Health inspection·February 10, 2026

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 three of four sampled residents (Residents 2, 3 and 4) were assisted with Activities of Daily Living (ADLs- activities related to personal care) in a timely manner.This deficient practice had the potential to result in skin breakdown and falls for Residents 2, 3 and 4 and could negatively affect the Residents' psychosocial well-being. Findings: During an observation on 2/10/2026 at 12:20 p.m., Resident 4's call light (a communication tool that allows residents to alert nursing staff when they need assistance) was on. A Licensed Vocational Nurse (LVN), Physical Therapist (PT), and Certified Nursing Assistants (CNAs) were observed passing by Resident 4's room without responding to the call light. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 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,) abnormalities of gait and mobility (refer to changes in walking patterns that can result from various medical conditions) and other lack of coordination (refers to difficulty performing smooth, precise movements due to impaired communication between the brain, muscles, and nerves). During a review of Resident 2's History and Physical (H&P) dated 2/10/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Residents 2's Minimum Data Set (MDS - a resident assessment tool) dated 2/3/2026, the MDS indicated Resident 2's was able to understand and be understood by others. The MDS indicated Resident 2 required substantial maximal assistance (helper does more than half the effort. Helper lifts or holds the trunk or limbs and provides more than half the effort) with ADLs such as lower body dressing, toileting hygiene, transfers (the ability to transfer to and from a bed to a chair or wheelchair) and bed mobility. During an interview on 2/10/2026 at 10:40 a.m. with Resident 2, Resident 2 stated it sometimes (dates unspecified) took between 30 minutes to one hour for nurses during the night shift (11:00 p.m. - 7:00 a.m.) to respond to her call light for assistance going to the bathroom and to obtain water to drink. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 3's diagnoses included DM, abnormalities of gait and mobility and acquired absences of right leg below knee (BKA-refers to the loss of the leg segment due to various causes, impacting mobility and requiring comprehensive rehabilitation). During a review of Resident 3's Care Plan titled, ADL Self-care Performance Deficit dated 8/10/2025, the Care Plan indicated Resident 3 had self-care performance deficit related to left foot diabetic ulcer (open sore), right BKA, DM.The Care plan interventions included for one to two staff to assist Resident 3 with toileting and bed mobility. During a review of Residents 3's MDS dated [DATE], the MDS indicated Resident 3 did not have cognitive (ability to think and reason) impairment. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steading assistance as resident completes Residents Affected - Few Page 1 of 3 055262 055262 02/10/2026 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few activity) for ADLs such as upper body dressing, bed mobility (the ability to roll to and from lying on back to left and right side and return to lying on back on the bed), transfers, and walking. The MDS indicated Resident 3 was frequently incontinent (lack of voluntary control over urination and/or defecation) of urine and occasionally incontinent of bowel. During an interview on 2/10/2026 at 10:50 a.m. with Resident 3, Resident 3 stated it sometimes (dates unspecified) took one hour for nurses during the night shift to respond to her call light for assistance to get incontinence care. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 4's diagnoses included Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease causing difficulty in breathing), DM, abnormalities of gait and muscle weakness (refers to a decrease in the strength or power of muscle contractions, making it difficult for individuals to perform everyday activities). During a review of Resident 4's H&P dated 2/10/2026, the H&P indicated Resident 4 had the capacity to make decisions. During a review of Residents 4's MDS dated [DATE], the MDS indicated Resident 4 was able to understand and be understood by others. The MDS indicated Resident 4 was totally dependent on staff for ADLs such as toileting, showering and lower body dressing. The MDS indicated Resident 4 was always incontinent with bowel and bladder. During a review of Resident 4's Care Plan titled, ADL Self-care Performance Deficit dated 1/3/2026, the Care Plan indicated Resident 4 had an ADL Self-Care performance deficit related to COPD.The Care Plan interventions indicated for nursing to provide assistance to Resident 4 during toilet use. During a concurrent observation and interview on 2/10/2026 at 12:40 p.m., with Resident 4, the ADM and CNA 3 in Resident 4's room, Resident 4 was observed sitting in a chair with the call light on, stating she needed to urinate. The ADM stated Resident 4 could not walk and informed the resident to urinate in her incontinence brief, and that CNA 3 would change her. CNA 3 entered the room and told Resident 4 to urinate in her incontinence brief. Resident 4 stated, nurses took about 30 minutes to respond to her call light and get assistance (with ADLs). Resident 4 stated she was continent however nurses would always tell her to urinate in her brief. Resident 4 stated the nurses had not provided her with a bedside commode (portable toilet). Resident 4 stated she did not like to be left wet in a brief and wait to be changed. During an interview on 2/10/2026 at 2:00 p.m., with CNA 3, CNA 3 stated call lights should be answered by all CNAs, even if the room was not part of their assignment. If a nurse passed by a residents' rooms and saw a call light on, the nurse should ask the resident about his/her needs. CNA 3 stated call lights should be answered as soon as possible. CNA 3 stated it was not acceptable for a call light to remain unanswered for 20 minutes, and failing to respond to a call light in a timely manner placed residents at risk for falls or skin issues. CNA 3 stated Resident 4 was incontinent but sometimes could feel the urge to urinate. CNA 3 stated she would tell Resident 4 to go in the brief because she could not stand up by herself. CNA 3 stated if Resident 4 did not want to use the brief, staff could offer a bedpan (a receptacle used by a bedridden patient for urine and feces) or a bedside commode. During an interview on 2/10/2026 at 3:00 p.m. with LVN 3, LVN 3 stated, call lights were to be answered by all staff in the facility. LVN 3 stated residents were dependent on nursing assistance, which is why they pressed the call light. LVN 3 stated, leaving a resident wet for a long period of time, placed the resident at risk for a urinary tract infection (UTI-an infection in the bladder/urinary tract) or falls. LVN 3 stated it was not acceptable for residents to wait 20 minutes for a call light to be answered. LVN 3 stated Resident 4 could verbalize her needs to use the restroom. LVN 3 stated nurses could offer a bedpan to Resident 4 and that telling the resident to urinate in her brief was not appropriate because it could make the resident uncomfortable. LVN 3 stated it was the 055262 Page 2 of 3 055262 02/10/2026 Lomita Post-Acute Care Center 1955 Lomita Blvd Lomita, CA 90717

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurses' responsibility to accommodate Resident 4's needs with a bedpan or bedside commode. It was Resident 4's right to have dignity and receive assistance in any way related to her care. LVN 3 stated that Resident 4 may feel sad knowing she could use a commode instead of being left wet in her brief. During an interview on 2/10/2026 at 3:26 p.m., with the Director of Nursing (DON), the DON stated it was everyone's (all staff) responsibility to answer call lights in the facility. The DON stated call lights should be addressed as soon as they were activated by residents. Any staff member passing by should ask the residents what they needed and then notify the appropriate person. The DON stated failure to respond to call lights in a timely manner placed the residents at risk of falling and having skin issues. During a review of the facility's Policy and Procedure (P&P) titled, Call Light/Bell dated 5/2007, the P&P indicated Call lights were answered within a reasonable time. The P&P indicated staff should respond to the request, if the item was not available or are unable to assist, explain to the residents and notify the charge nurses for further instructions. During a review of the facility P&P titled, Perineal Care dated 2/2024, the P&P indicated the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infection and skin irritation. Review the resident's care plan to assess any special needs of the resident. 055262 Page 3 of 3