the nurses would not help to ease his pain. On 6/18/19 at 8:58 a.m., during an interview, LVN 2 stated that Resident 1's pain medication was due at 8:30 a.m. (on the same day), but she did not medicate Resident 1 because the treatment nurse asked her to wait and medicate Resident 1 just before the wound care treatment. LVN 2 stated that she should have given Resident 1 his pain medications as prescribed to decrease the resident's pain and make him comfortable, as well to prevent the resident's pain from getting worse. On 6/18/19 at 9:05 a.m., during a concurrent interview and record review of Resident 1's clinical record nursing progress notes, Registered Nurse 1 (RN 1) stated that there was no documentation indicating the facility's Medical Director (a physician who provides guidance and leadership on the use of medicine in a healthcare organization) was called regarding the nurse's inability to reach Resident 1's primary physician for Resident 1's pain medication order. RN 1 stated that upon admission, residents are assessed by an RN and the physician was called within an hour for medication orders to be verified. RN 1 stated that if the physician did not respond to telephone calls within two (2) hours, the facility's Medical Director or the GACH's transferring physician should be called for resident's admitting orders. RN 1 stated after a physician prescribes narcotic medications it still FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RKXQ11 Facility ID: CA910000036 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055032 (X3) DATE SURVEY COMPLETED 08/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE EARLWOOD 20820 Earl St Torrance, CA 90503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE had to be authorize by the pharmacist before the narcotics (strong pain medicines) could be provided to the residents. On 6/18/19 at 9:39 a.m., during an interview, the facility's pharmacist (a person who is professionally qualified to prepare and dispense medicinal drugs) stated that Resident 1's physician was paged on 5/31/19 at 11 p.m., to authorize the narcotic orders for Resident 1, but the physician never returned the pharmacist's call. The pharmacist stated that Resident 1's narcotics could not be filled until the physician gave an approval. On 6/18/19 at 9:57 a.m., during an interview, LVN 1 stated on 5/31/19, as soon as Resident 1 was admitted to the facility, the physician gave written orders to continue with the GACH's medication orders. LVN 1 stated that the orders were sent to the pharmacy to be filled immediately because Resident 1 had a lot of pain to the back of 9 out of 10 upon admission. LVN 1 stated that the Omnicell could not be opened because the pharmacist was waiting for the physician's approval. According to LVN 1, Resident 1 was prescribed 8 mg of Dilaudid, but the pharmacist refused to send the medication because the physician did not provide an actual written order. LVN 1 stated that the facility's Medical Director was not called, because she "did not control the doctor." A review of the facility's policy with a revision date of 12/1/18 and titled, "Physician/Advanced Practice Provider Notification," indicated if a patient had a change of condition, the licensed nurse would assess the resident, and notify to the physician or advanced practice provider. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RKXQ11 Facility ID: CA910000036 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055032 (X3) DATE SURVEY COMPLETED 08/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE EARLWOOD 20820 Earl St Torrance, CA 90503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The policy also indicated if the staff were unable to reach the attending physician, the facility's medical director would be contacted, and interventions initiated as needed. On 6/18/19 at 10:54 a.m., during an interview, the Director of Nursing (DON) stated that upon admission, a licensed nurse should fax the resident's physician orders to the pharmacy within two (2) hours for prompt delivery of the residents' medications. The DON stated the pharmacist have to authorize for the nurse to get pain medications from the Omnicell to give to the resident. The DON stated that if Resident 1's physician did not respond to telephone calls for admitting orders within an hour the Medical Director should have been called for immediate pain medication orders. The DON stated the licensed nurse should have transferred Resident 1 to the ED upon admission because the resident's pain could have been be a complication from the surgery. A review of the facility's undated policy titled, "After Hour, Weekend and Holiday Calls to Physicians/Advanced Practice Providers Process Guidelines," indicated if a resident had a change of condition between the hours of 5 p.m., and 7 a.m., on the weekends or holidays, the supervisor would call the physician with the identified problems and document the notification in a change in condition follow- up note and then follow-up as indicated. A review of another policy, with a revision date of 3/1/18 and titled, "Pain Management," indicated the purpose of the policy was to maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat and evaluate pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RKXQ11 Facility ID: CA910000036 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055032 (X3) DATE SURVEY COMPLETED 08/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE EARLWOOD 20820 Earl St Torrance, CA 90503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of a policy, dated 1/15/18 and titled, "Automated Medication Dispensing System for Interim (temporary)/Stat/Emergency Supply (Omnicell, Pyxis) indicated the purpose of the policy was to ensure access to medically necessary medications and to facilitate administration of "STAT" (immediately) and "FIRST DOSES" by authorized center staff. A review of a policy titled, "Physician Notification," dated 12/1/06 indicated a change in a resident's condition would be communicated to the physician and interventions initiated as needed. According to this policy, if the resident's condition was life threatening or an emergency, the staff would call 911 and notify the physician immediately. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RKXQ11 Facility ID: CA910000036 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055032 (X3) DATE SURVEY COMPLETED 08/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE EARLWOOD 20820 Earl St Torrance, CA 90503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: RKXQ11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA910000036 (X5) COMPLETE DATE If continuation sheet 10 of 10