Lomita Post-Acute Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 2, 3 and 4) were assisted with Activities of Daily Living (ADLs- activities related to personal care) in a timely manner. This deficient practice had the potential to result in skin breakdown and falls for Residents 2, 3 and 4 and could negatively affect the Residents' psychosocial well-being.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure two of four sampled residents (Resident 25 and Resident 35) were free from unnecessary psychotropic medications (any drug that affects brain activity related to mental processes and behavior) by failing to:1. Ensure an appropriate diagnosis and evaluation was conducted for Resident 35 before starting the treatment with Seroquel ([generic name - quetiapine] a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought], bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs] and as an adjunct treatment option for depression (a serious mood disorder causing persistent sadness and loss of interest, affecting thoughts, feelings, and daily activities). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) for two of eight sampled residents (Residents 52 and 65) with ROM concerns by failing to: 1. Objectively measure Resident 65's limited finger ROM of the left hand during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 3/25/2025.2. Provide ROM exercises to Resident 65's right knee during a Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) session in accordance with physician's orders.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass, affecting four of five sampled residents (Residents 11, 29, 18 and 35) by failing to:1. Administer Resident 11's ferrous sulfate (a medication used to treat low levels of iron) within one hour of its prescribed time as per facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019.2. Administer Resident 29's ferrous sulfate within one hour of its prescribed time as per facility's P&P titled, Administering Medications, dated 4/2019.3. Ensure Resident 18's lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) was dated with the date of application and removed after 12 hours of application, in accordance with manufacturer specifications.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents for unnecessary medications review (Resident 3) was free from significant medication errors, by failing to follow parameters for pain level and ensuring hydrocodone (a controlled substance or also known as an opioid [medications that the use and possession of are controlled by the federal government] a medication used to treat pain) in combination with acetaminophen (APAP - a medication used to treat fever and pain) and morphine (a controlled substance or also known as an opioid used to treat severe pain) were only administered to Resident 3 for the prescribed pain score parameters, affecting one of five sampled residents for unnecessary medications review. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was properly labeled, monitored, and handled in a sanitary manner, to ensure that dietary staff had effective systems and oversight to safely perform assigned duties, creating the potential for food contamination (when food becomes unsafe or spoiled by harmful substances) and adverse resident outcomes by failing to: 1. Properly label and date food items.2. Monitor and document cold storage temperatures. 3. Monitor and document sanitation and equipment temperatures.4. Ensure the ice machine had a monitoring log for sanitation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement proper infection control practices. The facility failed to:1. Ensure Licensed Vocational Nurse (LVN) 1 wash hands before administering Artificial Tears eye drops (a medication used to treat dryness and itchiness in eyes) to Resident 18 during medication pass observation.2. Ensure open trash bags were not left on top of linen hampers.3. Ensure sorting of dirty linens were not performed in the same area where clean clothes were removed from washing machines.4. Ensure non-disposable yellow gown were not left hanging on the wall next to the clean area of the laundry room. [...]

Inspectors wroteBased on interview and record review the facility failed to honor a resident right by not obtaining a signed informed consent (a process where a person willingly agrees to a treatment) by the resident and/or resident representative prior to the administration of the influenza vaccine, in accordance with facility policy and resident rights requirements, for one of three residents (Resident 31). This failure placed Resident 31 at risk for receiving medical treatment without consent, violation of resident autonomy (the ability to make your own free, independent choices) and decision-making rights.

Inspectors wroteBased on interview and record review, the facility failed to provide and show documentation that an Advanced Directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was discussed with the residents and/or responsible parties and written information was provided for two out of 21 sampled residents (Resident 16, and 54). These deficient practices violated the residents' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding alternatives in the provision of health care and end of life decisions.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that assessment entries on the Minimum Data Set (MDS)-a resident assessment tool) accurately reflected the residents' status at the time of assessment for two of six sampled residents (Resident 25). The facility failed to: 1. Ensure Resident 25 had a documented diagnosis of depression (a serious mood disorder characterized by persistent sadness and loss of interest in activities affecting daily life) when Lexapro (Escitalopram-a prescription medication used to treat depression and anxiety) was administered. This failure resulted in an inaccurate representation of Resident 25's condition during the MDS assessment period and had the potential to impact on the quality and appropriateness of care provided to Resident 25.

Inspectors wroteBased on interview and record review, the facility failed to follow the care plan intervention for monitoring signs and symptoms of psychosis (a severe mental condition in which thoughts and emotions are so affected that contact with reality is lost ) for one of two sampled residents (Resident 25) related to the use of Seroquel (an antipsychotic medication prescribed to treat mental health conditions) by failing to: 1. Document behaviors associated with the use of Seroquel as ordered by the physician. This failure had the potential to prevent staff from determining whether Seroquel was effective in managing Resident 25's psychotic symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 18's order for lidocaine patch (a medication in patch form used to treat pain) was implemented according to manufacturer specifications and professional standards of practice. The facility failed to:1. Ensure the lidocaine patch applied to Resident 18's left knee was labeled with the date of application on the day it was applied.2. Ensure the lidocaine patch was removed after 12 hours of application, as required by manufacturer instructions. This deficient practice had the potential to result in adverse consequences such as local site reactions including skin irritation, redness, burning, and itching.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of six sampled residents (Resident 22) received respiratory care (specialized healthcare focused on the treatment, management, and prevention of respiratory disorders) consistent with professional standards of practice by failing to: 1. Ensure Resident 22's nasal cannula (a small plastic tube that fits into the nostrils to provide supplemental oxygen) was labeled and dated. 2. Ensure the prescribed amount of oxygen ordered by the physician was administered to Resident 22. This failure had the potential to place Resident 22 at risk for respiratory infection (an infection affecting the respiratory tract, including the nose, throat, and lungs, caused by viruses or bacteria) and respiratory distress (a condition where the body struggles to breathe effectively).

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff possessed the necessary knowledge and skill set (a collection of abilities, knowledge, personal traits, and expertise developed to perform tasks) for two of seven nursing staff. The facility failed to: 1. Complete and document a performance review for Licensed Vocational Nurse (LVN) 1.2. To follow its policy and procedure titled cardiopulmonary resuscitation ([CPR] an emergency lifesaving procedure performed when breathing or heartbeat stops) dated 6/2025 which indicated for staff to maintain current CPR certification through a provider whose training includes hands-on practice and in-person skills assessment, and specifically stated that online-only certification was not acceptable. These failures had the potential to place residents at risk of not receiving care in a safe and competent manner. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure performance evaluations were completed at least once every 12 months for three of five Certified Nursing Assistants (CNAs). This failure had the potential to prevent identification of areas for improvement or weaknesses in the delivery of care and services to residents by CNAs, which could result in unsafe or inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment, monitoring, and services for one of five sampled residents reviewed for unnecessary medications (Resident 3) with diagnosis of depression (a mood disorder causing persistent sadness and loss of interest, affecting feelings and thoughts in a person). This deficient practice had the potential to result in suicidal ideation (means thinking about, considering, or planning suicide) and impairment or decline in the resident's mental, physical condition, functional abilities, and psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders for medications were complete and accurate per facility policy for two out five sampled residents (resident 11 and 18). The facility failed to: 1. Ensure Resident 18's order for lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) clearly indicated number of patches (dose) to be applied, per facility's policy and procedure (P&P) titled, Physician Orders, dated 5/2007. 2. Ensure Resident 11's order for diclofenac sodium (a medication used to treat inflammation and pain) external gel had a dose, frequency and location for its use, per facility's P&P titled, Physician Orders, dated 5/2007. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure Resident 18's lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) applied to Resident 18's left knee was labeled with the date of application on the day it was applied affecting one of five residents observed for medication administration.2. Ensure Resident 38's Fluticasone-Salmeterol (a medication delivered through a device in the form of inhalation powder, used to treat breathing problems ) inhaler was removed from Station A and B Medication Cart 1 after being discontinued, and labeled with an open date in accordance with manufacturer's specifications and facility's policy and procedure (P&P), titled PH 1 Medication Administration, undated, affecting one of two medication carts reviewed (Station A B and Medication Cart 1). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff were competent and able to safely perform assigned job duties, including understanding and accurately following meal tickets (a card for residents' meals) and food service instructions, for two of two dietary staff (Dietary Aide #1 and #2). These failures placed residents at risk for receiving incorrect diets, aspiration (choking), allergic reactions, poor nutritional intake, and compromised resident safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's food preference for one of three sampled residents (Resident 54) by serving beef, despite the resident's stated dislike for it. This failure had the potential to negatively impact Resident 54's dining experience by providing food that did not align with the resident's preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) splinting (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) recommendations and interventions were accurately documented for one of eight sampled residents (Resident 65) in the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, RNA care plan, and RNA flowsheets (daily record of RNA services provided for each month). [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent and involve the resident representative (an individual chosen by the resident to act on their behalf in decision-making and to access medical, social, or other personal information) prior to administering the influenza vaccine for one of three sampled residents (Resident 31). Resident 31 influenza vaccine was administered after the resident representative had declined the vaccine. This failure placed Resident 31 at risk for receiving medical treatment without informed consent, violation of resident rights, adverse reactions or side effects, loss of trust between the facility and the resident's representative, legal and regulatory noncompliance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 12 residents' rooms (Rooms 1, 2, 3, 5, 6, 7, 9, 12, 14, and 15) met the requirements of 80 square feet (sq. ft.) for each resident. This deficient practice had the potential to result in inadequate space, provision for resident care and personal property, and privacy for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to resolve a grievance indicating a delayed call light response time for one out of three sampled residents (Resident 3). This deficient practice had the potential for Resident 3 to have anxiety (extreme worry).

Inspectors wroteBased on interview and record review, the facility failed to manage pain for one out of three residents (Resident 2), when Resident 2 informed the Certified Nursing Assistant (CNA) 1 she had left arm and hand pain. This deficient practice had the potential to cause Resident 2's pain to worsen, become uncontrolled, create discomfort, and cause fear of receiving treatment/services due to anticipated pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a contact precaution sign indicating the personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) that needed to be worn prior to visitors entering the room was posted for one of seven sampled residents (Resident 6) who tested positive for clostridium difficile (C. Diff - a highly contagious bacteria that causes severe diarrhea). This deficient practice had the potential to spread C. diff to other residents, visitors, and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective pest control program to prevent the infestation of gnats (fruit fly: flying, winged flies) by failing to: 1. Maintain a sanity environment for the residents' shared refrigerator in the dining room. 2. Prevent gnats from flying in Resident 1's room during lunch time. 3. Place UV fly traps throughout the facility and have working UV fly traps in Resident 5's room. 4. Maintain a sanitary environment in the storage room in the kitchen. These deficient practices have the potential to have flies in the food while having lunch and can affect residents that has open wounds prone to infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 20 sampled residents (Resident 22, 24 and 13) had a Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment done when diagnosed with a mental illness prior to admission. This failure had the potential to result in Resident 22, 24 and 13 not receiving the necessary services and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 12) Minimum Data Set (MDS- a federally mandated resident assessment tool) was accurately documented to reflect Resident 12 hearing status. This deficient practice had the potential to negatively affect Resident 12's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement care plan interventions for one of three residents (Resident 51) who received anti-coagulant therapy (a medication that prevents or treats blood clots in the heart and blood vessels). This failure had the potential to result in complications from the use of anti-coagulant therapy including bruising and bleeding.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 163) was helped with activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when Resident 163 requested to have a shower. This failure resulted in Resident 163 feeling abandoned and neglected.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 32) received necessary care and services by failing to: 1. Follow up and ensure venous and arterial doppler (imaging test that uses sound waves test and help diagnose problems that affect the flow of blood) was done in a timely manner as ordered by the physician on 10/28/2024. 2. Monitor and assess the size of hematoma on Resident 32's left leg. This failure had the potential to cause delays in diagnosis, which could lead to delays in appropriate treatment for Resident 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 12) received access to hearing services. This failure resulted in Resident 12 having trouble hearing properly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate safety precautions to residents at risk for fall for one of 20 sampled residents (Resident 40). Facility failed to ensure: a. Resident 40, who was on fall risk precaution with landing pads placed on the side of the bed had no bedside table on top of the landing pads. This failure had the potential for injury when Residents 40 would fall out of bed and hit their head on the bedside table placed on top of the landing pads.

Inspectors wroteBased on interview and record review, the facility failed to ensure employee files were reviewed and kept up to date to ensure an at the time of hire and annual competency skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully),Tuberculosis ( TB-lung disease) testing, performance evaluation, annual health examinations and background checks were completed for seven employees. The facility failed to: 1. Ensure DSD, Registered Nurse Supervisor (RNS) 1, Licensed Vocational Nurse (LVN) 3, LVN 4, LVN 5, Certified Nurse Assistant (CNA) 5, and CNA 6 had a Tuberculosis (TB- a lung disease) test, (a skin test to check if you have been infected with Tuberculosis) upon hire and annually. 2. [...]

Inspectors wroteb. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including laceration of popliteal artery of the left leg( cut or tear of popliteal artery which is the main blood vessel that supplies blood for the lower leg and knee area), displaced bicondylar fracture of left tibia ( severe injury that occurs when both upper and lower parts of shinbone are broken and displaced from their normal position), and heart failure (heart does not pump enough blood to meet body's needs). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents (Resident 11 and Resident 22) were free of unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) by failing to: a. Ensure Resident 11 was provided with non- pharmacological interventions (intervention that does not primarily use medicine) before administering as needed (prn) psychotropic medication. b. Ensure Resident 22's psychotropic medications were reevaluated for appropriateness of medication. These failures placed Resident 11 and Resident 22 at risk for using psychotropic medicines for excessive duration and developing adverse effects from the medicines.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication cart was locked and secure and not left unattended during administration of resident's medication. This failure had the potential to place residents at risk for accidental ingestion of non-prescribed medicines and unauthorized access of the medication cart from anyone in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for two of 10 sampled residents (Resident 17 and 168) by failing to: a. Ensure Resident 17's nasal cannula (a device used to deliver oxygen to a resident) was changed after seven days per facility's policy and procedure. b. Ensure Resident 168's nasal cannula was dated and labeled upon admission. These failures had the potential to result in the transmission of infectious microorganisms and increase the risk of respiratory infection for Residents 17 and 168.

Inspectors wroteBased on interview, and record review, the facility failed to have an Infection Preventionist (IP) on staff with required qualifications and completed specialized training in Infection Control and Prevention. This deficient practice had the potential for failure to monitor and implement Infection Control and Prevention in the facility.

Inspectors wroteBased on observation, and record review, the facility failed to ensure 12 residents rooms met the requirements of 80 square feet (sq. ft.) for each resident. Rooms 1, 2, 3, 5, 6, 7, 9, 12, 14, and 15, housed two residents per room and room [ROOM NUMBER] and 17 housed one resident per room. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to: 1) Label canned foods, corn bread powder, butter, meat products, and vegetables with opened date and received date. 2) Ensure damp cloth used by [NAME] 1 did not repeatedly touched the food inside the plate. 3) Ensure [NAME] 2 who handed utensils back and forth to [NAME] 1 wore gloves. 4) Ensure [NAME] 3 wore gloves while reaching inside the food cart and touches the plate inside the food cart. These deficient practices had the potential to result in foodborne illnesses and can lead to other serious medical complications and hospitalization for residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 41) were treated with dignity and respect by failing to ensure Resident 41 had a dignity bag (restores the dignity of [catheterized-a procedure used to drain the bladder and collect urine, through a flexible tube patient by concealing urinary drainage bags from public view) for his indwelling catheter ([foley catheter] plastic or rubber tube that is inserted into the bladder to drain the urine) drainage bag (collects urine). This deficient practice had the potential to affect Resident 41's self-esteem, self-worth, and feeling embarrassed.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure call lights was within reach for two of three sampled residents (Residents 33 and 39). This deficient practice had the potential to result in a delay and inability for Resdeint 33 and Resident 39 to obtain necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 41) received right arm sling (to ease pain, support healing and to protect arm from further injury) This deficient practice had the potential to place Resident 41 at risk for further range of motion (ROM - the extent of movement of a joint) decline, contracture (a condition of shortening and hardening of muscles, leading to deformity and rigidity of joints) and dehiscence (a surgery complication where the incision (surgical wound) reopens).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure it was free of not greater than 5 percent (%) or below medication error rate, as evidenced by eleven medications errors out of 42 opportunities for error, which yield a 26.19% medication error rate. This deficient practice resulted in a 26.19 percent (%) medication error rate for Resident 6.

Inspectors wroteCross Reference F759 Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 6) was free from significant medication errors by failing to ensure crushed medications were not mixed before medication administration according to facility's policy and procedure. This deficient practice had the potential to affect medication efficacy, compatibility and can have drug interactions for Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication cart and treatment cart were locked when unattended by Licensed Vocational Nurse (LVN 3). This deficient practice had the potential for unauthorized access to medications and medical supplies by residents, staff, and visitors.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure heparin lock (heplock- locking device on an intravenous catheter [ placed in a vein ] to administer medication) was covered. This deficient practice has the potential to contaminate the intravenous catheter, and risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call system was functional including the audible sounds to alert the staff for one of two sampled Residents (Resident 11). This deficient practice had a potential in a delay in meeting care or services for Resident's 11.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 12 of 34 resident rooms (Rooms # 1, 2, 3, 4, 5, 6, 7, 9, 12, 14, 15, and 17) met the requirements of 80 square feet (sq. ft.) for each resident. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.