The Earlwood: Resident Moved Twice Without Consent - CA
The moves happened on August 8 and August 28, 2025. By the time a state inspector arrived on September 3, neither transfer appeared anywhere in Resident 3's chart.
The facility's own social worker acknowledged she had the documentation. Then she replaced it. During the inspection, she told investigators she should not have swapped out the records, and that she had found no documentation for either room change when she went looking for it. Her explanation: she forgot to write it down after the first move, and forgot again after the second. She said it was her responsibility to obtain consent and follow up with proper paperwork. She said she forgot.
The Director of Nursing told inspectors that her job functions include reviewing room changes, and that the process is not complicated. Before any resident is moved, staff are supposed to inform the resident and their responsible party of the reason for the change, obtain consent, and provide written notification in advance. The DON said plainly that Resident 3 should have received notification and consent before either move. He did not.
The facility's own Room or Roommate Change policy, dated June 27, 2022, spells out what that process looks like. Notice of a room change can be oral or written, or both, but it must include the reason for the change. The resident, their representative, their current roommate, and their new roommate are all supposed to receive timely advance notice. And information about the transfer is supposed to be documented in the medical record.
None of that happened. Not once. Not twice.
What makes this harder to dismiss as a paperwork problem is the sequence. A resident was moved without notice in early August. No one caught it, corrected it, or told him why. Three weeks later, it happened again. The social worker responsible for both was the same person. The documentation gap for the first move went unaddressed long enough for a second move to occur under identical circumstances.
The right to know why you are being moved, and to agree to it before it happens, is not a bureaucratic formality for nursing home residents. For people who may have limited mobility, cognitive decline, or established routines built around a particular room and roommate, an unannounced transfer is a disruption with real consequences. The resident's existing roommate, who was also entitled to advance notice under the facility's own policy, received none either.
Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting a limited number of residents. The social worker's admission that she replaced documentation in the medical record drew specific attention during the investigation, with inspectors noting she acknowledged the substitution was improper.
The Earlwood is a skilled nursing facility in Torrance. The inspection was conducted in response to a complaint.
Resident 3 was moved out of his room twice in thirty days. Nobody asked him. Nobody wrote it down. And when an inspector came looking, the social worker who was supposed to handle both tasks acknowledged she had already been in his chart and had not left the documentation there that should have been.
He found out what the inspection report said about his own room changes the same way the inspector did: by reading what wasn't there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Earlwood from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
THE EARLWOOD in TORRANCE, CA was cited for violations during a health inspection on September 3, 2025.
The moves happened on August 8 and August 28, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.