Other·February 28, 2018

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 Public Health (DPH) during a complaint investigation. Amended 2/28/18 Complaint/ERI #: CA00559414 and CA00558947 - Substantiated with a deficiency Representing the DPH: Surveyor# 19152 RN, HFEN The inspection was limited to the specific complaint and entity reported incident investigated and does not represent the findings of a full inspection of the facility. Highest Scope/Severity= G 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: CDFD11 Facility ID: CA910000055 If continuation sheet 1 of 7 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: _______________ 055262 (X3) DATE SURVEY COMPLETED 01/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOMITA POST-ACUTE CARE CENTER 1955 Lomita Blvd Lomita, CA 90717 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F323 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/08/2018 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy and a resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CDFD11 Facility ID: CA910000055 If continuation sheet 2 of 7 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: _______________ 055262 (X3) DATE SURVEY COMPLETED 01/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOMITA POST-ACUTE CARE CENTER 1955 Lomita Blvd Lomita, CA 90717 (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 plan of care to ensure one of three sampled residents (Resident A) was adequately supervised. Resident A, who had a history of falls and a behavior of standing up without assistance, was left in the dining room, sitting in his wheelchair unsupervised. Resident A stood up from his wheelchair, fell, and complained of pain to his right hip. This deficient practice resulted in Resident A falling, complaining of pain and requiring a transfer to a general acute care hospital (GACH) for further evaluation. The x-rays concluded Resident A had a fracture (broken bone) right hip that required a surgical repair and an 11 day hospital stay. Findings: A review of Resident A's Admission Face Sheet, the resident was admitted to the facility on August 16, 2017. Resident A's diagnoses included dementia (progressive loss of mental ability), abnormalities of gait (manner of walking) with severe weakness and mobility, failure to thrive (as weight loss of more than 5%, decreased appetite, and poor nutrition ... ....) and a history of falling. A review of Resident A's Minimum Data Set (MDS), an assessment and a care screening tool, dated October 2, 2017, indicated Resident A's cognitive (thought process) skills for daily decision-making were severely impaired. According to the MDS, Resident A required extensive assistance with walking in the room and on the unit and was totally dependent on the staff when walking in the corridor. Resident A was frequently incontinent of both bowel and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CDFD11 Facility ID: CA910000055 If continuation sheet 3 of 7 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: _______________ 055262 (X3) DATE SURVEY COMPLETED 01/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOMITA POST-ACUTE CARE CENTER 1955 Lomita Blvd Lomita, CA 90717 (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 bladder functions (involuntary elimination of urine and stool). A review of Resident A's Care Plan, dated August 17, 2017, indicated the resident was at risk for falls and injury related to having a history of falls, balance problems when standing/ambulating, gait disturbance and an impaired cognition. The goal was to reduce and/or minimize the resident's falls and injury. The staff approaches included monitoring closely for unsafe behaviors such as restlessness, climbing out of bed, and getting up from the wheelchair unassisted. Resident A's Fall Risk Evaluation, dated August 16, 2017, indicated the resident had a high risk for falls with a score of 12 (a total score of 10 or above represented a high risk). On August 18, 2017, Resident A was reevaluated for fall risk, and had a score of 20, indicating the fall risk had increased due to the resident's increased confusion, balance problems while standing and walking, decreased muscular coordination, change in his gait pattern when walking through a doorway that, gait problems and requiring the use of an assistive devise. A review of a SBAR (Situation, Background, Appearance, Review and Notify), dated October 27, 2017, indicated Resident A was found on the floor on his left side with his right leg flexed (bent). The resident complained of pain of 10 (10 being the worse [on a pain scale]) to his right hip and was transferred to the GACH's emergency room. On November 16, 2017, at 11:25 a.m., during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CDFD11 Facility ID: CA910000055 If continuation sheet 4 of 7 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: _______________ 055262 (X3) DATE SURVEY COMPLETED 01/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOMITA POST-ACUTE CARE CENTER 1955 Lomita Blvd Lomita, CA 90717 (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 an interview and a subsequent interview on January 16, 2018, at 12:03 p.m., Restorative Nursing Assistant 1 (RNA 1 [expanded role of the Certified Nurse Assistant, who works with physical therapy]) stated four nurses, which included two RNAs and two certified nursing assistants (CNA) are assigned to the dining room. RNA1 stated that they were instructed that at least one of them should be in the dining room at all times when residents are present and they usually communicate with each other to make sure someone was there. RNA 1 stated on the day Resident A fell she was taking another resident back to the room and when she returned to the dining room Resident A was on the floor. RNA 1 stated she did not witness Resident A's fall. She stated she could not remember if she was the last one to leave the dining room, but did not see anyone in the dining room when she returned and found Resident A on the floor. RNA 1 stated Resident A had a history of standing up from in his wheelchair unassisted. During an interview, on November 16, 2017, at 11:31 a.m., and a subsequent interview on January 16, 2018, at 12 p.m., CNA 1 stated Resident A had a behavior of standing up from his wheelchair unassisted and had to be redirected to sit down many times. CNA1 stated on the day Resident A fell she was assigned to the dining room, but left to take another resident back to their room when she returned to the dining room Resident A was on the floor. CNA1 stated there was no nursing staff present in the dining room when the resident fell. On November 16, 2017, at 11:36 a.m., during a concurrent interview and observation with the Dietary Services Supervisor (DSS), the dining FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CDFD11 Facility ID: CA910000055 If continuation sheet 5 of 7 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: _______________ 055262 (X3) DATE SURVEY COMPLETED 01/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOMITA POST-ACUTE CARE CENTER 1955 Lomita Blvd Lomita, CA 90717 (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 room was observed to have a small entry area just before entering the actual dining area. The DSS stated he and the Activities Director (AD) were standing, talking, just inside the small entry area, which was approximately 20-30 feet away from the residents on the day Resident A fell. The DSS stated there were about five residents remaining in the dining room, the nursing staff were taking the residents back to their rooms and at the time Resident A fell there were no nurses present in the dining room. The DSS stated he and the AD were not facing the residents and did not witness Resident A's fall. On January 16, 2018, at 12:09 p.m., during a telephone interview, the Director of Staff Development (DSD) stated she assigns four nurses; two RNAs and two CNAs to the dining room, they are instructed not to leave the resident's unattended. On the day Resident A fell, one nurse was taking the resident's clothing protector's to the laundry room and the other three nurses were taking the residents back to their rooms. The DSD stated she was not able to determine where the breakdown in communication happened, but stated there should have been at least one nurse in the room with the residents at all times. A review of Resident A's physician's order, dated October 27, 2017, indicated to transfer Resident A to the emergency room via 911 due to a fall. A review of the GACH's Admission Face Sheet indicated Resident A was transferred following a fall and was admitted to the hospital on October 27, 2017. The X-ray report, dated October 27, 2017, indicated the resident had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CDFD11 Facility ID: CA910000055 If continuation sheet 6 of 7 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: _______________ 055262 (X3) DATE SURVEY COMPLETED 01/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOMITA POST-ACUTE CARE CENTER 1955 Lomita Blvd Lomita, CA 90717 (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 an intertrochanteric (femur and hip bone) fracture of the right proximal femur, which was minimally comminuted (fragments particles) and not significantly displaced (right hip fracture). A review of the GACH's Discharge Summary indicated Resident A was admitted on October 27, 2017. The Hospital Course indicated Resident A fell from the wheelchair onto the floor and was not able to move his right leg and was transferred a GACH's emergency room where an x-ray showed a fracture to his right hip. Resident A underwent an open reduction internal fixation ([ORIF] a surgical procedure used to repair a fracture involving the bone) and was discharged back to the facility on November 6, 2017 (eleven days after admission). A review of the facility's undated policy, titled "Safety and Supervision of Residents," indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facilitywide priorities. Residents who utilize common areas in the facility (dining room, activity room, rehabilitation room, etc.) will be provided staff supervision. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CDFD11 Facility ID: CA910000055 If continuation sheet 7 of 7