Other·August 14, 2020

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 of a Complaint investigation during an Abbreviated Standard Survey. Complaint number: CA00680615 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 34180 The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. One deficiency was issued for CA00680615

F580 SS=G Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 07/24/2020 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or 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: I59Q11 Facility ID: CA910000055 If continuation sheet 1 of 13 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 07/15/2020 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 (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy when a resident had a change of condition ([COC] a sudden clinically deviation from a resident's baseline in physical, cognitive [thought process], behavioral, or functional domains) and notify the physician for one of two sampled residents (Resident 1). Resident 1 had a COC (lethargy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 2 of 13 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 07/15/2020 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 and facial drooping) on 2/10/2020, which included a fall, and the physician was not notified timely (less than 2 hours). Three days later on 2/13/2020, the resident had an altered level of consciousness ([ALOC] not as awake, alert, and reactive) with facial drooping (limp/sagging) as observed by the family, but the nursing staff continued to insist Resident 1's condition was stable and had not changed and refused to notify the physician. This deficient practice resulted in a two-hour delay in diagnosis, care and services for Resident 1, who was transferred to the general acute care hospital (GACH) after the resident's family insisted the resident to be transferred on 2/13/2020 by emergency transport services via 911 call (an emergency service). Resident 1 had an altered mental status ([AMS] general changes in brain function, such as confusion, amnesia (memory loss), loss of alertness, and/or disorientation) and a possible stroke (cerebral vascular disease [CVA] no blood flow to the brain that results in minor or major deficits), as documented by the paramedics. Resident 1 was diagnosed in the GACH with sepsis (infection in the blood) metabolic encephalopathy (brain damage), urinary tract infection ([UTI] an infection in any part of the urinary system: kidneys, ureters, bladder and urethra). Resident 1 was hospitalized and expired (died) two days later. Findings: A review of Resident 1's GACH history and physical (H/P), prior to admission to the skilled nursing home (SNF), dated 1/30/2020 indicated Resident 1 was admitted to the GACH with abdominal (stomach) pain, dehydration (excessive loss of body water) and urine retention (inability to urinate). The H/P indicated an indwelling urinary catheter (tube FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 3 of 13 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 07/15/2020 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 inserted into the bladder to drain urine) was placed and Flomax (a medication to improve urine output) 0.4 milligrams ([mg] a unit of measurement) was ordered to be given by mouth, at bedtime for urine retention. A review of Resident 1's SNF Admission Record (face sheet), indicated Resident 1 was admitted to the facility on 2/5/2020. Resident 1's diagnoses included urine retention, muscle weakness, congestive heart failure ([CHF] the heart unable to pump sufficiently to maintain blood flow to meet the body's needs), and diabetes mellitus (high blood sugar levels). A review of Resident 1's H/P, dated 2/5/2020 indicated Resident 1 was alert, oriented, with adequate insight and judgement. According to the H/P, Resident 1 had normal muscle strength and nerve sensation/reflexes. A review of Resident 1's Admission Assessment, dated 2/6/2020 indicated Resident 1 was alert, oriented (able to identify oneself) to person, verbally appropriate, required total assistance with transferring, and utilized a walker and/or a wheelchair for mobility. The assessment indicated Resident 1 had a history of recurrent UTI and an indwelling urinary catheter for urine retention. A review of Resident 1's care plan, dated 2/6/2020 and titled, "At Risk for Urinary Retention secondary to indwelling catheter removal." The staff's interventions included to monitor Resident 1 for signs and symptoms of bladder retention and report to the physician promptly of any retention. A review of Resident 1's recapitulated (summary of orders) physician's orders, dated 2/6/2020, indicated for the staff to monitor Resident 1's indwelling urinary catheter for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 4 of 13 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 07/15/2020 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 patency (open, no blockage), character (color, transparency, odor) and consistency (thick/murky/dirty) of urine every shift, check the drainage bag as needed for leakage or increased sediment (gritty particles [grainy, resembling sugar]) every 24 hours. A review of Resident 1's nurse's note, dated 2/9/2020 and timed at 7:50 p.m. indicated Resident 1 was alert with episodes of confusion. A review of Resident 1's nurse's note, dated 2/10/2020 and timed at 5:05 a.m. indicated Resident 1 was found lying in a supine (flat on the back) position on the floor in her room after a fall. According to the note, Resident 1 stated she was trying to sit up and fell. The note indicated Resident 1's physician was called, but the licensed nurse (unspecified) was unable to leave a message, as there was no documentation the physician was notified. A review of Resident 1's nurse's notes, dated on 2/10/2020 indicated there was no documented evidence the licensed nurse made contact, with the physician and informed the physician of Resident 1's fall on 2/10/20 at 5:05 a.m. A review of Resident 1's Rehab Post-Fall Assessment, dated 2/10/2020 timed at 10:22 a.m., indicated Resident 1 had an unwitnessed fall on 2/10/2020 at 4:35 a.m. The assessment indicated Resident 1 complained of neck pain and x-ray (a device that creates a picture of the inside body) of an unspecified body part was ordered and a recommendation for a pad alarm (an alarm that activates and makes a sound upon resident's rising) due to the resident's history of getting out of bed unassisted. A review of Resident 1's nurse's note, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 5 of 13 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 07/15/2020 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 2/10/2020 and timed at 6:07 p.m. indicated Resident 1 was alert with forgetfulness. The xray was completed and awaiting results. The note indicated Resident 1's blood pressure was 147/69 millimeters of mercury [mmHg], (normal reference range [NRR] 139/79- 120/80 mm/hg). A review of Resident 1's untimed x-ray reports of the cervical (the neck), thoracic (upper and middle part of the back), lumbar spine (lower back), and the sacrum-coccyx (base of the backbone) area, dated 2/10/2020 indicated the resident did not have any fractures (broken bones). A review of Resident 1's laboratory results, dated 2/11/2020 timed at 4:30 a.m., indicated the white blood count ([WBC] part of the body's immune system to help to fight infections) was slightly elevated at 10.3 per microliter (uL) (NRR =levels 4.50 -10.00). A review of Resident 1's nurse's note, dated 2/11/2020 and timed at 11:07 p.m. indicated Resident 1 was seen and examined by the physician and had no hematuria (blood in the urine) or foul odors in the urine. A review of Resident 1's nurse's note, dated 2/12/2020 and timed at 5:45 p.m. indicated Resident 1 was alert with episodes of confusion and was being "frequently checked by the staff (without specific times mentioned)." There was no documentation that indicated the resident was being monitored by the staff. A review of Resident 1's COC note, dated 2/13/2020 and timed at 3:30 p.m. indicated Resident 1 had an altered mental status (a change in brain function). (shortly after lunch) The note indicated Resident 1's family member (FM 1) requested for Resident 1's vital signs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 6 of 13 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 07/15/2020 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 (measurements which includes body temperature, blood pressure, pulse (heart rate), and respiratory rate) to be checked, because Resident 1 was spitting out water and was not responding after being asked questions. The COC note indicated Resident 1's physician was made aware and there were no physician's orders. A review of Resident 1's nurse's note, dated 2/13/2020 and timed at 4:48 p.m. indicated FM 1 and FM 2, requested for Resident 1 to be transferred to the hospital due to Resident 1 becoming more lethargic (sleepiness, sluggish or lack of energy). The nurse documented Resident 1 was arousable to stimuli (awakened by someone or something). A review of Resident 1's nurse's note, dated 2/13/2020 and timed at 10 p.m., as a late entry (L/E) indicated at 5 p.m., FM 2 approached the charge nurse and stated he wanted Resident 1 transferred to the hospital because she did not look good and had looked much better the day prior. According to the note, FM 2 stated Resident 1's condition was getting worse and now had facial drooping. The nurse documented Resident 1 was arousable to tactile (touch) stimuli, had no facial drooping, but was not able to follow commands, was lethargic and had an altered mental status after being assessed by the charge nurse. A review of Resident 1's Paramedic Run Sheet, dated 2/13/2020 indicated the paramedics arrived at the facility on 2/13/2020 at 5:19 p.m. The paramedics documented Resident 1 had an altered level of consciousness, was unconscious (unable to respond to stimuli and appears to be asleep) with a Glasgow Coma Scale ([GSC] an assessment used to determine level of consciousness [alertness/function]) score of 7. According to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 7 of 13 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 07/15/2020 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 GCS, a score of 15 was normal and a score between 3-8 was indicative of severe decreased brain function and/or comatose. The paramedic's documented Resident 1 was last seen normal three hours (by the staff) prior to their arrival having a change in her mental status and became unresponsive to painful stimuli. The paramedic run sheet indicated Resident 1 was transported to the GACH for a possible cerebral vascular disease. A review Resident 1's GACH Emergency department (ED) H/P, dated 2/13/2020 indicated Resident 1 had altered mental status, somnolent (sleepy, drowsy), was non-verbal and did not follow simple commands. The H/P indicated FM 1 stated he had been at Resident 1's bedside at the SNF since that morning (the morning of 2/13/20) and she was at baseline and had normal conversations, but after lunch, she (Resident 1) had an episode of nausea (sickness of the stomach with an urge to vomit [to empty the contents of the stomach through the mouth]) and vomiting, then had decreased responsiveness, stopped talking, became severely sleepy and began going in and out of consciousness. The H/P indicated FM 1 stated the facility's nursing staff was made aware of Resident 1's ALOC and the nursing staff obtained Resident 1's vital signs without an indication of Resident 1's vital signs being normal. According to the GACH's H/P, the family member (FM 1) stated Resident 1's ALOC worsen had severe somnolent and he (FM1) insisted the facility's nursing staff call 911. The GACH's H/P indicated Resident 1 was admitted on a cardiac (heart) intensive care unit (ICU) with diagnoses that included acute encephalopathy (brain damage), possible CVA, suspected aspiration pneumonia (entry of material [food, drink or stomach contents] in to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 8 of 13 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 07/15/2020 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 lungs and choking) and acute UTI complicated with indwelling catheter. A review of Resident 1's GACH's progress notes, dated 2/15/2020 and timed at 12:52 a.m., 3:43 a.m. and 3:46 a.m., indicated while in the ICU, Resident 1 stopped breathing and was resuscitated (emergency procedure performed including chest compressions and manual breathing). The H/P indicated Resident 1 expired (died) on 2/15/2020 at 4:03 a.m. On 5/14/2020 at 5:15 p.m., during a telephone interview, FM 1 stated he and FM 2 made medical decisions for Resident 1. FM 1 stated Resident 1 was alert, able to make her needs known with some confusion and/or forgetfulness. FM 1 stated on 2/13/2020, he and FM 2 was at Resident 1's bedside when Resident 1 had a change of condition (after lunch). FM 1 stated he called and informed FM 3 Resident 1 was lethargic and not waking up. FM 1 stated he was sad Resident 1 passed away and that the facility did not believe them when Resident 1 had a change of condition. On 5/14/2020 at 5:31 p.m., during a telephone interview, FM 2 stated on 2/13/2020, he received a call from FM 1 indicating Resident 1 was slumped over in her wheelchair and when he arrived at the SNF, Resident 1 had a change of condition. FM 2 stated he told the nursing staff Resident 1 was not looking good and she had stopped talking, but the staff stated there was nothing wrong with Resident 1 and stated, "She (Resident 1) is okay." FM 2 stated a few days prior, Resident 1 had a fever and was agitated and he requested for Resident 1 to be transferred to the hospital, but the staff stated, "No." FM 2 stated he requested for the staff to call 911 and transfer Resident 1 to the hospital, but the staff stated Resident 1 would be transferred to the hospital in four (4) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 9 of 13 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 07/15/2020 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 hours, by an ambulance (non-emergency). FM 2 stated he asked the staff why Resident 1 had to be transferred in 4 hours when she was lethargic. FM 1 stated he continued to insist that the staff call 911. FM 2 stated the intensive care unit (ICU) physician at the GACH stated Resident 1's lethargy, lack of verbalization and facial drooping was a "red flag (warning)." On 5/18/2020 at 3:22 p.m., during a telephone interview, FM 3 stated it was difficult to discuss the events that occurred with Resident 1 while at the SNF. FM 3 stated Resident 1 was a fullcode (complete of life-saving measures). FM 3 stated on 2/13/2020 (time not mentioned), she received a call from FM 1 and 2, who were at Resident 1's bedside stating Resident 1 had a change of condition. FM 3 stated she asked the nursing staff if Resident 1 was able to answer questions and if they could transfer the resident to a wheelchair, but the staff insisted Resident 1 was normal. FM 3 stated she made a face-toface call to FM 1 and 2 and was able to observe Resident 1. FM 3 stated she observed Resident 1 being non-verbal and nonresponsive and asked the nursing staff if Resident 1 was responsive to physical stimuli. FM 3 stated she was frustrated the nursing staff could not see Resident 1 was not okay and had a change of condition. According to FM 3, the nursing staff stated Resident 1 did not have a change of condition and she was okay because the resident's vital signs were stable. On 5/19/2020 at 5:26 p.m., during a concurrent telephone interview and record review of Resident 1's nursing notes, Licensed Vocational Nurse 1 (LVN 1), stated from the time he initially provided care to Resident 1, the resident was alert with episodes of confusions. LVN 1 stated Resident 1 was able to respond to simple commands, but on 2/13/2020, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 10 of 13 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 07/15/2020 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 1's family had concerns about Resident 1 not being herself, but the resident's vital signs were normal. LVN 1 stated FM 1 and 2 requested for Resident 1 to be transferred to the GACH, the physician was notified and gave an order to transfer Resident 1. LVN 1 stated the Registered Nursing Supervisor (RNS) spoke with FM 3 and stated FM 1 and FM 2 requested a GACH transfer for Resident 1. LVN 1 stated FM 2 then approached the nurse's station and requested for Resident 1 to be sent out to the GACH because Resident 1 had facial drooping. LVN 1 stated he and the RNS assessed Resident 1 and did not observe any facial drooping and had equal arm strength. LVN 1 was asked on 2/13/2020, about Resident 1 having altered level of consciousness or lethargy, LVN 1 stated Resident 1 had increased confusion. LVN 1 was asked, did Resident 1 require a transfer to the GACH based on his observation and documentation of a nurse's note, dated on 2/13/2020 at 10 p.m. which indicated Resident 1 was lethargic and altered mental status, LVN 1 stated Resident 1's lethargy and altered mental status could have indicated the resident had a UTI, which could have been treated in the facility. On 5/20/2020 at 12 p.m. and 12:32 p.m., during a concurrent telephone interview and record review of Resident 1's nursing notes, LVN 2 stated on 2/13/2020 at 4:48 p.m., FM 1 and 2 approached the nurse's station and requested a hospital transfer for Resident 1. LVN 2 stated she did not provide care for Resident 1 on 2/13/2020, but she recorded Resident 1's vital signs. LVN 2 stated she called and informed FM 3 of Resident 1's vital signs being normal, after FM 3 asked if Resident 1 was okay and required a transfer to the GACH. LVN 2 stated according to LVN 1, Resident 1 was stable because she was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 11 of 13 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 07/15/2020 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 responsive to stimuli, but not verbal, although the resident had been verbally responsive before. On 5/20/2020 at 12:40 p.m., during a concurrent telephone interview and record review of Resident 1's nursing notes, RNS stated on 2/13/2020, LVN 1 informed her that FM 1 and 2 indicated Resident 1 appeared lethargic. The RNS stated she assessed Resident 1 and Resident 1 had minimal verbalization; did not speak much, but did not have any changes in her condition, and there were no changes from Resident 1's baseline (starting point). The RNS was asked about Resident 1's baseline, RNS stated she could not recall. RNS was asked how she determined that Resident 1 did not have a change of condition, if she was not knowledgeable or aware of Resident 1's baseline but was informed by LVN 1 that this was Resident 1's normal behavior and baseline. RNS stated she did not document an assessment she conducted on Resident 1 on 2/13/2020 and did not complete a change of condition note. RNS was asked if a resident was lethargic and had an altered mental status was that considered a change of condition, RNS stated, "Yes." The RNS stated she did not observe Resident 1 being lethargic and did not make the decision to transfer Resident 1 to the GACH, it was the family's decision. RNS stated she could not recall if Resident 1 had facial drooping or if the resident had difficulty swallowing. The RNS was asked if she reviewed Resident 1's records on 2/13/2020 to determine her baseline, RNS stated, "No." RNS was asked again how she determined Resident 1 did not have a change of condition based on no clinical knowledge of Resident 1, RNS stated she saw Resident 1 previously in passing, but did not have any contact with the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 12 of 13 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 07/15/2020 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 5/28/2020 at 3:36 p.m., during a concurrent telephone interview and record review of Resident 1's nurse's progress notes, the Director of Nursing (DON) stated on 2/13/2020 Resident 1 had a change of condition. The DON stated the nursing staff should have used their nursing judgement in recognizing Resident 1's change of condition. The DON stated it was the nursing staff's responsibility to transfer Resident 1 to the GACH when Resident 1's family made multiple requests to transfer Resident 1 to the GACH. A review of Resident 1's death certificate indicated the resident expired on 2/15/2020 at 1:04 a.m. and the cause of death was listed as sepsis (an infection in the blood); complicated UTI and pneumonia (lung infection). A review of the facility's revised policy and procedure, dated 9/2013 and titled, "Change in a Resident's Condition or Status" indicated our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy indicated the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a significant change in the resident's physical/emotional/mental condition, a "significant change" of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by the staff or by implementing standard disease-related clinical interventions impacts more than one area of the resident's health status. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I59Q11 Facility ID: CA910000055 If continuation sheet 13 of 13