Health inspection·March 11, 2025

F 0925 Resident 3 does not have the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated 2/18/2025, the MDS indicated Resident 3's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 3 was dependent on toileting, required maximal assistance for chair/bed-to-chair transfer, dressing upper (waist and above) and lower (below waist) body, moderate assistance for oral hygiene, and required supervision for eating. Residents Affected - Many During a concurrent observation and interview on 3/11/2025 at 12:33p.m. in Resident 3's room, two gnats flying were observed. Resident 3's Family Member 3 (FM 3) stated the gnats emerge during meal times and has seen gnats around since Resident 3 was readmitted to the facility on [DATE]. FM 3 stated the gnats comes out the minute the food comes out and see the gnats occasionally when there are no food. FM 3 stated the Administrator (ADM) is aware and indicated he came around with zappers through the hallway. FM 3 stated if residents are dependent during feeding, the gnat might get into the food and the residents would not know. FM 3 was observed swatting and killing gnats during the interview. Resident 3 was observed swatting the gnat away from her lunch. A gnat was observed a gnat walking on the corner of Resident 3's water pitcher. During an observation on 3/11/2025 at 12:35p.m., a gnat was observed flying inside a plate with a sandwich and a bag of potato chips that has been saran wrapped. During an observation on 3/11/2025 at 12:49p.m., there were gnats flying by the loafs of breads in the dry storage room in the kitchen. During a concurrent observation and interview on 3/11/2025 at 12:52p.m. with Dietary Manager (DM), DM stated he noticed the gnats around 3 days ago and does not know where they came from. DM stated at the moment, the source of the gnats was the drainage and have been moping everything clean and pouring hot water down in the drain every evening shift. There was one (1) gnat observed flying near the drainage. DM stated gnats being in the storage room is not acceptable due to cross contamination. During a concurrent observation, interview, and record review on 3/11/2025 at 1:01p.m. with Maintenance Director/Housekeeper (MDH),. MDH stated the gnats have been in the facility for a week and have seen then before, but not to this extent. MDH stated since there were gnats in some of the residents rooms, they placed fly traps. Fly traps were observed in one of the residents rooms, another close by to a different resident's room, one by the entrance, an industrial sized pest control zapper in the dining room, and another in the staff breakroom. MDH stated the big pest control zappers have been for a year and the sticky board is replaced once a month. MDH stated some of the UV fly traps are concentrated by three rooms as one of the residents has complained about gnats. MDH stated he spoke to pest control on 3/4/2025 and they came to assess the situation and made recommendations: to keep the door closed and per special service commercial agreement from the pest control, will fog the kitchen to knockdown adult fruit fly activity in five (5) to seven (7) day. MDH stated he is not sure where they originated from but indicated gnats thrive from anything organic (substance that is derived from or related to living organisms such as fruit, vegetables, juice). MDH stated gnats in the facility is not acceptable as they can contaminate the food. During an interview on 3/11/2025 at 1:19pm with FM 3,. FM 3 stated the residents can eat the gnat since it can look like pepper when it goes into the soup. FM 3 stated the gnats became more prominent within the last two (2) to 3 weeks and has the facility has been trying to mitigate it as much as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055262 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many possible. FM 3 stated she does not know where the source is, but the residents storing food in and out of the refrigerator might not be good idea. During a review of Resident 5's Face Sheet, the Face Sheet indicated Resident 5 was initially admitted on [DATE] and was readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) with dyskinesis (uncontrolled movements of face, arms, legs), abnormal posture, and bullous pemphigoid (autoimmune skin disorder [when body attacks own healthy tissues] that causes large, fluid-filled blisters on the skin). During a review of Resident 5's H&P dated 2/6/2025, the H&P indicated Resident 5 has the capacity to understand and make decisions. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5's cognitive skills were moderately impaired. The MDS indicated Resident 5 was dependent on chair/bed-to-chair transfer, bathing, toileting hygiene, lower body dressing, required maximal assistance for oral hygiene and upper body dressing, and required supervision for eating. During a concurrent observation and interview on 3/11/2025 at 1:40p.m, with Resident 5, Resident 5 stated the gnats show up when there is food. Resident 5 stated the gnats have been around a week or so ago and has been multiplying every day. Resident 5 stated they had placed a UV fly trapper 2-3 days ago on the wall and it used to light up blue. It was observed the UV fly trap was covered behind a fall mat and did not appear to be on. During an interview on 3/11/2025 at 1:50p.m. with MDH, MDH stated most of the gnats were in the kitchen as they had bad fruits in the pantry, so pest control was called on the same day. MDH stated it was reported to him that gnats were observed in the hallway, so he assessed the hallways and ordered the pest control traps. MDH stated when the issue persisted for 48 hours, he called pest control. MDH stated pest control came on 3/4/2025 but could not do the kitchen fogging until 3/11/2025 at 7:30p.m. due to scheduling. MDH stated they could have identified the issue quicker as gnats are difficult to get rid of once they are present During a concurrent observation and interview on 3/11/2025 at 2:03p.m. with MDH, MDH stated the UV fly zapper in Resident 5's room was assessed last week and indicated the sticky paper was missing and was not on. MDH stated the sticky paper is replaced as needed and indicated the UV fly zapper was supposed to be on and working. During an interview on 3/11/2025 at 2:08p.m. with Activities Assistant (AA), AA stated food it stored in the shared resident's refrigerator for 3 days and housekeeping will toss them out after the 3rd day. AA stated she has observed gnats in the dining room and are there all day bother her and the residents while doing activities. AA stated gnats in the dining room not okay as they are annoying during mealtimes, uncomfortable, and unsanitary. AA stated they do not touch the refrigerator unless the residents ask for their food, and it is housekeeping's responsibility to clean the fridge. During an interview on 3/11/2025 at 2:44p.m. with Pest Control (PC), PC stated he observed fruit flies in a couple of residents room as they had exposed food items, in the kitchen near the soda dispenser, and some in the dry storage area, but indicated the area of concern was the corner by the soda dispenser where there was a lot of organic buildup by the juice box. PC stated the recommendation was to do sanitation to get rid of the fruit flies and required sanitation education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055262 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent observation and interview on 3/11/2025 at 4:05p.m. with HK 1, it was observed that the shared refrigerator was cleaned, but HK 1 stated it is the first time she has seen the shared refrigerator with gnats flying inside. During a concurrent interview and record review on 3/11/2025 at 4:21p.m. with HK 1, HK 1 stated the Refrigerator Cleaning Log (Clean Every 3 Days) was last dated on 2/10/2025 and indicated it was cleaned, but no one has documented that it was cleaned. During a concurrent interview and record review on 3/11/2025 at 5:01p.m. with Director of Nursing (DON), DON stated there are still gnats within the facility. DON stated some of the gnats were in the residents rooms. DON stated some of the residents have complained about it and has seen the family and residents swatting the gnats DON stated the food is supposed to be thrown away every 3 days as it can cause spoilage and want to prevent residents from getting sick. DON stated family members bring food, the staff are notified at the entrance, will label the food with name and date, and will place the food in the refrigerator. DON stated they were trying to target the source of where the gnats were coming from but indicated it would have benefited the facility if they had placed the UV fly traps throughout the facility to prevent the gnats from flying. During a review of the facility's policy and procedure (P&P) titled, Departmental: Pest Control, revised 5/2023, the P&P indicated it is the policy of this facility to provide an environment free of pests. Monitoring of the environment will be done by the facility's staff. During a review of the facility's P&P titled, Storage of Food and Supplies, undated, the P&P indicated food, and supplies will be stored properly in a safe manner. Routine cleaning and pest control procedures should be developed and followed. During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, undated, the P&P indicated environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC: organization that protect public's health) for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: non-critical items are those that come in contact with intact skin but not mucous membranes. Environmental surfaces will be disinfected (or cleaned) on a regular basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055262 If continuation sheet Page 4 of 4