Infinity Care Of East Los Angeles

F-F609 Residents Affected - Few Based on interview and record review, the facility failed to investigate an allegation of verbal abuse (a range of words of behaviors used to manipulate, intimidate and maintain power and control over someone) for two (2) of 24 sampled residents (Residents 28 & 77) as indicated in the facility's abuse policy when Resident 77 used inappropriate verbal language with Resident 28.

This failure had the potential to result in failing to protect Resident 28 and other residents from abuse.

Findings:

1. During a review of Resident 28's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with diagnoses of bilateral (both) primary osteoarthritis (degenerative joint disease in which the tissues in the joint break down over time) of the knee and hemiplegia (one sided muscle paralysis or weakness) following cerebral infarction (damage to tissues in

the brain due to a loss of oxygen to the area) affecting the right dominant side.

During a review of Resident 28's History and Physical Examination (H&P), dated 4/1/2023, the H&P indicated the resident has the capacity to understand and make decisions.

During a review of Resident 28's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 3/4/2024, the MDS indicated the resident had intact cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 28 was dependent ( helper dopes all of the effort) for bed-to-chair transfers and needed substantial/maximal assistance (helper does more than half the effort) with dressing (how a resident puts on, fastens, and takes off all items of clothing). Resident 28 needed supervision or touching assistance (helper provides verbal cues/or touching/steadying and/or contact guard assistance as resident completes activity) with personal hygiene & needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating.

2. During a review of Resident 77's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] with diagnoses of atherosclerotic heart disease (involves plaque buildup in artery walls) and cerebral infarction.

During a review of Resident 77's H&P, dated 4/25/2024, the H&P indicated the resident has the capacity to understand and make decisions.

During a review of Resident 77's, dated 4/12/2024, the MDS indicated the resident had intact cognitive skills for daily decision making. Resident 77 was dependent with transfers (how resident moves to and from bed, chair, wheelchair, standing position), lower body dressing and personal hygiene, and needed setup or clean-up assistance (helper set up or cleans up; resident completes activity) with eating.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 056063 Department of Health & Human Services Printed: 09/23/2025 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 056063 B. Wing 06/07/2024

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

Infinity Care of East Los Angeles 101 S Fickett Street Los Angeles, CA 90033

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 0610 During a review of Resident 77's Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and Level of Harm - Minimal harm or responsibilities) Note dated 5/6/2024, the IDT Meeting Note indicated that when Certified Nursing Assistant 2 potential for actual harm (CNA 2) was assisting Resident 28 to the shower, Resident 77 yelled at Resident 28 and used socially inappropriate verbal language towards her. Residents Affected - Few

During a concurrent interview and record review on 6/6/2024 at 3:49 PM with Social Services Director (SSD), Resident 77's IDT Meeting Note, dated 5/6/2024, was reviewed. Resident 77's IDT Meeting Note addressed

an incident that occurred when Resident 77 yelled at Resident 28 using socially inappropriate verbal language. SSD stated that the language Resident 77 used toward Resident 28 was considered verbal abuse.

During an interview on 6/6/2024 at 4:00 PM with Resident 28, Resident 28 stated that on the morning of 5/8/24 Resident 77 used socially inappropriate verbal language towards her as CNA 2 was helping her to the shower. Resident 28 stated that the next day, she spoke with SSD and MDS Nurse (MDSN) about the incident and told them that no one is allowed to or has the right to speak to her like that and that. Resident 28 further stated that Resident 77 using inappropriate language towards her made her feel very angry.

During an interview on 6/7/2024 at 2:40 PM with SSD, SSD stated that verbal abuse is when someone says something to someone that is offensive and unacceptable. SSD stated that what Resident 77 said to Resident 28 offended her and was unacceptable. SSD also stated that the Administrator (ADM) is the facility's abuse coordinator and that there was no documentation of the allegation being investigated.

During an interview on 6/7/2024 at 3:18 PM with CNA 3, CNA 3 stated, Verbal abuse is when bad words are used, yelling, saying something degrading or negative. CNA3 also stated the incident that happened between Resident 77 using inappropriate language toward Resident 28 was considered verbal abuse.

During an interview on 6/7/2024 at 3:26 PM with the Director of Nursing (DON), the DON stated that verbal abuse is when a person directly screams at another person by swearing and using foul language. The DON also stated that if a resident was offended by this type of behavior, then it was not acceptable and should be considered an allegation of abuse. The DON further stated that if an allegation of abuse was not investigated, it could psychologically (affects the mind or relates to the emotional state of a person) harm the resident, could be detrimental (formal way of saying harmful) to the resident's mental health and the incident could possibly happen again.

During a review of the facility's Policy and Procedure (P&P) titled, Identifying Types of Abuse, revised March 2024, the P&P indicated, Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability and Examples of mental and verbal abuse include, but are not limited to:

a. Harassing a resident;

b. Mocking, insulting, ridiculing;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 056063 Department of Health & Human Services Printed: 09/23/2025 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 056063 B. Wing 06/07/2024

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

Infinity Care of East Los Angeles 101 S Fickett Street Los Angeles, CA 90033

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 0610 c. Yelling or hovering over a resident, with the intent to intimidate.

Level of Harm - Minimal harm or During a review of the facility's P&P titled, Abuse Investigation and Reporting, revised March 2024, the P&P potential for actual harm indicated:

Residents Affected - Few All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source (abuse) shall be thoroughly investigated by facility management.

If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 056063

F-F610

Based on interview and record review, the facility failed to report an allegation of verbal abuse (a range of words of behaviors used to manipulate, intimidate and maintain power and control over someone) within two hours for two (2) of 24 sampled residents (Residents 28 and 77) to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement, in accordance with the facility's abuse policy.

This deficient practice has the potential to result in unreported abuse in the facility and failure to protect Resident 28 and other residents from abuse.

Findings:

1. During a review of Resident 28's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with diagnoses of bilateral (both) primary osteoarthritis (degenerative joint disease in which the tissues in the joint break down over time) of the knee and hemiplegia (one sided muscle paralysis or weakness) following cerebral infarction (damage to tissues in

the brain due to a loss of oxygen to the area) affecting the right dominant side.

During a review of Resident 28's History and Physical Examination (H&P), dated 4/1/2023, the H&P indicated the resident has the capacity to understand and make decisions.

During a review of Resident 28's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 3/4/2024, the MDS indicated the resident had intact cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 28 was dependent ( helper dopes all of the effort) for bed-to-chair transfers and needed substantial/maximal assistance (helper does more than half the effort) with dressing (how a resident puts on, fastens, and takes off all items of clothing). Resident 28 needed supervision or touching assistance (helper provides verbal cues/or touching/steadying and/or contact guard assistance as resident completes activity) with personal hygiene & needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 7 056063 Department of Health & Human Services Printed: 09/23/2025 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 056063 B. Wing 06/07/2024

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

Infinity Care of East Los Angeles 101 S Fickett Street Los Angeles, CA 90033

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 0609 2. During a review of Resident 77's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] with diagnoses of atherosclerotic heart disease (involves plaque Level of Harm - Minimal harm or buildup in artery walls) and cerebral infarction. potential for actual harm

During a review of Resident 77's H&P, dated 4/25/2024, the H&P indicated the resident has the capacity to Residents Affected - Few understand and make decisions.

During a review of Resident 77's, dated 4/12/2024, the MDS indicated the resident had intact cognitive skills for daily decision making. Resident 77 was dependent with transfers (how resident moves to and from bed, chair, wheelchair, standing position), lower body dressing and personal hygiene, and needed setup or clean-up assistance (helper set up or cleans up; resident completes activity) with eating.

During a review of Resident 77's Interdisciplinary Team (IDT; team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Note dated 5/6/2024, the IDT Meeting Note indicated that when Certified Nursing Assistant 2 (CNA 2) was assisting Resident 28 to the shower, Resident 77 yelled at Resident 28 and used socially inappropriate verbal language towards her.

During a concurrent interview and record review on 6/6/2024 at 3:49 PM with Social Services Director (SSD), Resident 77's IDT Meeting Note, dated 5/6/2024, was reviewed. Resident 77's IDT Meeting Note addressed

an incident that occurred when Resident 77 yelled at Resident 28 using socially inappropriate verbal language. SSD stated that the language Resident 77 used toward Resident 28 was considered verbal abuse.

During an interview on 6/6/2024 at 4:00 PM with Resident 28, Resident 28 stated that on the morning of 5/8/24 Resident 77 used socially inappropriate verbal language towards her as CNA 2 was helping her to the shower. Resident 28 stated that the next day, she spoke with SSD and MDS Nurse (MDSN) about the incident and told them that no one is allowed to or has the right to speak to her like that and that. Resident 28 further stated that Resident 77 using inappropriate language towards her made her feel very angry.

During an interview on 6/7/2024 at 2:40 PM with SSD, SSD stated that verbal abuse is when someone says something to someone that is offensive and unacceptable and stated that what Resident 77 said to Resident 28 offended her and was unacceptable. SSD stated that the timeline for reporting is within two hours and that CNA 2 should have reported the incident to the supervisor and charge nurse since she was the one who witnessed the incident. SSD further stated that it was important that allegations of abuse be reported to SA so it will not happen again for the safety and wellbeing of the residents and staff involved.

During an interview on 6/7/2024 at 3:18 PM with CNA 3, CNA 3 stated, Verbal abuse is when bad words are used, yelling, saying something degrading or negative. CNA3 also stated the incident that happened between Resident 77 using inappropriate language toward Resident 28 was considered verbal abuse. CNA 3 also stated that the incident should have been reported within two hours to CDPH, the ombudsman, and the police.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 056063 Department of Health & Human Services Printed: 09/23/2025 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 056063 B. Wing 06/07/2024

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

Infinity Care of East Los Angeles 101 S Fickett Street Los Angeles, CA 90033

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 0609 During an interview on 6/7/2024 at 3:26 PM with the Director of Nursing (DON), the DON stated that verbal abuse is when a person directly screams at another person by swearing and using foul language. The DON Level of Harm - Minimal harm or also stated that if a resident was offended by this type of behavior, then it was not acceptable and should be potential for actual harm considered an allegation of abuse. The DON stated the allegation of abuse should have been reported by CNA 2 within two hours or earlier to the authorities and the facility's abuse coordinator. The DON further Residents Affected - Few stated that if an allegation of abuse was not investigated, it could psychologically (affects the mind or relates to the emotional state of a person) harm the resident, could be detrimental (formal way of saying harmful) to

the resident's mental health and the incident could possibly happen again.

During a review of the facility's Policy and Procedure (P&P) titled, Identifying Types of Abuse, revised March 2024, the P&P indicated, Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability and Examples of mental and verbal abuse include, but are not limited to:

a. Harassing a resident;

b. Mocking, insulting, ridiculing;

c. Yelling or hovering over a resident, with the intent to intimidate.

During a review of the facility's P&P titled, Abuse Investigation and Reporting, revised March 2024, the P&P indicated:

1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:

a. The State licensing/certification agency responsible for surveying/licensing the facility;

b. The local/State Ombudsman;

c. The Resident's Representative (Sponsor) of Record;

d. Adult Protective Services (where state law provides jurisdiction in long-term care);

e. Law enforcement officials;

f. The resident's Attending Physician; and

2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:

- Two (2) hours if the alleged violation involves abuse of any kind.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 056063 Department of Health & Human Services Printed: 09/23/2025 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 056063 B. Wing 06/07/2024

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

Infinity Care of East Los Angeles 101 S Fickett Street Los Angeles, CA 90033

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 0609 During a review of the facility's policy and procedure (P&P) titled Abuse Reporting revised 4/2023, the P&P indicated that, If you suspect an incident of abuse has occurred, you must report the event to the first three Level of Harm - Minimal harm or agencies listed below via telephone within two (2) hours of the suspected abuse incident. Follow the steps potential for actual harm below to report:

Residents Affected - Few Step 1 - Call California Department of Public Health (CDPH), Long term Care (LTC) Ombudsman, and Police Department (PD) within two hours of the alleged event.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 056063 Department of Health & Human Services Printed: 09/23/2025 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 056063 B. Wing 06/07/2024

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

Infinity Care of East Los Angeles 101 S Fickett Street Los Angeles, CA 90033

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48395 potential for actual harm Cross reference: