Health inspection·July 22, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to resolve a grievance indicating a delayed call light response time for one out of three sampled residents (Resident 3).This deficient practice had the potential for Resident 3 to have anxiety (extreme worry).Findings:During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage).During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated 5/28/2025, the MDS indicated Resident 3 had mild cognitive impairment (memory and thinking problems), and had the ability to understand and be understood by others. The MDS indicated Resident 3 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, showering/bathing, and dressing the lower body.During an interview on 7/22/2025 at 11:35 a.m., Resident 3 stated the nursing staff would take anywhere from 15 to 30 minutes to respond to her light at least once a week. Resident 3 stated she previously filed a grievance regarding the call light response time and stated her concern with the call lights had not been resolved and nobody came to talk to about a resolution. Resident 3 stated she is worried she will have another heart attack, and nobody will come to check on her. Resident 3 stated if she really had an emergency, she could die eight times within 15 minutes before anyone would come to check on her. During a concurrent interview and record review on 7/22/2025 at 12:07 p.m., with the Social Services Director (SSD), Resident 3's Grievance Form dated 5/29/2025 was reviewed. The Grievance Form indicated Resident 3 had a grievance regarding the call light response time. The Grievance Form did not indicate a plan of correction. The SSD stated she was the one that wrote down the grievance on the form for Resident 3 and brought it to the attention of the department heads, but it is nursing responsibility to resolve the plan of correction. The SSD stated there should have been a plan of correction done by the Director of Staff Development (DSD) to in-service the staff.During an interview on 7/22/2025 at 1:41 p.m., the DSD stated she was no longer currently the DSD but was at the time the grievance form was filed for Resident 3. The DSD stated she was never informed about Resident 3's concern but it should have been resolved, and an in-service should have been conducted with the nursing staff. The DSD stated call lights should be answered right away in case there is an emergency, and the grievance that Resident 3 reported needed a plan of correction.During review of facility's undated policy and procedure (P&P) titled Grievances, the P&P indicated the facility the purpose of the policy was to respect resident's right to file a grievance and to receive a timely and thoughtful resolution. The P&P indicated the facility will make prompt efforts to resolve grievances and keep a log of those resolutions, and the facility will actively seek a resolution and keep the resident appropriately apprised of its (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055262 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 07/22/2025 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)