Other·October 24, 2019

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 during a Recertification Survey. Representing the Department of Public Health: Health Facilities Evaluator, Nurse: 41489, RN, HFEN Health Facilities Evaluator, Nurse: 36385, RN, HFEN Health Facilities Evaluator, Nurse: 36396, RN, Senior HFEN Total Census: 53 Total Sample: 15 Highest Severity and Scope: E

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 09/27/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the 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: EHBB11 Facility ID: CA910000055 If continuation sheet 1 of 29 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 09/24/2019 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 allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report an allegation of verbal abuse for two of 2 sampled residents (14, 49) to the local law enforcement and licensing agencies as indicated in the facility's policy and procedures. This deficient practice had the potential to compromise the safety of Resident 14, and the other residents, when Resident 49 verbally threatened Resident 14 by saying "I'm going to rip you apart and kill you." Findings: A review of Resident 14's "Record of Admission" indicated the resident was admitted to the facility on 5/20/19 with diagnoses including end stage renal disease (condition where kidneys are not functioning) and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 2 of 29 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 09/24/2019 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 dependence on renal hemodialysis (process of removing excess water and toxins from the blood in people whose kidneys does not function). A review of Resident 14's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/16/19 indicated the resident had intact cognition (thought process) for daily decision making. On 9/18/19 at 2:30 p.m., during an interview, Resident 14 stated Resident 49 was his previous roommate. Resident 14 stated Resident 49 verbally threatened him on 9/14/19 by saying, "I'm going to rip you apart and kill you." Resident 14 stated he felt threatened and feared for his safety. Resident 14 stated the facility moved Resident 49 to a different room. On 9/20/19 at 2:10 p.m., during an interview, Registered Nurse (RN 1) stated she heard about the resident-to-resident altercation between Residents 14 and 49. RN 1 also stated the resident-to-resident altercation was the reason why Resident 49 was moved to another room. On 9/23/19 at 11:16 a.m., during an interview, Resident 14 stated he filled out a grievance report on 9/15/19, about the verbal altercation that took place because of Resident 49 verbally threatening him. Resident 14 stated he gave the grievance report to RN 2. A review of Resident 14's "Grievance Form" dated 9/15/19 indicated Resident 49 threatened Resident 14 on 9/14/19. The grievance form also indicated Resident 49 threatened to "kill" and cut open Resident 14. The grievance form also indicated Resident 14 feared for his safety and was uncomfortable all night. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 3 of 29 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 09/24/2019 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 On 9/23/19 at 12:57 p.m., during an interview, the Social Services Director (SSD) stated she kept the grievance form filed by Resident 14. The SSD stated she received the grievance filed by Resident 14 from the Director of Nurses (DON) on 9/16/19. The SSD stated she talked to Resident 14 on 9/16/19 and room change was made, by moving Resident 49 on 9/16/19 to another room. The SSD acknowledged and stated the allegation made by Resident 14 was considered a form of verbal abuse. The SSD further stated she was not sure if the allegation of verbal abuse was reported to the local law enforcement and licensing agency. On 9/23/19 at 1:20 p.m., during an interview, the Director of Nursing (DON) stated she knew about the verbal altercation between Resident 14 and 49 on 9/16/19. The DON verified and stated the allegation filed by Resident 14 against Resident 49 was a form of verbal abuse. On 9/23/19 at 1:35 p.m., during an interview, the Administrator stated he did not report the incident to the department of public health because the problem was already resolved. On 9/23/19 at 1:57 p.m., during an interview, RN 2 stated she knew about the allegation of verbal abuse between Resident 14 and 49. RN 2 stated Resident 14 made an allegation that Resident 49 threatened Resident 14's physical safety. A review of RN 2's signed statement dated 9/14/19 at 10 p.m., indicated the incident between Residents 14 and 49 was brought to her attention. The signed statement also indicated Resident 49 was threatening Resident 14. Resident 49 was verbally aggressive and accusatory towards Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 4 of 29 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 09/24/2019 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 14. The signed statement also indicated the Administrator and DON were made aware of the situation. The signed statement further indicated Resident 14 did not feel safe being in the room with Resident 49. A review of the facility's policy and procedure titled "RR P/P" revised 1/19/18 indicated all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, the mandated reporter shall: 1. Make phone report or phone 911 immediately (no later than two hours) to the local law enforcement and licensing agencies observing, obtaining knowledge of, or suspecting the physical abuse; 2. Fax within two hours a written report (SOC 341) to the local ombudsman, licensing agency and local law enforcement.

F641 SS=E Accuracy of Assessments CFR(s): 483.20(g)

F641 09/27/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to accurately code the Minimum Data Set ([MDS] a standardized assessment and care screening tool) assessment for three of 15 sampled residents (13, 14, 28). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 5 of 29 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 09/24/2019 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 This deficient practice had a potential to result in inaccurate information coding regarding Resident 13, 14, and 28's health status. Findings: a. During a tour of the facility on 9/23/19 at 08:14 a.m., Resident 13 was observed lying on bed and stated she needed a Tylenol (medication used to relieve pain) for a headache. The resident was unable to state how long she had the headache. During an interview with Certified Nurse Assistant (CNA 1) on 9/24/19 at 9:12 a.m., stated Resident 13 had dementia (a brain condition characterized by a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities) and was forgetful. A review of Resident 13's admission records (Facesheet) indicated the resident was admitted on 12/21/17 with diagnoses not limited to chronic kidney disease, diabetes mellitus type 2 (abnormal blood sugar levels), and Alzheimer's disease (a brain disease that causes a slow decline in memory, thinking and reasoning skills). A review of Resident 13's physician order dated 7/25/19 indicated an order for Quetapine fumarate ([Seroquel] medication used to treat certain mental and mood conditions) 25 milligrams (mg) 1/2 tablet, twice daily for dementia with psychosis manifested by yelling and screaming. A review of Resident 13's Medication Administration Record (MAR) for behavior monitoring dated July 2019 indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 6 of 29 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 09/24/2019 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 resident had episodes of yelling and screaming on 7/6/19, 7/7/10 and 7/8/19. During a review of records with the Minimum Data Set nurse on 9/24/19 at 9:47 a.m., Resident 13's comprehensive MDS assessment dated 7/12/19 section E200 (Behavioral Symptoms - Presence and Frequency) indicated there was no behaviors coded. The MDS nurse stated the look back period (days of assessment) for section E was 7 days prior to the MDS completion date. The MDS nurse acknowledged the incorrect coding, and stated section E200-C (other behavioral symptoms included verbal symptoms like screaming) should have been coded as "1" (behavior occurred 1 to 3 days) to reflect the true health status of Resident 13. During an interview with the Social Services Director (SSD) on 9/24/19 at 10:17 a.m., stated she was responsible for completing the sections D, E and Q of the MDS assessment. The SSD was unable to state the look back period for section E, and stated MDS accuracy was important because, the staff had to know if a resident's behaviors was occurring, if the medications and interventions had to be reviewed and discussed in the resident care plan meetings. b. A review of Resident 28's admission records (Facesheet) indicated the resident was admitted on 8/17/16 and re-admitted on 11/20/17 with diagnoses not limited to hypertensive heart disease (heart problems that occur because of high blood pressure), diabetes mellitus type 2 (abnormal blood sugar levels), and hypertension (high blood pressure). A review of Resident 28's physician order dated 5/17/19 indicated Quetapine fumarate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 7 of 29 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 09/24/2019 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 ([Seroquel] medication used to treat certain mental and mood conditions) 25 milligrams, one tablet, three times a day for psychosis manifested by yelling, and screaming. A review of Resident 28's Medication Administration Record (MAR) for behavior monitoring dated August 2019 indicated there was an episode of yelling and screaming on 8/14/19. During a review of records with the Minimum Data Set (MDS) nurse on 9/24/19 at 10:37 a.m., Resident 28's quarterly MDS assessment dated 8/17/19 section E200 (Behavioral Symptoms - Presence and Frequency) indicated there was no behaviors coded. The MDS nurse stated the look back period (days of assessment) for section E was 7 days prior to the completion date. The MDS nurse acknowledged, and stated section E200-C (other behavioral symptoms included verbal symptoms like screaming) should have been coded as "1" (behavior occurred 1 to 3 days) to reflect the true health status of Resident 29. During an interview with the Social Services Director (SSD) on 9/24/19 at 10:17 a.m., stated she was responsible for completing the sections D, E and Q of the MDS assessment. The SSD was unable to state the look back period for section E, and stated MDS accuracy was important because, the staff had to know if a resident's behaviors was occurring, if the medications and interventions had to be reviewed and discussed in the resident care plan meetings. c. A review of Resident 14's "Record of Admission" indicated the resident was admitted to the facility on 5/20/19 with diagnoses including end stage renal disease (condition where kidneys are not functioning) and dependence on renal hemodialysis (process of removing excess water and toxins FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 8 of 29 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 09/24/2019 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 from the blood in people whose kidneys does not function). A review of Resident 14's Physician Orders indicated a diet order, dated 8/30/19, consisting of regular low fat, low cholesterol, no added salt, double protein portioned meals. On 9/18/19 at 2:45 p.m., during an interview, Resident 14 stated he was on a special kind of diet. Resident 14 also stated he goes to hemodialysis center for treatments three times a week. A review of Resident 14's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 5/27/19 and 7/16/19 did not code the resident was receiving a therapeutic diet of regular low fat, low cholesterol, no added salt, double protein portioned meals. A review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2018, indicated, "... An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations ... It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment..."

F684 Quality of Care FORM CMS-2567(02-99) Previous Versions Obsolete

F684 Event ID: EHBB11 09/27/2019 Facility ID: CA910000055 If continuation sheet 9 of 29 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 09/24/2019 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) SS=D CFR(s): 483.25 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to apply sequential compression devices ([SCD] sleeves that wrap around the legs, inflate with air, intermittently squeezing the legs, imitating walking to help prevent blood clots) for one of 1 sampled resident (204), as ordered by the physician. This deficient practice had the potential to cause Resident 204 from achieving the highest practicable level of functioning and increased the risks of developing blood clots. Findings: A review of the admission records indicated Resident 204 was admitted on 9/12/2019 with a diagnoses of but not limited to abnormalities of gait, mobility and muscle weakness. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/19/2019, indicated Resident 204 had moderate cognitive impairement for daily decision making, and needed extensive assistance from two or more staff members to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 10 of 29 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 09/24/2019 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 move between surfaces icluding from the bed, chair, and wheelchair as well as repositioning from side to side in the bed. During a review of Resident 204's physician order on 9/19/2019 at 10:56 a.m., indicated an order for "SCD machine to both lower extremity when in bed. Check for placement and skin integrity every shift." to be used on on 9/12/2019. During an observation of Resident 204 on 9/19/2019 at 11:10 a.m.. the resident was lying in bed. However, there was no SCD's applied to Resident 204's legs. During an interview, and observation of Resident 204, along with the resident's family member (FM 1) on 09/23/19 at 9:13 a.m., there was no SCD's applied to the resident's legs. During interview FM 1 states they were aware of what SCD's were but the facility had not provided Resident 204 with SCD's since the resident had been admitted. During an interview with certified nursing assistant (CNA 6) on 9/23/19 at 9:31 a.m., states she had taken care of Resident 204 approximately two times since admission. However, CNA 6 stated she had not witnessed SCD's applied to Resident 204's legs. During an interview with licensed vocational nurse (LVN 3) on 9/23/2019 at 9:53 a.m., acknowledged Resident 204 did not have SCD's applied to both legs. LVN 3 states there was a physician order for SCD's for Resident 204 to have SCD's applied to lower extremities since 9/12/2019.

F689 Free of Accident Hazards/Supervision/Devices F689 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 09/27/2019 Facility ID: CA910000055 If continuation sheet 11 of 29 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 09/24/2019 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) SS=D CFR(s): 483.25(d)(1)(2) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide padded bed rails (padding on the side rails to prevent injuries) for one of 8 sampled residents (202), who was at risk for seizure activities (a sudden, uncontrolled electrical disturbance in the brain that may cause the body to shake), as ordered by the physician. The deficient practice had the potential to cause injury to Resident 202 during seizure activities. Findings: A review of the admission records indicated Resident 202 was admitted to the facility on 9/13/2019 with diagnoses of but not limited to subdural hemorrhage (a collection of pooled blood between the brain and its outermost covering). A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/20/2019 sections C and I indicated Resident 202 had extreme mental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 12 of 29 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 09/24/2019 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 impairment and had an active diagnoses of seizure disorder or epilepsy. During an observation of Resident 202 room on 09/18/19 at 08:12 a.m., the resident was lying in bed with no padding on siderails. During an observation of Resident 202 room on 09/23/19 at 7:36 a.m., the resident was observed lying in bed sleeping with both upper siderails in up position, but there was no padding on the side rails. During an interview with Certified Nursing Attendant (CNA 8) on 9/23/19 at 07:38 a.m, stated Resident 202 had a fall previously and the side rails were up to help assist the resident with turning. CNA 8 stated if there was an order for side rails to be padded, the order would come from the physician. CNA 8 stated padded side rails could be used to prevent the resident from getting bruises and to prevent the resident from injuries. CNA 8 stated seizures would also be a reason for the side rails to be padded. CNA 8 acknowledged Resident 202 did not have any padding on the bedrails and stated the resident had not had seizures since admission. During an interview with Licensed Vocational Nurse (LVN 5) on 09/23/19 at 8:13 a.m., stated Resident 202 was at risk for seizures and clotting because of the blood on her brain. LVN 5 stated when the residents was at risk for seizures they should have padded siderails, low bed and landing pad. LVN 5 stated she was not able to recall if Resident 202 was provided with padded side rails but she was aware they were up. LVN 5 stated there should be an order for the padded siderails. During a chart review with LVN 5 on 09/23/19 at 8:20 a.m., noted there was an order for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 13 of 29 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 09/24/2019 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 padded upper side rails dated 9/13/19. LVN 5 acknowledged nurses should review orders everyday and stated the siderails show have been padded by now. LVN 5 stated the pads should be placed on the siderails as soon as possible after the order was placed. During an interview with LVN 3 on 9/23/19 at 8:35 a.m., stated Resident 202 had a subdural hemorrhage. LVN 3 stated Resident 202 was at risk for seizures and high blood pressure. LVN 3 stated one of the interventions for Resident 202 was the siderails should be padded to prevent from injuries. LVN 3 stated pads should be placed on the siderails within 24 hours. LVN 3 acknowledged that was an order for padded siderails for Resident 202 dated 9/13/19 and that there was no pads on the siderails. LVN 3 acknowledged Resident 202 was at risk for injury because there were no pads on her siderails.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 09/27/2019 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 14 of 29 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 09/24/2019 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 indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to personalize the plan of care for one of 15 sampled residents (38), when the resident was assessed at high risk for dehydration (a condition that can occur when the loss of body fluids, mostly water, exceeds the amount that is taken in). The deficient practice could potentially result in Resident 38's plan of care not being personalized with the resident's preferences to ensure decreasing the risks of dehydration and urinary tract infections (UTI). Findings: During a tour of the facility on 9/18/19 at 1:21 p.m., Resident 38 was observed inside her room with a Contact Isolation (precautions used for infections that are spread by touching FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 15 of 29 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 09/24/2019 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 the resident or items in the room) sign outside the door. A review of Resident 38's admission records indicated the resident was admitted to the facility on 6/28/19 with diagnoses not limited to after care following joint replacement with the presence of a left artificial hip joint, muscle weakness, dysphagia (difficulty swallowing) and Parkinson's disease (a progressive nervous system disorder that affects movement). A review of Resident 38's records with the Medical Records on 9/24/19 at 8:43 a.m., indicated the resident was transferred to a general acute care hospital (GACH) on 8/9/19. The discharge summary dated 8/9/19 from the GACH included diagnoses not limited to a urinary tract infection (UTI) with E. coli (a type of bacteria). The resident was transferred a second time to the GACH on 8/29/19. A review of the discharge summary dated 8/31/19 indicated Resident 38 was admitted to the GACH for UTI with acute kidney injury likely secondary to dehydration. A review of Resident 38's Hydration Risk Evaluation dated 6/28/19 indicated a score of 16 (a resident score of 8 or higher may be at risk for dehydration). A review of another Hydration Risk Evaluation form dated 8/9/19 indicated a score of 17, and one dated 8/31/19 indicated a score of 15. During an interview with Certified Nurse Assistant (CNA 6) on 9/24/19 at 2:57 a.m., stated Resident 38 was continent (had control) of urine but was not asking for assistance to use the restroom. CNA 6 stated she needed to check and asked the resident if the resident wanted to go to the restroom, about three times during her eight hour shift. CNA 6 stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 16 of 29 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 09/24/2019 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 resident had been in and out of the hospital for UTIs. CNA 6 stated the resident would not drink fluids unless it was offered to her. During an interview with Licensed Vocational Nurse (LVN 6) on 9/24/19 at 3:07 p.m., stated Resident 38 was continent with episodes of incontinence (inability to control urine flow) and needed assistance going to the restroom. LVN 6 stated the resident would drink water when offered, more so if it was bottled water. During an interview and concurrent review of Resident 38's Dietary Progress notes with the Minimum Data Set nurse ([MDS] a standardized care screening and assessment tool) on 9/24/19 at 3:30 p.m. indicated a registered dietician recommendation on 7/12/19 indicated a daily intake of 1,500 cubic centimeter (cc, unit of volume) of fluids a day and on 9/13/19 the recommendation was for 1,440 to 1,680 cc per day. A review of Resident 38's daily fluid input and output records (I & Os) with the MDS nurse acknowledged that from 6/28/19 to 8/1/19 Resident 38 had less than the recommended daily amount of fluid intake and from 8/9/19 9/23/19 indicated less than the daily recommended daily amount of fluid intake. A review of Resident 38's care plans and concurrent interview with the MDS nurse on 9/24/19 at 3:30 p.m. for Dehydration dated 6/28/19 and risk for UTI dated 6/29/19 compared to Dehydration and UTI care plans dated 8/9/19 indicated there were no changes made to the interventions. The MDS nurse stated to prevent recurrent UTIs, additional interventions could have included good peri care, add Resident 38's preference for bottled water, and meet with the family to discuss further interventions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 17 of 29 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 09/24/2019 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

F697 Pain Management CFR(s): 483.25(k)

F697 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/27/2019 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure sufficient pain reduction was achieved after the pain medication was administered, prior to providing physical therapy exercises to one of 1 sampled resident (154). This deficient practice had the potential for Resident 154 not to maximize the therapy exercises provided, when having pain. Findings: A review of Resident 154's Record of Admission indicated the resident was admitted to the facility on 9/9/19 with diagnoses including fractured (broken bone) right pubis (one of the bones that make up the hip), and fractured sacrum (a large triangular bone on the lower back). On 9/20/19 at 8:51 a.m., during a medication administration observation for Resident 154, Licensed Vocational Nurse (LVN 4) prepared FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 18 of 29 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 09/24/2019 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 five medications for administration including Tramadol (pain medication) 50 milligram, 1 tablet by mouth two times a day routinely and every 4 hours as needed for moderate to severe pain, for 4 out of 10 pain level (using pain rating scale from 0 to 10, 0 being no pain and 10 being the worst pain experienced). On 9/20/19 at 9:07 a.m., during a concurrent interview and observation, Resident 154 stated the pain level experienced was 6 out of 10 on a pain rating scale. Resident 154 took the medications prepared by LVN 4 including the Tramadol tablet. On 9/20/19 at 9:16 a.m., during an observation, Physical Therapist (PT 1) took Resident to the Physical Therapy room. PT 1 started providing therapy to Resident 154's right lower extremity on 9/20/19 at 9:17 a.m. On 9/20/19 at 9:43 a.m., during an observation, Resident 154 was walking with PT 1 along the hallway near the nursing station. Resident 154 sat down in the wheelchair after the therapy had finished. On 9/20/19 at 9:56 a.m., during an interview, Resident 154 stated her lower extremities were "sore." Resident 154 stated she had pain during therapy. Resident 154 stated the pain medication (Tramadol) she took had "not kicked in yet." Resident 154 also stated she had "5 out of 10 pain level now." Resident 154 further stated it takes about 30 minutes before the pain medication was effective in controlling the pain. On 9/20/19 at 2:24 p.m., during an interview, LVN 4 stated she reassessed to reevaluate Resident 154's pain, while in the physical therapy room. LVN 4 stated Resident 154 was holding her hip area and massaging it while the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 19 of 29 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 09/24/2019 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 resident was in therapy. LVN 4 acknowledged and stated Resident 154 was in pain during therapy. A review of the facility's policy and procedure titled, "Pain Assessment and Management," dated 10/2010, indicated "...Pain management is a multidisciplinary care process that includes...assessing the potential for pain, effectively recognizing the presence of pain...addressing the underlying causes of the pain...Possible behavioral signs of pain include...guarding , rubbing or favoring a particular part of the body..."

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 09/27/2019 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 20 of 29 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 09/24/2019 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 by: Based on observation, interview, and record review, the facility failed to accurately monitored the adverse effects of Lovenox ([anticoagulant] prevents blood clots) medication for one of 5 sampled residents (49), who was reviewed for unnecessary drugs. This failure had the potential to result in Resident 49 not monitored for adverse effects (unwanted or unexpected events or reactions to a drug) of the Lovenox medication, such as bleeding and bruising, to ensure the medication and dosage were still relevant and were not causing undesired complications. Findings: A review of Resident 49's Admission Record indicated the resident was admitted to the facility on 8/27/19 with diagnoses including atrial fibrillation (irregular heart beat), coronary artery disease (blockage of blood vessels supplying the heart muscle), and hyperlipidemia (elevated fats in the blood). A review of Resident 49's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 9/3/19, indicated the resident had severe cognitive impairment for daily decision making, required extensive assistance with one staff for activities of daily living that includes transfers, personal hygiene and eating. A review of Resident 49's physician order dated 8/27/19 indicated to administer Lovenox 40 milligrams, subcutaneously (under the skin), once a day. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 21 of 29 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 09/24/2019 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 On 9/18/19 at 2:50 p.m., during an observation, Resident 49 had a bruise on the right forearm. Resident 49 stated he did not know how he got it. On 9/20/19 at 1:20 p.m., during a concurrent observation and interview, Licensed Vocational Nurse (LVN 3) verified and stated Resident 49 had a bruise on the right forearm. LVN 3 stated there was no documented evidence of the presence of the right forearm bruise in the nurses notes and the medication administration records. LVN 3 also stated the nurses had to monitor accurately and document to determine if the bruising was an adverse effects of the Lovenox medication. LVN 3 further stated one of the adverse effect of Lovenox was bleeding, which may manifest as bruising. A review of the facility's policy and procedure titled, "Medication Utilization and PrescribingClinical Protocol," dated 9/2012, indicated, "...The staff and physician will periodically reevaluate the conditions and symptoms for which each resident is receiving medications to ensure that the medication and dosage are still relevant and are not causing undesired complications..."

F803 SS=E Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 09/27/2019 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 22 of 29 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 09/24/2019 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 §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the planned menus were followed for five of 11 sampled residents (9, 30, 31, 37, 155), who had a physician's order for special diets. The facility failed to provide double portions of protein to Residents 30, 31 and 155, and did not use the appropriate scooper size for a small portion diets for Residents 9 and 37. These deficient practices had the potential to affect Resident 9, 30, 31, 37, and 155's nutritional intake, when foods were not served according to the planned menus, which could lead to an unplanned weight variance of weight loss and or weight gain. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 23 of 29 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 09/24/2019 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 On 9/19/19 at 5:04 p.m., during a tray line observation, Cook 1 was observed plating the meat, rice and salad using a green scooper for each of the food items. Cook 1 finished plating for all the resident trays at 5:45 p.m. A review of the facility's planned menu dated 9/19/19 indicated to use a number (#) 12 scooper size for a regular portion diet, when plating for meat and rice. The menu also indicated to use #16 scooper size for small portion diets when plating for rice. a. A review of Resident 31's diet order dated 8/30/19 indicated mechanical soft diet with vegetables and double protein portions. b. A review of Resident 155's diet order dated 9/13/19 indicated regular no added salt with double protein portions. c. A review of Resident 30's diet order dated 9/13/19 indicated mechanical soft no added salt double protein portions. d. A review of Resident 9's diet order dated 8/17/19 indicated consistent carbohydrate (helps people keep their carbohydrate consumption at a steady level) diet, mechanical soft, with small starch (carbohydrate) portions. e. A review of Resident 37's diet order dated 12/21/18 indicated small portions diet with no added salt. On 9/19/19 at 6:20 p.m., during interview, Cook 1 acknowledged using a green scooper to plate for all food items. Cook 1 also stated the scooper for small portions was colored blue. Cook 1 stated he did not use the small scooper size when he served the small portions diet which included Residents 9 and 37. Cook 1 further stated he did not provide double FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 24 of 29 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 09/24/2019 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 portions of protein when he plated the trays in the middle cart, which included Residents 30, 31 and 155. A review of the facility's policy and procedure titled, "Food Preparation," dated 2018, indicated, "...Recipes are specific as to portion yield, method or preparation, amounts of ingredients..."

F880 SS=B Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 09/27/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 25 of 29 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 09/24/2019 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 include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 26 of 29 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 09/24/2019 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 Based on observation, interview, and record review, the facility failed to provide evidence the infection prevention and control program (IPCP) policy was reviewed annually, and updated as necessary. This deficient practice had the potential to prevent the facility from recognizing, controlling, and preventing the onset and spread of infections. Findings: During a review and concurrent interview with the Director of Staff Development (DSD) a review of facility's infection control policy on 09/24/19 at 3:50 p.m. revealed the policy was not reviewed and signed within the past year. The DSD acknowledged the facility did not review and revise, when necessary, the infection control policy on an annual basis.

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) 09/27/2019 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure 12 of 24 residents bedroom measured at least 80 square feet (sq ft) per resident in bedrooms 1, 2, 3, 4, 5, 6, 7, 9, 12, 14, 15, and 17. This deficient practice resulted in reduced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 27 of 29 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 09/24/2019 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 required space per resident in resident bedrooms 1, 2, 3, 4, 5, 6, 7, 9, 12, 14, 15, and 17, which had the potential for inadequate space during residents care, and or the inability for residents' access, use of personal assistive devices, furniture, and enough space for the visitors. Findings: According to the entrance conference on 9/18/2019 at 11:40 a.m. with the administrator, the facility's variance request dated 9/09/2019 indicated 12 of 24 resident bedrooms did not measure 80 sq ft per resident. A review of the facility's Client Accommodations Analysis form dated 9/20/2019 indicated the resident bedrooms 1, 2, 3, 4, 5, 6, 7, 9, 12, 14, 15, and 17 had two resident beds per each room, with average dimensions of 12.5 feet by 11 feet, a total of 132 feet or 71.5 sq ft per resident. On 9/18/2019 and 9/19/2019, during observation and interview with the residents, staff, and families there was no issues noted about the lack of adequate space to provide care and for the visitors to visit with the residents. During interviews with the residents, staff and visitors, there were no complaints about the resident bedroom sizes for rooms 1, 2, 3, 4, 5, 6, 7, 9, 12, 14, 15, and 17. At the time of observation, the rooms provide adequate space for care, dignity, privacy and the residents' equipment. There was ample room for the resident's to move around freely. There were no concerns observed related to the space during the care to the residents residing in the aforementioned rooms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 28 of 29 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 09/24/2019 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 During an interview an and concurrent record review on 9/18/2019 at 11:50 a.m. the administrator stated that granting the room variance will not adversely affect the residents' health and safety and that the waiver was in accordance with the special needs of the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EHBB11 Facility ID: CA910000055 If continuation sheet 29 of 29