Other·January 3, 2020

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 the investigation of a complaint during an Abbreviated Standard Survey. Complaint number: CA00659344 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 36526 The inspection was limited to the specific complaint investigation and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for complaint CA00659344 On 10/25/19 at 3:15 p.m., the Administrator (ADM) and the Director of Nursing (DON) were notified that an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared for F684 for the facility's inability to provide the necessary care and services, identify abnormal vital signs, and changes of conditions (COC's). The IJ was lifted on 10/26/19 at 4:30 p.m., and the ADM and DON were notified after the team verified the Plan of Action (POA) was followed and implemented.

F684 Quality of Care

F684 01/17/2020 SS=J 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: CQK111 Facility ID: CA910000055 If continuation sheet 1 of 30 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 12/06/2019 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 CFR(s): 483.25 § 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 implement its policy "Temperature, Oral-Digital Thermometer," and accurately assess resident's change of condition ([COC] sudden, clinical deviation from a resident's baseline), implement a care plan to ensure resident to receive 1800 milliliter ([ml] measuring unit) of fluids a day as indicated, and follow-up with the primary physician for abnormal laboratory results for two of three sampled residents (Residents 1 and 2). Resident 1 had an elevated temperature and shortness of breath (SOB) on 3/13/19 at 8:30 a.m., but was not assessed immediately upon notification to the licensed nurse; abnormal laboratory results received on 3/12/19 were not relayed to the physician timely; a puree diet was not provided as prescribed for difficulty in swallowing, and a care plan to provide 1800 ml of fluid to prevent constipation (difficulty emptying stools due to hardened feces) was not implemented. Resident 2 who had SOB, chest pain and a low body temperature on 10/26/19, the staff failed to provide breathing treatments as ordered, assess the resident's SOB, low temperature of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 2 of 30 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 12/06/2019 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 96.2 Fahrenheit (F [normal reference ranges [NRR] for temperature is 97 F to 99 F), chest pain and report to the physician regarding Resident 2's COC. These deficient practices resulted in Resident 1 being transferred to the general acute care hospital (GACH) with a temperature of 104.1 F. Resident 1 was diagnosed with aspiration pneumonia (aspiration of large amount of gastric [fluid or food from the stomach] contents into the lungs causing respiratory distress) and septic shock (multiple organ damage due to an infection resulting in dangerously low blood pressure). Resident 1 died of aspiration pneumonitis (inflammation of the lungs) 30 hours after experiencing SOB and fever. Resident 2 experienced unnecessary chest pain and SOB for 2 hours. On 10/25/19 at 3:15 p.m., during an interview, with the Administrator (ADM) and the Director of Nursing (DON), an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's inability to provide the necessary care and services, identify abnormal vital signs and COC's. The facility's ADM and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 10/26/19 at 4:19 p.m., the ADM and DON submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. Certified Nurse Assistants (CNAs) to notify licensed nurse and/or Registered Nurse (RN) supervisor of any changes of condition noted. 2. Licensed nurses and/or RN supervisor to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 3 of 30 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 12/06/2019 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 address any patients or family concerns immediately to prevent delay in care by assessing patient and notifying physician for new orders. 3. RN supervisor to document findings through Situation/Background/Assessment/Recommen dations ([SBAR] internal documentation technique use to facilitate prompt and appropriate communication). 4. CNAs and licensed nurses to know the difference between normal and abnormal ranges of vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and when to report to the physician. Abnormal vital signs to be rechecked no longer than an hour after an abnormal finding. Any abnormal findings to be reported to the physician. 5. Licensed nurses and supervisors to assess patients when change in condition is brought to their attention and know scope of practice of what a CNA, Licensed Vocational Nurse (LVN), RN can perform. 6. Charge nurse to ensure completion of SBAR forms. Medical Records Staff to review completion performed audits. 7. In-service by DON to licensed nurses and CNAs On 10/26/19 at 4:30 p.m., during a concurrent observation, interview and record review, the ADM and DON were notified the IJ was removed, after the team verified the Plan of Action (POA) was followed and implemented. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 4 of 30 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 12/06/2019 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 a. A review of Resident 1's records indicated the following: A Face Sheet (Admission Record) indicated the resident was initially admitted to the facility on 3/6/19. Resident 1's diagnoses included dysphagia (inability to swallow liquids), right humerus (long bone of the upper arm) fracture (broken bone), and Parkinson's disease (disorder that affects movement causing tremors [shakiness]). An Activities of Daily Living (ADL) detail report, dated 3/6/19 and timed at 7:49 p.m., indicated Resident 1 was totally dependent and required a one-person physical assist for feeding, showering, toilet use, and dressing. A swallowing screening dated 3/7/19 indicated for Resident I to receive a puree diet due to dysphagia (difficulty in swallowing). A Physician Order Report indicated an order, dated 3/7/19 for a puree (smooth, creamy substance made of liquidized or crushed fruit or vegetables), low salt diet with nectar thick liquids (easily pourable and comparable to thicker cream soups), with a one-to-one (one staff always) feeder and monitor intake and output every day. A Physician Order Report indicated an order, dated 3/11/19 for a urinalysis ([UA] analysis of urine to test for the presence of disease) complete metabolic panel ([CMP] blood test that measures 14 different substances such as sugar level, electrolyte (are minerals that are involved in many essential processes in your body) and fluid balance, kidney function, and liver function), and basic metabolic panel ([BMP] checks for 8 substances in the blood) to be done on 3/12/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 5 of 30 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 12/06/2019 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 A care plan titled, "Dysphagia," dated 3/7/19 indicated Resident 1 was at risk for aspiration (breathing foreign objects into the airways) and would demonstrate safe swallowing strategies. The staff interventions included to perform trial feedings (attempts with different textures of food), and diet texture analysis (detailed examination of the structure of something). A care plan titled, "Constipation," dated 3/7/19 indicated Resident 1 would have a bowel movement at least every three days. The staff interventions included to encourage fluid intake of 1800 ml or more in 24 hours and encourage Resident 1 to drink all fluids in the meal tray. An Intake and Output Record ([I&O] internal document indicating the amount of fluids consumed and the amount of fluids excreted) indicated Resident 1 had a total daily fluid intake as follow: 3/6/19 total of 300 ml 3/7/19 total of 1000 ml 3/8/19 total of 600 ml 3/9/19 total of 720 ml 3/10/19 total of 670 ml 3/11/19 total of 700 ml 3/12/19 total of 650 ml The I&O report did not indicate the total amount Resident 1 had as output during the review period, as per Resident 1's plan of care. There was no documented evidence the physician was notified of Resident 1's low fluid intake. A care plan titled, "Dehydration (harmful reduction in the amount of water in the body)," dated 3/7/19 indicated Resident 1 would be free from signs and symptoms of dehydration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 6 of 30 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 12/06/2019 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 every day through the next review on 6/2019. The staff's intervention included to monitor for increased confusion, dry mucous membranes, low output, labs as ordered, monitor vital signs, monitor bowel movement frequency and amount, evaluate diuretic medications (medications designed to increase the amount of water and salt expelled from the body as urine), and notify physician for any COC and level of consciousness (state of being awake and aware). A review of the Vital Detail Report indicated Resident 1 had no vital signs taken from 3/10/19 through 3/13/19 as indicated per Resident 1's care plan. A laboratory form results, dated 3/12/19 and indicated the results were reported to the facility on 3/12/19 at 3:56 p.m., via fax indicated Resident 1's BUN (blood, urea, nitrogen [NRR 7-25 mg/dL] indicative of liver damage) of a high level of 51 milligrams (mg)/deciLiters (dL), high sodium (high or low level indicate a kidney problem) levels of 157 milliequivalent (mEq/dL [NRR is 136-145 mEq/dL]), elevated white blood cells (indicative of infection) of 16.9 (NRR 4-10). The laboratory form indicated the facility's staff faxed the results to Resident 1's physician on 3/12/19 at 6:35 p.m., two and a half hours after receiving the abnormal results for the laboratory. A review of a SBAR, dated 3/13/19 and timed at 10:05 a.m., indicated Resident 1 was noted with increased lethargy (lack of energy) and elevated body temperature of 104.1 F, low blood pressure of 92/85 ([B/P]120/80 normal reference ranges [NRR]), pulse of 82 beats per minute ([bpm] NRR 60-100 bpm), and respirations of 18 (NRR is 12-20). The SBAR indicated Resident 1's physician was notified and orders to transfer Resident 1 to the GACH FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 7 of 30 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 12/06/2019 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 were obtained. A review of a Licensed Progress Record (LPR), written by RN 1, dated 3/13/19 and timed at 10:30 a.m., indicated CNA 1 notified RN 1 on 3/13/19, at approximately 10 a.m., Resident 1 was tachypneic (abnormal rapid breathing) and had a fever. The LPR indicated Resident 1's B/P was 128/61, heart rate of 128 bmp, respirations 30, and a temperature of 104.9 F. the LPR indicated Resident 1 was transferred to the GACH on 3/13/19 at 10:20 a.m. A review of the facility's undated policy titled, "Temperature, Oral-Digital Thermometer," indicated if the residents' temperature was 100 F or greater, it should be taken at least every four hours until it returns to normal. The policy indicted that temperatures below 97 F and above 99 F must be rechecked with other thermometer and must be reported to the staff/charge nurse. The policy indicated that information such as date, time, name of the performing staff, temperature reading, any changes noted in the resident's chart. On 10/18/19 at 12:50 p.m., during an interview and a review of Resident 1's nurse's progress notes, the DON stated there was no documentation in the nurses' progress notes of Resident 1's physician being notified of Resident 1's abnormal laboratory results from 3/12/19 and of Resident 1 having a COC. The DON stated the physician ordered for Resident 1's I&O to be monitored and documented, but the staff failed to monitor and report to the physician. A review of Resident 1's physician untimed telephone order, dated 3/13/19 indicated to transfer Resident 1 to the GACH for SOB and fever for evaluation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 8 of 30 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 12/06/2019 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 A review of the paramedics run sheet, dated 3/13/19 indicated the paramedics saw Resident 1 on 3/3/19 at 10:09 a.m. and transferred Resident 1 to the GACH at 10:33 a.m. The paramedic run sheet indicated Resident 1 was unconscious (not alert), "appeared septic," hot to touch and with a B/P of 128/78, pulse of 128 bpm and an elevated respiration of 38. The paramedic's run sheet indicated per the facility's staff, "Resident 1 had not been himself for the past six days and had a fever since the morning of 3/13/19 of 104 F." A review of the GACH's Emergency Department (ED) history and physical (H/P), dated 3/13/19 and timed at 2:14 p.m., indicated Resident 1's vital signs upon arrival to the ED on 3/13/19 at 10:49 a.m., were as follow: 106.4 F temperature, B/P 81/54, heart rate 126 bpm, respiratory rate 56 breaths per minute, and oxygen saturation (oxygen in the blood) of 83% on room air. The ED report indicated Resident 1 was in septic shock with respiratory failure upon arrival to the GACH from the facility, 106 F rectal (final section of the large intestine terminating at the anus) temperature ([NRR] 97.5-100 F) and an elevated heart rate. A review of the GACH's Suction/Cough Report, dated 3/13/19 and timed at 11:56 a.m., indicated pieces of aspirated food were found in Resident 1's airway during suction of the naso/endotracheal (nose/tube from the larynx to the lung [mechanical aspiration of pulmonary secretions]). A review of the GACH's death documentation signed 3/15/19 at 4:06 p.m., indicated Resident 1 was found with an elevated temperature and was lethargic upon arrival to the ED with severely abnormal laboratory results that indicated an acute renal failure (rapid failure of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 9 of 30 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 12/06/2019 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 kidney to filter waste). The death documentation indicated Resident 1 was pronounced deceased on 3/14/19 at 4:36 p.m., 30 hours after admission to the GACH. A review of Resident 1's death certificate listed the cause of death as septic shock and aspiration pneumonia. The certificate indicated Resident 1 died on 3/14/19 at 4:36 p.m. A review of the facility's policy and procedures titled, "Lab and Diagnostic Test Results-Clinical Protocol," revised 9/2012 indicated if the receiving nurse assessing a resident's lab results cannot follow-up with the physician, report should be given to another nurse to follow-up with the documentation and the results. The policy indicated lab results were something that should be conveyed to a physician regardless of other circumstances (that is, the abnormal results are problematic regardless of any other factor). On 10/18/19 at 2 p.m., during an interview and record review, LVN 3 stated CNAs took vital signs in the morning and wrote them on a paper and then submitted them to the licensed nurses. LVN 3 stated there was no way of knowing at what time the vital signs were taken since the CNAs did not write the time on their sheet. On 10/18/19 at 2:35 p.m., during an interview, CNA 1 stated on 3/13/19 at approximately 7:30 a.m., she fed Resident 1 breakfast of a chopped diet (not as prescribed by the physician) and noted Resident 1 was weak and hot (to touch). CNA 1 stated she took Resident 1's temperature after noticing the resident was hot to touch. CNA 1 stated she did not remember what Resident 1's temperature was but did remember it was higher than 100 F. CNA 1 stated she notified LVN 1 at 8:30 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 10 of 30 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 12/06/2019 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 of Resident 1's elevated temperature, but did not see LVN 1 go into Resident 1's room. CNA 1 stated she notified RN 1 of Resident 1's elevated temperature before 10 a.m., on 3/13/19. On 10/23/19 at 3:10 p.m., during an interview, LVN 1 stated on 3/13/19 at approximately 10 a.m., while passing medications, Resident 1 was noted to be hot. LVN 1 stated upon assessment, Resident 1 was extremely hot to touch, and he immediately initiated cooling measures with an ice pack under Resident 1's arm pits and forehead. LVN 1 stated he did not have time to administer medication by mouth to help decrease Resident 1's temperature. LVN 1 stated he forgot to document on Resident 1's clinical record of his interventions he did for Resident 1's elevated temperature. LVN 1 stated he did not remember at what time he took Resident 1's temperature or what the temperature was. LVN 1 stated normal body temperature was from 96 F to 98 F. On 10/24/19 at 9:35 a.m., during a telephone interview, Resident 1's Responsible Party (RP) stated she was not notified by the facility of Resident 1's COC and abnormal vital signs, prior to her arrival to the facility. The RP stated on 3/13/19 at approximately 10:30 a.m., it was devastating to see Resident 1 being taken out of the facility unconscious by the paramedics. On 10/25/19 at 9:30 a.m., during a telephone interview, Resident 1's physician (Physician 1) stated he did not see Resident 1's laboratory results until the next day on 3/13/19 after Resident 1's transfer to the GACH. Physician 1 stated time was essential to provide adequate care and the staff should have called the afterhours number to ensure Resident 1's abnormal lab results were read to a physician. Physician 1 stated he did not know if seeing the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 11 of 30 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 12/06/2019 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 laboratory results that day would had made a difference in Resident 1's outcome, but he would had ordered a transfer to the GACH that same day (3/12/19) for further evaluation. Physician 1 stated Resident 1's laboratory results did indicate Resident 1 was dehydrated and had an infection. Physician 1 also stated he was not made aware of Resident 1's poor intake. On 10/25/19 at 12:50 p.m., during an interview, RN's 3 and 4 both stated normal body temperatures were 97 F to 98.8 F. RN 4 stated if the resident's temperature was out of range, the next step was to assess the resident, recheck the temperature and call the physician if needed. On 10/25/19 at 12:54 p.m., during an interview, LVN's 3 and 4 stated normal body temperatures ranged between 97 F to 98.6 F. On 10/25/19 at 1 p.m., during an interview, the Director of Staff Development (DSD) stated normal body temperatures range from 97 F to 98.8 F. The DSD stated she provided an inservice with the licensed nurses and CNAs in 7/2019 regarding the importance of vital signs. On 10/25/19 at 1:14 p.m., during an interview, the DON stated the staff were not following the physician's orders to take Resident 1's vital signs three times a day. The DON stated all the vital signs taken by the staff were not documented on the residents' charts and the ones documented were not complete. b. A review of Resident 2's records indicated the following: A Face Sheet (Admission Record) indicated Resident 2 was initially admitted to the facility on 9/30/19. Resident 2's diagnoses included FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 12 of 30 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 12/06/2019 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 malignant neoplasm of the left lung (cancer), kidney failure, and high blood pressure. A Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 10/9/19 indicated Resident 2 was able to make her needs know and was able to understand and make herself understood. The MDS indicated Resident 2 required extensive assistance of a one-person physical assist in eating, transferring, dressing, and bed mobility. A Physician Order Report, dated 10/24/19 indicated an order for Resident 2 to receive Duoneb (medication that relax muscles in the airways and increase air flow to the lungs) via inhaler aerosol solution every six hours for cough and to check Resident 2's heart rate before and one hour after administration. A care plan titled, "Productive Cough," created on 10/24/19 indicated the goal was for Resident 2 to not develop further complications. The staffs' intervention indicated the staff would monitor vital signs, perform an x-ray of the chest and encourage fluids. A care plan titled "Potential Ineffective Airway Clearance related to lung Secretions," created on 10/24/19 indicated the goal was for Resident 2 to have optimal airway movement in and out of the lungs. The staffs' interventions included to assess lung sounds, assess for sign of aspiration, administer oxygen as ordered, assess resident for signs of restlessness and confusion, administer medications and assess for adverse side effects and notify the physician. A Medication Administration Record (MAR) for the month of 10/2019 indicated Resident 2 received a duoneb treatment on 10/26/19 at 1 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 13 of 30 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 12/06/2019 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 A LPR document by RN 2 dated, 10/26/19 and timed at 3:15 p.m., indicated 10/26/19 at 9:45 a.m., the physician was notified of Resident 2's cough. The LPR indicated Resident 2's Power of Attorney ([POA] someone appointed to make decisions on their behalf) notified RN 2 regarding Residents' cough. The LPR did not indicate that an assessment was done on Resident 2 or that a second attempt was made to notify Resident 2's physician of Resident 2's COC. An untimed Vital Signs Sheet dated 10/26/19 indicated Resident 2 had a B/P of 142/89, heart rate of 75 bpm, respirations of 19, and a temperature of 96.2 F. On 10/26/19 at 1:20 p.m., during an interview and record review of Resident 2's vital sign sheet, the DON stated Resident 2 had a temperature of 96.2 F at 8:30 a.m. The DON stated the staff rechecked Resident 2's temperature at 1:30 p.m., and read 98.9 F. On 10/26/19 at 1:50 p.m., during a concurrent observation, interview, and record review of Resident 2's chart, in the presence of the DON, while in the residents' room, CNA 2 was observed attempting to take Resident 2's vitals signs with two different vital signs machines. CNA 2 stated the vital signs machines had not been working since that morning. During a concurrent interview, Resident 2's Power of Attorney (POA) stated on 10/26/19 at approximately 9:30 a.m., upon entering Resident 2's room, she noticed Resident 2 was unable to speak and was having trouble breathing while complaining of chest pain. The POA stated she immediately went to the nurses' station and notified RN 2 of Resident 2's difficulty breathing and chest pain. The POA stated the staff did not come into Resident 2's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 14 of 30 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 12/06/2019 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 room until an hour later at 10:30 a.m., to give Resident 2 a breathing treatment. On 10/26/19 at 2 p.m., during an observation in the resident's room, interview, and record review of resident's clinical chart, in the presence of the DON, Resident 2's POA, RN 2, and LVN 2, Resident 2 stated she notified the staff early in that morning that she was having difficulty breathing, but the staff did not do anything. During the concurrent interview, with LVN 2 and RN 2, in the presence of the DON and the POA, LVN 2 stated she was notified by RN 2 Resident 2's POA was complaining of Resident 2's having difficulty breathing but did not do anything. RN 2 stated during the assessment, Resident 2's lung sounds was positive for rhonchi (rattling, continuous and low-pitched wheezing that indicates airway obstruction), and with difficulty breathing. RN 2 stated that no vital signs were taken, but he had made three attempts to notify Resident 2's physician of the findings, but no return call back had been received from the physician. RN 2 stated there was no SBAR documentation done. RN 2 stated that it was the facility's policy to document a SBAR upon resident's COC and to follow-up with the facility's medical director if the resident's physician was not available. On 10/26/19 at 2:10 p.m., during an interview, the DON stated RN 2 should have taken care of Resident 2 and not delegate the assessment of the resident to a CNA since COC assessments are not in their (CNA) scope of practice. On 10/26/19 at 3:37 p.m., during a concurrent interview and record review of the vital signs sheet, LVN 2 stated she rechecked Resident 2's vital signs at 9:30 a.m. and 1:30 p.m. but FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 15 of 30 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 12/06/2019 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 failed to document them in Resident 2's chart. On 10/26/19 at 4:10 p.m., during an interview, the DON stated the staff should assess the resident and notify the physician immediately when a COC was identified. The DON stated staff should document on the residents' clinical chart vital signs and rechecked the vitals to ensure the appropriate interventions are done for the residents.

F692 SS=D Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 01/17/2020 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interviews and record review, the facility failed to implement its policy and a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 16 of 30 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 12/06/2019 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's care plan to ensure enough fluids were given for one of three sampled residents (Resident 1). Resident 1's plan of care indicated Resident 1 would receive 1800 milliliters ([ml] unit of measurement) of fluid to prevent dehydration (harmful reduction in the amount of water in the body) and constipation (difficulty emptying hardened feces). This deficient practice resulted in Resident 1 not receiving 1800 ml of fluids daily as per Resident 1's plan of care. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was initially admitted to the facility on 3/6/19. Resident 1's diagnoses included dysphagia (difficulty swallowing), right humerus (long bone of the upper arm) fracture (broken bone), and Parkinson's disease (disorder that affects movement causing tremors [shakiness]). A review of Resident 1's Activities of Daily Living ([ADL] activities of self-care such as feeding, bathing, dressing, grooming, work, and homemaking) detail report, dated 3/6/19 and timed at 7:49 p.m., indicated Resident 1 was totally dependent of a one-person physical assist for feeding, showering, toilet use, and dressing. A review of Resident 1's care plan titled, "Constipation," dated 3/7/19 indicated Resident 1 would have a bowel movement at least every three days. The staff interventions included to encourage fluid intake of 1800 ml or more in 24 hours and encourage Resident 1 to drink all fluids on the meal tray. A review of Resident 1's Physician Order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 17 of 30 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 12/06/2019 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 Report indicated an order, dated 3/7/19 for puree (smooth, creamy substance) low salt diet and nectar thick liquids (cream soup consistency) with a one-to-one feeder and monitor intake and output every day. Resident 1's Intake and Output Record (I&O) indicated Resident 1 had a total daily fluid intake as followed: 3/6/19 total of 300 ml 3/7/19 total of 1000 ml 3/8/19 total of 600 ml 3/9/19 total of 720 ml 3/10/19 total of 670 ml 3/11/19 total of 700 ml 3/12/19 total of 650 ml The I&O report did not indicate the total amount Resident 1 had as output during the review period, as per Resident 1's plan of care. There was no documented evidence the physician was notified of Resident 1's low fluid intake. A review of Resident 1's care plan titled, "Dehydration," dated 3/7/19 indicated Resident 1 would be free from signs and symptoms of dehydration every day through the next review on 6/2019. The staff's intervention included to monitor for increase confusion, dry mucous membranes, low output, labs as ordered, monitor vital signs, monitor bowel movement frequency and amount, evaluate diuretic medications (medications designed to increase the amount of water and salt expelled from the body as urine), and notify physician for any change in of condition ([COC] sudden, clinical deviation from a resident's baseline) and level of consciousness (state of being awake and aware). A review of Resident 1's Physician Order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 18 of 30 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 12/06/2019 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 Report indicated an order, dated 3/11/19 for a urinalysis ([UA] analysis of urine to test for the presence of disease) complete metabolic panel ([CMP] blood test that measures 14 different substances such as sugar level, electrolyte and fluid balance, kidney function, and liver function), and basic metabolic panel ([BMP] checks for 8 substances in the blood) to be done on 3/12/19. A review of Resident 1's laboratory results, dated 3/12/19 and reported to the facility on 3/12/19 at 3:56 p.m., via fax indicated Resident 1's BUN (blood, urea, nitrogen [NRR 7-25 mg/dL]) was elevated at 51 milligrams (mg)/deciLiters (dL), high sodium (high or low level indicate a kidney problem) levels of 157 milliequivalent (mEq/dL [NRR is 136-145 mEq/dL]), elevated white blood cells (indicative of infection) of 16.9 (NRR 4-10). The laboratory form indicated the facility's staff faxed the results to Resident 1's physician on 3/12/19 at 6:35 p.m., two and a half hours after receiving the abnormal elevated results. On 10/18/19 at 12:50 p., during an interview and record review, the DON stated there was no documentation in the nurses' progress notes of Resident 1's physician being notified of abnormal laboratory results from 3/12/19 and of Resident 1 having a COC. The DON stated the physician ordered for Resident 1's I & O to be monitored and documented, but the staff failed to monitor and report to the physician. On 10/25/19 at 9:30 a.m., during a telephone interview, Resident 1's physician (Physician 1) stated he did not see Resident 1's laboratory results until 3/13/19 after Resident 1's transfer to the GACH. Physician 1 stated time was essential to provide adequate care and the staff should have called the exchanged number to ensure Resident 1's abnormal lab results were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 19 of 30 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 12/06/2019 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 read to a physician. Physician 1 stated he did not know if seeing the laboratory results that day would had made a difference in Resident 1's outcome, but he would had ordered a transfer to the GACH that same day (3/12/19) for further evaluation. Physician 1 stated Resident 1's laboratory results did indicate Resident 1 was dehydrated and had an infection. Physician 1 also stated he was not made aware of Resident 1's poor intake. On 10/26/19 at 4:10 p.m., during an interview, the DON stated the staff should assessed the resident and notify the physician immediately when a COC was identified. The DON stated staff should document on the residents' clinical chart vital signs and rechecked the vitals to ensure the appropriate interventions are done for the residents. A review of the facility's policy titled, "Intake, Measuring and Recording," revised in 10/2010 indicated the purpose of the procedure was to accurately determine the amount a resident consumes in a 24-hour period. The policy indicated the staff would report information in accordance with facility's policy and professional standard of practice.

F726 SS=G Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 01/17/2020 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 20 of 30 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 12/06/2019 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 determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to implement its policies to ensure the nursing staff were competent and possessed skills to identify and assessed abnormal body temperatures, abnormal laboratory results, physician notification, and accurately document findings for two of three sampled residents (Residents 1 and 2). Resident 1 had an elevated temperature and shortness of breath (SOB) on 3/13/19 at 8:30 a.m., but was not assessed immediately upon notification to the licensed nurse; abnormal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 21 of 30 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 12/06/2019 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 laboratory results received on 3/12/13 were not relayed to the physician; a puree diet was not provided, and a care plan to provide 1800 milliliters ([ml] unit of measurement) of fluid to prevent constipation (difficulty emptying stools due to hardened feces) was not implemented. Resident 2 who had SOB, chest pain and a low body temperature on 10/26/19, the staff failed to provide breathing treatments as ordered, assess the resident's SOB, low temperature of 96.2 Fahrenheit (F [normal reference ranges [NRR] for temperature is 97 F to 99 F) chest pain and report to the physician regarding Resident 2's change of condition ([COC] sudden, clinical deviation from a resident's baseline). These deficient practices resulted in Resident 1 being transferred to the general acute care hospital (GACH) with a temperature of 104.1 F, diagnosed with aspiration pneumonia (aspiration of large amount of gastric contents into the lungs causing respiratory distress) and septic shock (multiple organ damage due to an infection resulting in dangerously low blood pressure). Resident 1 died of aspiration pneumonitis 30 hours after experiencing SOB and fever. Resident 2 experienced unnecessary chest pain and SOB for 2 hours. Findings: a. A review of Resident 1's records indicated the following: A Face Sheet (Admission Record) indicated the resident was initially admitted to the facility on 3/6/19. Resident 1's diagnoses included dysphagia (inability to swallow liquids), right FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 22 of 30 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 12/06/2019 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 humerus (long bone of the upper arm) fracture (breaking of a hard object), and Parkinson's disease (disorder that affects movement causing tremors [shakiness]). An Activities of Daily Living (ADL) detail report, dated 3/6/19 and timed at 7:49 p.m., indicated Resident 1 was total dependent of a oneperson physical assist for feeding, showering, toilet use, and dressing. A Physician Order Report indicated an order, dated 3/11/19 for a urinalysis ([UA] analysis of urine to test for the presence of disease) complete metabolic panel ([CMP] blood test that measures 14 different substances such as sugar level, electrolyte and fluid balance, kidney function, and liver function), and basic metabolic panel ([BMP] checks for eight substances in the blood) to be done on 3/12/19. A review of the laboratory results dated 3/12/19 and reported to the facility on 3/12/19 at 3:56 p.m., via fax indicated Resident 1's BUN (blood, urea, nitrogen [NRR 7-25 mg/dL]) of a high level of 51 milligrams (mg)/deciLiters (dL), high sodium (high or low level indicate a kidney problem) levels of 157 milliequivalent (mEq/dL [NRR is 136-145 mEq/dL]), elevated white blood cells (indicative of infection) of 16.9 (NRR 4-10). The laboratory form indicated the facility's staff faxed the results to Resident 1's physician on 3/12/19 at 6:35 p.m., two and a half hours after receiving the abnormal results. A review of the Vital Detail Report indicated Resident 1 had no vital signs taken from 3/10/19 through 3/13/19 as indicated per Resident 1's care plan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 23 of 30 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 12/06/2019 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 10/18/19 at 12:50 p., during an interview and record review, the DON stated there was no documentation in the nurses' progress notes of Resident 1's physician being notified of abnormal laboratory results from 3/12/19 and of Resident 1 having a COC. The DON stated the physician ordered for Resident 1's I & O to be monitored and documented, but the staff failed to monitor and report to the physician. A review of the facility's policy titled, "Lab and Diagnostic Test Results-Clinical Protocol," revised 9/2012 indicated if the receiving nurse assessing a resident's lab results cannot followup with the physician, report should be given to another nurse to follow-up with the documentation and the results. The policy indicated lab results were something that should be conveyed to a physician regardless of other circumstances (that is, the abnormal results are problematic regardless of any other factor). A review of a Situation/Background/Assessment/Recommen dations ([SBAR] internal documentation technique use to facilitate prompt and appropriate communication), dated 3/13/19, and timed at 10:05 a.m., indicated Resident 1 was noted with increased lethargy (lack of energy) and elevated body temperature of 104.1 F, low blood pressure of 92/85 (120/80 normal reference ranges [NRR]), pulse of 82 beats per minute ([bpm] NRR 60-100 bpm), and respirations of 18 (NRR is 12-20). The SBAR indicated Resident 1's physician was notified and orders to transfer Resident 1 to the GACH were obtained. A review of the physician's untimed telephone order (TO), dated 3/13/19 indicated to transfer Resident 1 to the GACH for SOB and fever evaluation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 24 of 30 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 12/06/2019 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 A review of the GACH's Emergency Department (ED) history and physical (H/P) dated 3/13/19 and timed at 2:14 p.m., indicated Resident 1's vital signs upon arrival to the ED on 3/13/19 at 10:49 a.m., were as follow: 106.4 F temperature, B/P 81/54, heart rate 126 bpm, respiratory rate 56 breaths per minute, and oxygen saturation (oxygen in the blood) of 83% on room air. The ED report indicated Resident 1 was in septic shock with respiratory failure upon arrival to the GACH from the facility, 106 F rectal (final section of the large intestine terminating at the anus) temperature ([NRR] 97.5-100 F) and an elevated heart rate. On 10/18/19 at 2 p.m., during an interview and record review, Licensed Vocational Nurse (LVN 3) stated CNAs took vital signs in the morning and wrote them on a paper and then submitted them to the licensed nurses. LVN 3 stated there was no way of knowing at what time the vital signs were taken since the CNAs did not write the time on their sheet. On 10/18/19 at 2:35 p.m., during an interview, CNA 1 stated on 3/13/19 at approximately 7:30 a.m., CNA feed Resident 1 a chopped diet breakfast and noted Resident 1 was weak and hot (to touch). CNA 1 stated she took Resident 1's temperature after noticing the resident was hot to touch. CNA 1 stated she did not remember what Resident 1's temperature was but did remember it was higher than 100 F. CNA stated she notified LVN 1 at 8:30 a.m., of Resident 1's elevated temperature, but did not see LVN 1 going into Resident 1's room. CNA 1 stated she notified RN 1 of Resident 1's elevated temperature before 10 a.m., on 3/13/19. On 10/25/19 at 9:30 a.m., during a telephone interview, Resident 1's physician (Physician 1) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 25 of 30 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 12/06/2019 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 stated he did not see Resident 1's laboratory results until 3/13/19 after Resident 1's transfer to the GACH. Physician 1 stated time was essential to provide adequate care and the staff should have called the exchanged number to ensure Resident 1's abnormal lab results were read to a physician. Physician 1 stated he did not know if seeing the laboratory results that day would had made a difference in Resident 1's outcome, but he would had order a transfer to the GACH that same day (3/12/19) for further evaluation. Physician 1 stated Resident 1's laboratory results did indicate Resident 1 was dehydrated and had an infection. Physician 1 also stated he was not made aware of Resident 1's poor intake. On 10/25/19 at 12:50 p.m., during an interview, RNs 3 and 4 stated normal body temperatures were 97 F to 98.8 F. RN 4 stated if the resident's temperatures were out of range, the next step was to assess the resident, recheck the temperature and call the physician if needed. On 10/25/19 at 12:54 p.m., during an interview, LVNs 3 and 4 stated normal body temperatures ranged between 97 F to 98.6 F. On 10/25/19 at 1 p.m., during an interview, the Director of Staff Development (DSD) stated normal body temperatures range from 97 F to 98.8 F. The DSD stated she provided an inservice with the licensed nurses and CNAs in 7/2019 regarding the importance of vital signs. On 10/25/19 at 1:14 p.m., during an interview, the DON stated that normal body temperatures were from 97 F to 98.8 F. The DON stated the staff were not following the physician's orders to take Resident 1's vital signs three times a day. The DON stated all the vital signs taken by the staff were not documented on the residents' FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 26 of 30 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 12/06/2019 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 charts and the ones documented were not complete. b. A review of Resident 2's records indicated the following: A Face Sheet (Admission Record) indicated Resident 2 was initially admitted to the facility on 9/30/19. Resident 2's diagnoses included malignant neoplasm of the left lung (cancer), kidney failure, and high blood pressure. A Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 10/9/19 indicated Resident 2 was able to make her needs know and was able to understand and make herself understood. The MDS indicated Resident 2 required extensive assistance of a one-person physical assist in eating, transferring, dressing, and bed mobility. A Licensed Progress Record (LPR), document by RN 2, dated 10/26/19 and timed at 3:15 p.m., indicated 10/26/19 at 9:45 a.m., the physician was notified of Resident 2's cough. The LPR indicated Resident 2's Power of Attorney ([POA] someone appointed to make decisions on their behalf) notified RN 2 regarding Residents' cough. The LPR did not indicate that an assessment was done on Resident 2 or that a second attempt was made to notify Resident 2's physician of Resident 2's COC. An untimed Vital Signs Sheet dated 10/26/19 indicated Resident 2 had a B/P of 142/89, heart rate of 75 bpm, respirations of 19, and a temperature of 96.2 F. On 10/26/19 at 1:20 p.m., during an interview and record review of Resident 2's vital sign sheet, the DON stated Resident 2 had a temperature of 96.2 F at 8:30 a.m. The DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 27 of 30 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 12/06/2019 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 stated the staff rechecked Resident 2's temperature at 1:30 p.m., and read 98.9 F. On 10/26/19 at 1:50 p.m., during a concurrent observation, interview, and record review, in the presence of the DON, CNA 2 was observed attempting to take Resident 2's vitals signs with two different vital signs machines. CNA 2 stated the vital signs machines had not been working since the morning 10/26/19. During a concurrent interview, Resident 2's Power of Attorney (POA) stated on 10/26/19 at approximately 9:30 a.m., upon entering Resident 2's room, she noticed Resident 2 was unable to speak and was having trouble breathing while complaining of chest pain. The POA stated she immediately went to the nurses' station and notified RN 2 of Resident 2's difficulty breathing and chest pain. The POA stated facility staff did not come into Resident 2's room until an hour later at 10:30 a.m., to give Resident 2 a breathing treatment. On 10/26/19 at 2 p.m., during an observation, interview, and record review, in the presence of the DON, Resident 2's POA, RN 2, and LVN 2, Resident 2 stated she notified the staff early in that morning that she was having difficulty breathing, but the staff did not do anything. During the concurrent interview, with LVN 2 and RN 2, in the presence of the DON and the POA, LVN 2 stated she was notified by RN 2 Resident 2's POA was complaining of Resident 2's having difficulty breathing but did not do anything. RN 2 stated during the assessment, Resident 2's lung sounds was positive for rhonchi (rattling, continuous and low-pitched wheezing that indicates airway obstruction), and with difficulty breathing. RN 2 stated that no vital signs were taken, but he had made three attempts to notify Resident 2's physician of the findings, but no return call back had been received from the physician. RN 2 stated there FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 28 of 30 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 12/06/2019 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 was no SBAR documentation done. RN 2 stated that it was the facility's policy to document a SBAR upon resident's COC and to follow-up with the facility's medical director if the resident's physician was not available. On 10/26/19 at 3:37 p.m., during a concurrent interview and record review, LVN 2 stated she rechecked Resident 2's vital signs at 9:30 a.m. and 1:30 p.m. but failed to document them in Resident 2's chart. On 10/26/19 at 4:10 p.m., during an interview, the DON stated the staff should assess the resident and notify the physician immediately when a COC was identified. The DON stated staff should document on the residents' clinical chart vital signs and rechecked the vitals to ensure the appropriate interventions are done for the residents. A review of the facility's undated policy titled, "Temperature, Oral-Digital Thermometer," indicated if the residents' temperature was 100 F or greater, it should be taken at least every four hours until it returns to normal. The policy indicted that temperatures below 97 F and above 99 F must be rechecked with other thermometer and must be reported to the staff/charge nurse. The policy indicated that information such as date, time, name of the performing staff, temperature reading, any changes noted in the resident's chart. A review of the facility's undated document titled, "Charge Nurse," indicated that the essential functions of the charge nurse were to practice professional nursing that is consistent with the department of nursing philosophy, objectives and standards. Initiate emergency support measures, maintain knowledge of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 29 of 30 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 12/06/2019 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 necessary documentation necessary. Performs personal, physical and cognitive assessment and identifies deviation from norms for defined population. Makes nursing diagnosis based on the assessment. The policy indicated that the charge nurse would identify nursing interventions necessary to accomplish goals. Documents all interventions according to policy, and reports changes in resident's condition or deviation from prescribed treatments promptly to the physician and supervisor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CQK111 Facility ID: CA910000055 If continuation sheet 30 of 30