Kei-ai South Bay Healthcare Center

F-F759.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 555306 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555306 B. Wing 01/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kei-Ai South Bay Healthcare Center 15115 S Vermont Ave Gardena, CA 90247

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46832 Residents Affected - Few Based on observation, interview and record review, the facility failed to:

1. Ensure Tylenol suppositories (a rectal medication used to relieve mild to moderate pain from headaches or muscle aches and to reduce a fever) stored in a clear, Ziplock bag was labeled and dated in the Station 1 Medication Storage room.

This deficient practice had the potential to result in medication errors.

Findings:

During a concurrent observation and interview, on [DATE REDACTED], at 9:17 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 observed an unlabeled and undated clear Ziplock bag with 52 rectal Tylenol suppositories stored in the medication fridge. LVN 3 stated the Ziplock bag should had been labeled and dated with an open date and expiration date. LVN 3 stated the risk of storing an unlabeled bag of medication in the medication refrigerator could result in medication errors. LVN 3 stated there was no label on the bag. LVN 3 stated We don't know if the medication is expired, if it belongs to a resident or what the medication is.

During an interview, on [DATE REDACTED], at 4:03 p.m., with the Administrator (ADM), the ADM stated all medication in

the medication storage room was to be labeled and dated with open dates and expiration dates. The ADM stated the risk of having unlabeled medication in the medication storage refrigerator could result in medication errors. The ADM stated, We wouldn't know if the medication belongs to a resident or if it's a house medication. We also wouldn't know if the medication is expired. It could result in bad consequences if given to the wrong resident.

During a review of the facility's policy and procedures, titled Storage of Medications, dated ,d+[DATE REDACTED], indicated Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 555306 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555306 B. Wing 01/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kei-Ai South Bay Healthcare Center 15115 S Vermont Ave Gardena, CA 90247

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Provide routine and 24-hour emergency dental care for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46832 potential for actual harm Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Ensure dental services were provided for one of 7 sampled residents (Resident 35).

This deficient practice had the potential to result in a delay in necessary dental care and services.

Findings:

During a review of Resident 35's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 35 was originally admitted to the facility on [DATE REDACTED] with a readmitted [DATE REDACTED]. The face sheet indicated Resident 35's had diagnoses which included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), atrial fibrillation (an irregular and often very rapid heart rhythm), and pneumonia (an infection/inflammation in the lungs).

During a review of Resident 35's Minimum Data Set (MDS- a federally mandated resident assessment tool),

the MDS indicated Resident 35 cognitive skills was severely impaired. The MDS also indicated Resident 35 was dependent on staff with toileting hygiene, showering and upper/lower body dressing.

During an interview, on 01/07/2025, at 11:20 a.m., with Resident 35's son, Resident 35's son stated the facility's dental services, Golden Age Dental Care, visited residents monthly. Resident 35's son stated Resident 35's upper dentures had been loose for the past year. Resident 35's son stated Resident 35's upper dentures was supposed to be realigned for a better fit and was not.

During an interview, on 01/10/2025, at 11:00 a.m., with Social Services Director (SSD), the SSD stated the facility's dental service visited all residents every month. The SSD stated Resident 35's last dental appt with Golden Age was 11/1/2024. SSD stated Resident 35 needed a realignment of her upper dentures. The SSD stated the Social Services department was responsible for following up with dental services for residents.

The SSD stated there was no follow up with dental services for Resident 35. The SSD stated the risk of not following up on dental services could result in a resident not being able to eat, pain and discomfort.

During an interview, on 01/10/2025, at 11:31 a.m., with the SSD, SSD stated she had called Golden Age at 11:25 a.m. on 01/10/2025 and received an approval to have Resident 35's dentures fixed.

During an interview, on 1/10/2025, at 4:03 p.m., with the Administrator (ADM), the ADM stated Social Services was responsible for setting appointments, follow ups, transportation, and reimbursements of dental services. The ADM stated Resident 35's upper dentures should had been followed up on. The ADM stated

the risk of not following up with dental services could result in weight loss, not eating and being uncomfortable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 555306 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555306 B. Wing 01/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kei-Ai South Bay Healthcare Center 15115 S Vermont Ave Gardena, CA 90247

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 During a review of the facility's policy and procedures, titled Dental Services, revised 12/2016, indicated Social services representatives will assist residents with appointments, transportation arrangements, and for Level of Harm - Minimal harm or reimbursement of dental services under the state plan, if eligible. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 555306 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555306 B. Wing 01/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kei-Ai South Bay Healthcare Center 15115 S Vermont Ave Gardena, CA 90247

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46144 potential for actual harm Based on observation and interview the facility failed to change oxygen tubing in seven days for one out of Residents Affected - Few five Residents (Resident 66).

This deficient practice placed Resident 66 at risk for infection.

Findings:

During a review of Resident 66's Admission Record (Face Sheet), the Face Sheet indicated Resident 66 was initially admitted to the facility on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED]. Resident 66's diagnoses included chronic obstructive pulmonary disease (a medical condition that cause airflow blockage and breathing-related problems), heart failure (a medical condition that develops when the heart does not pump enough blood for your body's needs), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood).

During a review of Resident 66's History and Physical (H&P), dated 12/7/2023, the H&P indicated Resident 66 does not have the capacity to understand and make decisions.

During a review of Resident 66's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 12/7/2023, the MDS indicated Resident 66's cognition (ability to learn, reason, remember, understand, and make decisions) to recall information when ask to repeat information with some cueing (giving a signal or reminding member to do a task). The MDS indicated Resident 66 activities of daily living (ADL) dependent assistance with toileting, showering, and dressing.

During an observation on 12/26/2023 at 9:43a.m. in Resident 66's room there was oxygen tubing (a device that gives additional oxygen through your nose) infusing to Resident 66 at 2 liters per unit attached to a humidifier (a device for keeping the atmosphere moist) unit with the date of 12/18/2023.

During an interview on 12/28/2023 at 9:30a.m. with Licensed Vocational Nurse (LVN) 1. LVN 1 stated oxygen tubing is changed once a week. LVN 1 stated the humidity () build up in the oxygen tubing and can get in the lungs of Resident 66 if the oxygen tubing is not changed every 7 days. LVN 1 stated it is important to change the oxygen tubing once a week to prevent infection.

During an interview on 12/28/2023 at 1:20p.m. with Assistant Director of Nursing (ADON) 1. ADON 1 stated oxygen tubing is changed once a week. ADON 1 stated the oxygen tubing needed to be changed for Resident 66 to prevent infection.

During an interview on 12/28/2023 at 1:32p.m. with Infection Preventionist Nurse (IPN) 1. IPN 1 stated 1oxygen tubing should be changed every seven days. IPN 1 stated If the oxygen tubing is not changed it can put Resident 66 at risk for infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 555306 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555306 B. Wing 01/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kei-Ai South Bay Healthcare Center 15115 S Vermont Ave Gardena, CA 90247

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of the facility's policy and procedure titled, Infection Prevention and Control Program, dated 6/2021, the P&P indicated, An infection prevention and control program (IPCP) is established and Level of Harm - Minimal harm or maintained to provide a safe, sanitary and comfortable environment and to help prevent the development potential for actual harm and transmission of communicable diseases and infections .Policies and procedures reflect the current infection prevention and control standards of practice .Updating or supplementing polices and procedures as Residents Affected - Few needed . Assessment of staff compliance with existing policies and regulations.

During a review of facility's policy and procedure titled, Respiratory Therapy-Prevention of Infection, dated 11/2023, the P&P indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .Change the oxygen cannula and tubing every seven days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 555306