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 9 of 39 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 10 of 39 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 11 of 39 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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46919

Residents Affected - Few Based on observation, interview, and record review, the facility failed to revise and update the care plan as indicated on the facility policy and procedure to address Resident 2's preference for activities of daily living (ADL) while in the shower.

This deficient practice placed Resident 2 at risk of not having appropriate care and interventions during showering and potential to violate resident's rights to choose preferred care.

Findings:

A review of Resident 2's Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] with diagnoses of paroxysmal (an attack or sudden increase or recurrence of symptoms) atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time), and cerebral infarction (damage to the tissues in the brain due to a loss of oxygen in the area).

A review of Resident 2's History and Physical Examination (H&P), dated 9/16/2024, indicated the resident had the capacity to understand and make decisions.

A review of Resident 2's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 3/22/2024, indicated Resident 2 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 2 required supervision or touching assistance with shower/bathe self, tub/shower transfer, lower body dressing, putting on/taking off footwear, walking 10 feet, and walking 50 feet with two turns.

During an interview, on 6/4/2024, at 1:09 PM, Resident 2 stated she showers by herself without the assistance or supervision from the facility staff.

During a concurrent interview and observation of Resident 6 on 6/6/2024, at 8:11 AM, Resident 2 was observed sitting on a chair in the hallway with a basin on her lap that contained several washcloths. Resident 2 stated she was going to take a shower.

During an interview with Certified Nursing Assistant 4 (CNA 4) on 6/6/2024, at 8:25 AM, CNA 4 stated Resident 2 was inside the shower room. CNA 4 stated CNA 3 was assigned to Resident 2 but was not inside

the shower to supervise and assist Resident 2.

During a concurrent observation of Shower 1 and interview with CNA 3 on 6/6/2024, at 8:26 AM, CNA 3 was observed standing next to the Shower 1. CNA 3 stated Resident 2 likes to shower by herself. CNA 3 stated

she waits outside to make sure Resident 2 was alright.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 39 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 0657 During a follow up interview with CNA 3 on 6/6/2024, at 9:06 AM, CNA 3 stated she sets up the shower for Resident 2 on her shower days. CNA 3 stated Resident 3 refuses to have facility staff in the shower with her. Level of Harm - Minimal harm or CNA 3 stated she monitors Resident 2's needs by standing outside the door. CNA 3 stated she can hear potential for actual harm Resident 2 call out her needs through the door. CNA 3 stated Resident 2 informs her when she is done in the shower and CNA 3 helps dry up Resident 2. Residents Affected - Few

During a concurrent record review of Resident 2's MDS, dated [DATE REDACTED], and interview MDS Nurse (MDSN) on 6/6/2024, at 9:51 AM, MDSN stated Resident 2 was assessed to require supervision/touching assistance in

the shower/bathe and with tub/shower transfer. MDSN stated supervision means the CNA will be in the shower with Resident 2 to supervise and assist Resident 2 with her needs. MDSN stated facility staff should inform the charge nurse, document, and inform the physician if Resident 2 refused to be supervised in the bathroom. MDSN stated Resident 2's care plan should also be updated to inform facility staff of Resident 2's preference regarding her activities of daily living. MDSN stated licensed nurses and MDSN are responsible for updating and revising the resident's care plan. MDSN stated Resident 2's care plan did not indicate Resident 2's refusal to be supervised in the shower.

During an interview with the Director of Nursing (DON), on 6/7/2024, at 6:03 PM, the DON stated Resident 2's care plan for showering should have been revised to reflect Resident 2's refusal to be supervised in the shower. The DON stated it was important for Resident 2's care plan to be up to date for facility staff to know how to properly implement interventions regarding Resident's 2 refusal to be supervised in the shower.

A review of the facility's policy and procedure (P&P), titled, Care Plans-Revising, revised on 6/7/2024, indicated the following:

Person Centered Care Plans are revised based on clinical or behavioral changes observed by the facility staff.

Any member of staff is capable of reporting noticeable changes in a resident' behavior and is therefore able to document those findings and report these changes to the licensed nurse.

Not all the items listed in a resident's individualized plan of care need to be clinical in nature to be included into the individualized plan of care; resident preferences can be added to plan of care.

Individualized Plans of Care should be updated within 48 hours, or as needed, by the licensed nursing staff OR relevant member of the interdisciplinary team (IDT- a coordinated group of experts from different departments)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 39 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45523 potential for actual harm Based on interview and record review, the facility failed to provide care services to prevent worsening and Residents Affected - Few promote healing of pressure ulcer/injury (damaged skin caused by staying in one position for too long) for one of three sample residents (Resident 26) who was admitted in the facility with a UTD (unable to determine or unstageable pressure ulcer). The facility did not accurately monitor and set the correct settings of the low air loss mattress (LALM, is designed to prevent and to treat pressure sores, or pressure ulcers) according to Resident 26's weight.

These deficient practices placed Resident 26 at risk of poor wound healing and deterioration of current pressure ulcers.

Findings:

A review of the admission record indicated Resident 26 was admitted to the facility on [DATE REDACTED], with diagnoses that included but not limited to encounter for palliative care (specialized medical care for people living with a serious illness), retention of urine (the inability to empty the urine from your bladder), and pressure ulcer of sacral region (an area of the skin that has been damaged as a result of constant pressure).

During record review of Resident 26's Physicians Telephone Orders dated 4/3/24 at 5:39 PM, indicated, LALM skin maintenance.

A review of the Physician History and Physical dated 4/5/2024 indicated Resident 26 does not have the capacity to understand and make decisions.

A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 4/10/2024, indicated Resident 26 was severely impaired in cognitive skills for daily decision making, and needed total assistance from the staff for the activities of daily living such as eating, oral and toilet hygiene, shower, and dressing.

During record review of Resident 26's Integumentary/Skin assessment dated [DATE REDACTED], indicated, altered skin integrity related to disease progression, Stage IV pressure ulcer (full thickness skin loss with extensive destruction. Damage to muscle, bone or supporting structures such as tendons) to sacral (at the bottom of

the spine and tail bone) area, multiple unstageable (UTD) sites to left 5th metatarsal (five long bones found

in each foot), left lateral malleolus (bony part on the side of the ankle), right heel, left lateral mid foot. Multiple Deep Tissue Pressure Injury (DTPI, a serious form pf pressure injuries/ ulcer. Purple or maroon discoloration under the skin but with underlying soft tissue damage and can progress rapidly to extensive tissue damage) to 1st metatarsal (toe), right medial malleolus.

During an observation on 6/4/2024 at 8:26 AM, Resident 26 was resting on LALM set to maximum of 400 pounds (lbs., unit of measurement for weight).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 39 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 0686 During a concurrent observation in Resident 26' room and interview with Certified Nurse Assistant 2 (CNA2)

on 6/5/2024 at 8:43 AM, CNA2 stated Resident 26's LALM was set to 400 lbs. the maximum in the settings. Level of Harm - Minimal harm or CNA2 stated, the company that brings the bed is the one that programs the settings, we only report if the potential for actual harm mattress deflates then we call the charge nurse.

Residents Affected - Few During an interview and record review with LVN2 on 6/5/2024 at 9:38 AM, LVN2 stated I was not here when

they brought the mattress, she (Resident 26) came in with a wound. There is an order for a LALM, but the settings would not be on the order.

During a concurrent interview and record review of Resident 26 admission orders with Licensed Vocational Nurse (LVN2) on 6/5/2024 at 9:41 AM, LVN2 stated, the order for LALM should be upon admission. She is a wound patient so she should have an order for the LALM. LVN2 stated the LALM is important for Resident 26's for prevention of further ulcers and because Resident 26 is bedbound and requires full assistance. LVN2 stated, we do not touch the settings on the bed at all, we just make sure it's turned on to the green light and inflated.

During an interview with Medical Director on 6/7/2024 at 12:30 PM, Medical Director stated, there was an order for Resident 26's LALM but it did not include the indication and it was needed either for weight or comfort. Medical Director stated, I just give the order, but the wound care nurse is the one that follows with

the settings (LALM settings).

During an interview with the Director of Nursing (DON) on 6/7/2024, the DON stated, the setting for a low air loss mattress should be according to the resident's weight.

During an interview and record review with Treatment Nurse on 6/7/2024 Treatment Nurse stated, I do not check the settings for the LALM, during the initial assessment if there is an order for settings then it will be in

the treatment book. Treatment Nurse could not find an order for LALM settings in the treatment book.

During an interview with the DME Vendor Trainer Tech on 6/7/2024 at 1:33 PM, Trainer Tech stated, when

the bed gets delivered, we test it out before setting it up as firm as possible to make sure there are no holes

on the mattress. We set it as firm as possible which is 400 lbs. making it very firm, but the bed is supposed to be set determined to patient's (resident's) weight. Technically it is the patient's weight. The tech checks the form for the patient's weight or grabs the nurse and asks them for the resident's weight that way he can set it accordingly.

During record review of Resident 26's weight chart on 6/7/2024 at 1:40 PM, it indicated, as of 6/6/2024 Resident 26' weight was 121 lbs.

During a concurrent observation of Resident 26' LALM setting and interview with the DON on 6/7/2024 at 1:42 PM, the DON confirmed the settings for the LALM were set at 400 lbs. The DON also stated it was set to alternating and normal pressure, but the settings should be according to Resident 26's weight which is 121 lbs.

A review of the Brand 1 Alternating Pressure Low Air Loss Mattress Replacement System Operators Manual revised 3/22/2021 indicated, Determine the patient's weight and set the control knob to that weight setting on

the control unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 39 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 0686 A review of the facility's Policy titled Prevention of Pressure Injuries, revised 3/2024 indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and Level of Harm - Minimal harm or interventions for specific risk factors. The policy also indicated to select appropriate support surfaces based potential for actual harm the resident's risk factors, in accordance with current clinical practice.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 39 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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48395

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide appropriate services to prevent complications for one of three sampled residents (Resident 46) who has G-tube (GT, is a tube inserted through the belly that brings nutrition directly to the stomach).observe infection control measures for Resident 46:

1. Failed to ensure Resident 46's [NAME] valve (a device allowing movement in one direction only to use for

the administration of medication without having to disconnect a suction or feeding line and reduces exposure to potentially infectious bodily fluids or gastric secretions) was covered at GT site.

2. Failed to ensure Resident 46's enteral tube feeding (delivery of liquid nutrients through a tube directly into

the gastrointestinal tract) equipment were cleaned and did not have an accumulation of dried brown stains.

3. Ensure Resident 46's enteral tube feeding was labeled, with date and time formula was prepared as per Facility's Policies and Procedures (P&Ps).

These deficient practices had the potential to transmit infectious microorganisms (bacteria, viruses, parasites, or fungi) and increase the risk of infection and contamination of the resident's care equipment and placed Resident 46 at risk for infection.

Findings:

A review of Resident 46's Face Sheet indicated Resident 46 was originally admitted on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses that included but not limited to unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), encounter for attention to gastrostomy (artificial opening to stomach), contracture, left hand (one or more fingers to bend toward the palm of the hand. The affected fingers can't straighten completely), and primary generalized osteoarthritis (a degenerative joint disease- causing pain, stiffness, swelling, and decreased mobility).

A review of Resident 46's Care Plan dated 5/5/2024 indicated Resident 46 needs GT feeding due to impaired swallowing. Resident 46's goals were Resident 46 will have no infection at GT site daily for 3 months.

A review of the Physician History and Physical dated 5/7/2024 indicated Resident 46 does not have the capacity to understand and make decisions.

A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 5/29/2024, indicated Resident 46 was severely impaired in cognitive skills for daily decision making, and needed total assistance from the staff for the activities of daily living such as eating, oral and toilet hygiene, shower, and dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 39 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 0693 During an observation on 6/4/2024 at 9:16 AM, Resident 46 was resting in bed with GT feed running. There was no name, date, or time labeled on the GT feeding bag of when the formula was prepared or hung. Level of Harm - Minimal harm or potential for actual harm During an observation and interview with Licensed Vocational Nurse (LVN) 3 on 6/6/2024 at 7:57 AM, LVN3 confirmed Resident 46's [NAME] valve was not capped, was not clean and had accumulation of dried brown Residents Affected - Few stains. LVN3 stated, the [NAME] valve should be covered, and it should not be dirty. If it is not covered and it is dirty, it has the potential to cause the resident infection and bacteria can go in there causing the resident harm.

During an observation and interview with the Director of Nursing (DON) on 06/07/2024 at 9:00 AM, the DON confirmed the [NAME] valve was not covered and was dirty. The DON stated, the [NAME] Valve for the GT feed should have a cap for infection control, it is important to have a cap to prevent any type of possible infection to the resident and it should also be clean. The DON also stated, for the [NAME] valve, the nurse should either use a cap or change the whole part. The nurses know they can go to the supply room and grab

a new one.

A review of the Facility's P&Ps titled Enteral Tube Feeding via continuous Pump revised 3/2024 indicated,

The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings. The P&P also indicated, on the formula label document initials, date, and time the formula was hung/administered and initial that the label was checked against the order.

A review of the Facility's P&Ps titled Infection Prevention and Control Program revised 3/2024 indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P also indicated:

a. Important facets of infection prevention include:

(1) Identifying possible infections or potential complication of existing infections

(2) Instituting measures to avoid complications or dissemination

(3) educating staff and ensuring that they adhere to proper techniques and procedures

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 39 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45456 potential for actual harm Based on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment Residents Affected - Some that provides supplemental, or extra oxygen) and necessary respiratory care services for two (2) of three (3) sampled residents (Resident 92 and 22) in accordance with the facility's policy and care plan by failing to:

1. Administer oxygen at 2 liters per minute (lpm, unit of measurement) via nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) to Resident 92 as indicated on the physician's order. This deficient practice had the potential to result in respiratory distress and/or other complications to Resident 92.

2. Keep Residents 22's oxygen nasal cannula (NC, a device that delivers extra oxygen through a tube into your nose) tubing sprawled out on and touching the floor. This deficient practice had the potential to result in infection to Resident 22.

Findings:

1. A review of Resident 92 's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses which included pulmonary hypertension (a serious condition where there is abnormally high pressure in the blood vessels between the lungs and the heart), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with hypoxia (lack of oxygen in the body tissues)

A review of Resident 92's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/20/23, indicated Resident 92 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 92 needed supervision or touching assistance (helper provides verbal cues/touching/steady/contact guard assistance as resident completes activity) with eating, oral hygiene, lower and upper body dressing. Resident 92 needed partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides [NAME] than half the effort) toileting hygiene, sit to lying, and putting on/taking off footwear.

A review of Resident 92's Care Plan (CP) for Ineffective airway clearance, dated 5/18/2024, indicated Resident 92 has a potential for shortness of breath associated with COPD exacerbation. The staff intervention included was to administer oxygen as needed.

A review of Resident 92's Physician's Order, dated 5/10/2024, indicated oxygen at 2 lpm per nasal cannula continuously for shortness of breath.

During a concurrent observation in Resident 92's room on 6/4/2024 at 9:18 AM, Resident 92 was observed

on oxygen at 2.5 lpm via nasal cannula.

During an observation in Resident 92's room on 6/5/2024 at 7:04 AM, Resident 92 was sleeping and observed with oxygen at 2.5 lpm via nasal cannula.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 39 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 0695 During a concurrent record review of Resident 92's physician's order and interview with the Licensed Vocational Nurse 1 (LVN 1) on 6/5/2024 at 2:54 PM, LVN 1 stated Resident 92's Physician's order indicated Level of Harm - Minimal harm or oxygen at 2 lpm via nasal cannula continuously for shortness of breath. potential for actual harm

During a concurrent observation in Resident 92's room and interview with the LVN 1 on 6/5/2024 at 2:56 PM, Residents Affected - Some Resident 92 was laying on his bed with his oxygen between 2.5-3 lpm via NC. LVN 1 verified Resident 92's oxygen machine was set between 2.5-3 lpm. LVN 1 stated The oxygen level was set incorrectly. The licensed staff should always check the oxygen every time we come inside the resident's room. If the oxygen setting is lower than the physician's order, the resident will not get enough oxygen. if the oxygen setting is higher, the resident will retain carbon dioxide and will not get enough oxygen in his body.

During a concurrent record review of CP for Ineffective airway clearance, dated 5/18/2024, and interview with

the Director of Nursing (DON) on 6/7/2024 at 4:34 PM, the DON stated, The care plan indicated oxygen as needed, it should have been added continuously. We have to revise the care plan, or we are not able to implement the correct intervention that we have to give to the Resident.

During a concurrent observation and interview with the DON on 6/7/2024 at 5:59 PM, the DON stated, Oxygen was set incorrectly. The DON stated Resident 92 has COPD and if the oxygen setting was wrong,

the resident might be receiving lesser or more oxygen that was ordered. The DON stated, It could have a negative effect on the Resident.

A review of facility's policy and procedure (P&P) titled, Oxygen Administration, dated 3/2024, indicated the purpose of the procedure was to provide guidelines for safe oxygen administration. P&P indicated To verify that there is a physician's order for this procedure, adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

48395

2. A review of Resident 22's Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness and difficulty with balance and coordination) and epilepsy (a disorder of the brain characterized by repeated seizures [a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain]).

A review of Resident 22's History and Physical Examination (H&P), dated 8/10/2023, indicated the resident does not have the capacity to understand and make decisions.

A review of Resident 22's MDS, dated [DATE REDACTED], MDS indicated the resident was severely impaired (never/rarely made decision) with cognitive skills for daily decision making. Resident 22 had minimal difficulty (difficulty in some environments [for example when person speaks softly or setting is noisy]) with hearing and had no speech (absence of spoken words). Resident 22 was also dependent (helper does all the effort) with tub/shower transfers, bed-to-chair transfers, rolling left and right (ability to roll from lying on back to the left and right side and return to lying on back on the bed), dressing (how resident puts on, fastens and takes off all items of clothing), personal hygiene and eating.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 39 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 0695 During a review of Resident 22's Physician's Order, dated 8/9/2023, the Physician's Order indicated oxygen at 2 lpm via (by) nasal cannula as needed (PRN) for shortness of breath (SOB). Level of Harm - Minimal harm or potential for actual harm During an observation on 6/4/2024 at 8:57 AM in Resident 22's room, Resident 22's oxygen tubing was observed on the floor. Residents Affected - Some

During a concurrent observation and interview on 6/4/2024 at 9:01 AM with Certified Nursing Assistant 3 (CNA 3) in Resident 22's room, Resident 22's oxygen NC tubing was observed on the floor. CNA 3 stated that the resident's oxygen NC tubing should not be on the floor.

During an interview on 6/6/2024 at 2:57 PM with Infection Preventionist (IP), IP stated the residents' oxygen tubing is changed weekly by central supply and that the NC tubing should not be touching the floor because residents could get an infection and could potentially get something from the floor onto the tubing and into their nose which could result in a respiratory infection.

A review of the facility's P&P titled, Oxygen Administration, revised June 2024, indicated, If tubing is visibly soiled or touching the floor or any other potentially unclean surface, tubing shall be changed by a licensed nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 39 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45456 potential for actual harm Based on observation, interview and record review, the facility failed to ensure a one (1) of 1 sampled Residents Affected - Few resident (Resident 33) who was receiving dialysis (process of removing waste products and excess fluid from

the body) received care and treatment in accordance with the resident's care plan by failing to ensure a dialysis emergency kit was placed at bedside.

This deficient practice had the potential for Residents 33 to be at risk for complications such as bleeding and potential for delay in provision of dialysis care and treatment in case of emergencies.

Findings:

A review of Resident 33's Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis that included end stage renal disease (ESRD, stage when

the kidneys can no longer support the body's needs of removing waste and excess water from the body), dependence on renal dialysis, and hypertension (high blood pressure).

A review of Resident 33's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 5/17/2024, indicated Resident 33 has intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 33 needed supervision or touching assistance (helper provides verbal cues/touching/steady/contact guard assistance as resident completes activity) with toileting hygiene, shower/bathe self, lower and upper body dressing and putting on/taking off footwear and personal hygiene.

A review of Resident 33's care plan for hemodialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately), revised on 4/25/2024, indicated staff interventions included to have a dialysis kit readily available at bedside when unusual bleeding occurs at access site.

During an observation inside Resident 33's room on 6/4/2024 at 8:28 AM, there was no emergency dialysis kit on Resident 33's bedside.

During a concurrent observation in Resident 33's room and interview with Licensed Vocational Nurse 1 (LVN 1) on 6/4/2024 at 12:55 PM, LVN 1 stated Resident 33 did not have an emergency dialysis kit at bedside earlier.

During a concurrent review of the Dialysis Care Policy and interview with the Director of Nursing (DON) on 6/6/2024 at 2:35 PM, the DON stated, Emergency dialysis kit should be on Resident 33's bedside so we can use it in case of emergency to stop the bleeding on the dialysis access. The emergency dialysis kit should always be on the Resident's bedside, and it should be included in the dialysis policy because it is part of the nursing measures just in case the resident had an emergency incident like bleeding on the dialysis site.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 39 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 0698 A review of the facility's Policy and Procedure titled, Dialysis Care, dated 8/4/2007, indicated facility shall ensure provision of standards if care for residents on Renal Dialysis, including but not limited to monitoring Level of Harm - Minimal harm or and assessment of resident every shift for the following potential for bleeding, infection, edema and/or potential for actual harm dehydration.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 39 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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48143

Residents Affected - Few Based on interview and record review, the facility failed to follow its policy on Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with

the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for two of five sampled residents (Residents 15 and 40) by failing to:

1. Conduct an MRR for Resident 15 for May 2024

2. Act upon the pharmacy recommendations for Resident 40's MRR for May 2024

This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to Residents 15 and 40.

Findings:

1. A review of Resident 15's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and pleural effusion (abnormal fluid accumulation within the thin cavity between the pleural layers surrounding the lungs).

A review of the Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 5/24/2024, indicated Resident 15 had moderately impaired cognitive (the process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. Resident 15 required extensive assistance with two or more persons physical assist for toilet use and personal hygiene. The MDS also indicated Resident 15 was receiving antipsychotic medications.

During a concurrent interview and record review on 6/7/24 at 9:21 A.M., with Director of Nursing (DON), the DON confirmed there was no Medication Regiment Review (MRR) for the month of May 2024 for Resident 15. The DON stated this was important to prevent the use of unnecessary medications.

2. A review of Resident 40's Admission Record indicated the resident was admitted to the facility 4/11/2018 and readmitted on [DATE REDACTED] with diagnosis that included cardiomegaly (various conditions leading to enlargement of the heart).

A review of Resident 40's MDS, dated [DATE REDACTED], indicated the resident was moderately impaired with cognitive skills for daily decision making. The MDS indicated Resident 40 was independent with walking, eating, and oral hygiene.

During an interview on 6/7/24 at 9:21 AM. with the DON, the DON stated she had just printed out the May 2024 MRR and will work on the MRR for Resident 40. The DON stated each resident in the facility should have their medications reviewed monthly by the consultant pharmacist to prevent the use of unnecessary medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 39 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 0756 A review of the facility's Policy and Procedure titled, Medication Regimen Reviews, updated in October 2015, indicated the consultant pharmacist reviews the medication regimen of each resident at least monthly. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 39 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 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** 45456 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to properly label the medications of one (1) of 24 sampled residents (Resident 19) as indicated on the facility policy.

This deficient practice had the potential for adverse reaction if these improperly labeled medications were administered to Resident 19 in the wrong route.

Findings:

A review of Resident 19's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident 57's diagnoses included diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).

A review of Resident 19's history and physical dated 5/11/2024, indicated Resident 19 has the capacity to understand and make decisions.

A review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/7/2024, indicated Resident 19 has intact cognition (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 19 needs supervision or touching assistance (helper provides verbal cues/touching/steady/contact guard assistance as resident completes activity) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear.

A review of Resident 19's Nurses' Progress notes dated 4/17/2023 at 3:15 PM, Resident 19 was readmitted from the hospital with diagnosis of status post gastrostomy tube (G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach) removal.

During a concurrent interview with Licensed Vocational Nurse 4 (LVN 4) and record review of Resident 19's lisinopril (medication to treat high blood pressure) bubble pack (medication packaging in which each tablet is sealed between a cardboard backing and a clear plastic over) on 6/6/2024, at 9:36 AM, stated, LVN 4 stated,

The label on the bubble pack was wrong. The doctor's order has changed, and we have the round sticker (sig change refer to chart date) for the medication administration. LVN 4 stated, it was wrong because the bubble pack indicated to be given via G- Tube but Resident 19 did not have G- Tube anymore.

During an interview with the Pharmacist (PHR) on 6/6/2024 at 10:40 AM, PHR stated, The label on the bubble pack for lisinopril is via G-tube route and it is not the correct route because the direction has changed and now, the staff in the facility needs to send the new order for this request. But a request did not come with any modification or adjustment. We are not aware of any modification.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 39 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 0761 During a concurrent observation and interview with the Registered Nurse Supervisor 1 (RNS 1) on 6/6/2024 at 10:44 PM, RNS 1 stated, The bubble pack label was incorrect because Resident 19 was receiving oral Level of Harm - Minimal harm or medications. The staff who received the new order from the doctor should have faxed the updated order (to potential for actual harm give oral and not via G- Tube) to the pharmacy.

Residents Affected - Few During a concurrent interview with the Director of Staff Development (DSD) and record review on 6/6/2024 at 2:45 PM, DSD stated, the label on the lisinopril bubble pack was wrong because it did not indicate to give the medication by mouth. The DSD also stated the staff who received the physician's order to give the lisinopril by mouth should have clarified with the doctor or pharmacist and should have faxed the new order to the pharmacy to correct and update Resident 19's order. DSD stated, it is important to send the updated order to

the pharmacy, to clarify the order, and to provide correct label and direction for Resident 19's medication to avoid medication error (any preventable event that may cause or lead to inappropriate medication use and resident harm).

During a concurrent observation and interview with the Director of Nursing (DON) on 6/7/2024 at 4:45 PM,

the DON stated, the medication label for Resident 19's lisinopril in the bubble pack was incorrect. The DON also stated, the pharmacy did not receive the new order and the staff did not communicate to the pharmacy.

The DON also stated, the label on Resident 19's lisinopril bubble pack was wrong because it indicated to give the medication via G-tube, the physician order was by mouth (PO). The DON further stated, if medication has the wrong label, the facility must call pharmacy because they (pharmacy) need to change the label then send the medication with the correct label.

A review of the facility's policy and procedure titled, Storage of Medication, dated 03/2024, indicated drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before being stored.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 39 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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 48143 potential for actual harm Based on observation, interview and record review, the facility failed to ensure one of two outside garbage Residents Affected - Some dumpsters' lids were fully closed per facility policy and procedure (P&P).

This failure had the potential to attract pests and insects to the facility and can place its resident's health at risk for potential infections.

Findings:

During an observation on 6/4/2024 at 2:39 PM in the facility's parking lot, one of the dumpster's lids was wide open and not closed properly.

During an observation on 6/5/2024 at 7:12 AM, in the facility's parking lot, both dumpster's lids was open and not closed properly because of they are overflowing with trash bags.

During an observation on 6/6/2024 at 7:15 AM, in the facility's parking lot, one of the dumpster's lids was wide open and not closed.

During a concurrent observation in the facility's parking lot and interview on 6/6/2024 at 12:05 PM with the Dietary Supervisor (DS), DS stated the dumpsters lids are supposed to be closed. DS stated that it is the infection control issue, flies will be everywhere if the lids of the dumpster were left open, and all the departments will be responsible for the trashes.

During a review of the facility's P&P titled, Waste Disposal revised in March 2024, the policy and procedure indicated:

- All infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner.

- All infectious and regulated waste destined for disposal shall be placed in closable leak-proof containers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 39 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 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** 45456 potential for actual harm Based on observation, interview, and record review, the facility failed to observe infection control measures Residents Affected - Some as indicated on the facility policy when facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease (LD, a serious and often deadly form of lung infection [pneumonia], acquired by breathing in water droplets caused by the bacteria, legionella [the bacteria that causes LD]).

This deficient practice placed the residents in the facility at risk for developing severe respiratory infection (pneumonia).

Findings:

During an interview with the Maintenance Supervisor (MS) on 6/6/2024, at 9:59 AM, MS stated, We do not have a particular treatment for Legionella (a [NAME] of pathogenic gram-negative bacteria that includes the species L. pneumophila, causing legionellosis [all illnesses caused by Legionella] including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) or water pathogens. We do not treat the water coming from outside the facility. We do not have binder for water management treatment.

During an interview with MS on 6/6/2024, at 10:29 AM, MS stated, We have a company doing the treatment for the water management. I have not seen them come in the facility to do the testing or monitoring. Nobody came in yet since 2018.

During an interview with the MS on 6/6/2024, at 11:04 AM, MS stated, We do not have any water treatment

this year (2024). Water management is important to make sure we're protecting the residents' health and prevention of any infection.

During a concurrent interview with the Administrator (ADM) and record review on 6/6/2024, at 12:38 PM, Hot Water Monitoring Log dated May 2024 from the Kitchen and Laundry were reviewed. ADM stated, On 3/12/2019 the facility only had Legionella program review that year and nothing after that year. We only have hot water temperature log from the kitchen and laundry where hot water temperatures were recorded daily.

We do not have any monitoring, testing, or analyzing of water samples done in the facility.

During an interview with the Director of Nursing (DON) on 6/7/2024, at 4:43 PM, the DON stated, Water management is important because they also have bacteria, and it can be delivered to the residents in the facility, and we can all get sick.

A review of the facility's Policy and Procedure titled, Legionella Water Management Program, revised 6/7/2024, indicated the water management program used by the facility is based on the Centers for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) recommendations for developing a Legionella water management program. The water management program included the following elements:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 39 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 0880 5.d. The identification of situations that can lead to Legionella growth such as construction; water main breaks; changes in municipal water quality; the presence of biofilm, scale, or sediment; water temperature Level of Harm - Minimal harm or fluctuations; water pressure changes; water stagnation; and inadequate disinfection. potential for actual harm e. Specific measures used to control the introduction and/or spread of legionella (e.g. temperature, Residents Affected - Some disinfectants);

f. The control limits or parameters that are acceptable and that are monitored;

g. A diagram of where control measures are applied;

h. A system to monitor control limits and the effectiveness of control measures;

i. A plan for when control limits are not met and/or control measures are not effective; and

j. Documentation of the program.

6. The water management program will be reviewed at least once a year, or sooner if the control limits are consistently not met.

A review of the CDC's toolkit titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/24/2021, indicated control measures and limits should be established for each control point. You will need to monitor to ensure your control measures are performing as designed. Control limits, in which a chemical or physical parameter must be maintained, should include a minimum and a maximum value. Examples of chemical and physical control measures and limits to reduce the risk of Legionella growth: Water quality should be measured throughout the system to ensure that changes that may lead to Legionella growth (such as a drop in chlorine levels) are not occurring. Water heaters should be maintained at appropriate temperatures. Decorative fountains should be kept free of debris and visible biofilm. Disinfectant and other chemical levels in cooling towers and hot tubs should be continuously maintained and regularly monitored. Surfaces with any visible biofilm (i.e., slime) should be cleaned.

A review of ASHRAE Addendum to ASHRAE Standard [PHONE NUMBER] (defines types of buildings and devices that need a water management program) titled, Legionellosis: Risk Management for Building Water Systems, dated 6/23/2018, indicated the Program Team shall establish procedures to confirm, both initially and on an ongoing basis, that the Program is being implemented as designed. The resulting process is verification. The Program Team shall establish procedures to confirm, both initially and on an ongoing basis, that the Program, when implemented as designed, controls the hazardous conditions throughout the building water systems. The resulting process is validation. The Program Team shall determine whether testing for Legionella shall be performed and if so, how test results will be used to validate the Program. If the Program Team determines that testing is to be performed, the testing approach, including sampling frequency, number of samples, locations, sampling methods, and test methods, shall be specified and documented. The Program Team shall consider include the following as part of the determination of whether to test for Legionella:

a. Program control limits are not maintained in the building water systems, including in water systems with supplemental disinfection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 39 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45456 potential for actual harm Based on observation, interview and record review, the facility failed to adequately equip and allow resident Residents Affected - Some to call for staff assistance for five (5) of 24 sampled residents (Residents 74, 55, 79, 26 and 46) by:

1., 2, and 3. Failing to ensure the call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach of Residents 74, 26 and 46 as indicated in the facility's policy and procedure.

4. and 5. Failing to ensure the call light was working for Resident 79 and 55.

This deficient practice had the potential not to meet Resident 74, 55, 79, 26 and 46's needs and preference.

Findings:

1. A review of Resident 74's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses which included chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), ataxia (poor muscle control that causes clumsy or awkward movements, having trouble walking or balancing), hypoxia (low levels of oxygen in the body tissues) and history of falling.

A review of Resident 74's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/12/2024, indicated Resident 74 has severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 74 required setup or clean-up assistance (helper sets up or cleans up, Resident completes the activity) in eating, oral hygiene, personal hygiene, upper body dressing and walk 10-50 feet. The MDS also indicated Resident 74 needs supervision or touching assistance (helper provides verbal cues/ touching/ steady/ contact guard assistance as resident completes activity) with toileting hygiene, shower/ bathe self, lower body dressing and putting on/ taking off footwear.

A review of Resident 74's care plan dated on 5/17/2024, indicated Resident 74 potential for self-care deficit and requires assistance in activities of daily living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). The care plan intervention indicated maintain call light within easy reach and frequently used items.

During an observation in Resident 74's room on, 6/4/2024 at 8:30 AM, Resident 74 was sleeping, and the call light was hanging on her overhead lights, and it was not within Resident 74's reach.

During an observation in Resident 74's room on, 6/5/2024 at 7:08 AM, Resident 74 was sleeping, and the call light was hanging on her overhead lights, and it was not within Resident 74's reach.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 39 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 0919 During concurrent observation in Resident 74's room and interview with the Registered Nurse Supervisor 1 (RNS 1) on, 6/5/2024 at 2:58 PM, Resident 74 was sleeping on her bed. RN supervisor observed the Level of Harm - Minimal harm or Resident 74's call light was hanging on the overhead light and not within resident's reach. RNS 1 stated the potential for actual harm call light should be placed next to Resident 74 so that the resident can easily reach or access the call light and use it right away to call for assistance. The DON stated, it is important to have the call light within the Residents Affected - Some residents' reach so the residents can call for help if they need assistance.

During concurrent observation in Resident 74's room and interview with the Director of Nursing (DON) on, 6/5/2024 at 3:06 PM. Resident 74's call light is not within Resident 74's reach. DON stated, The call light should be within Resident 74's reach all the time. It is important to have the call light within the resident's reach because it is their way of communicating their needs with the staff.

A review of facility's policy and procedure (P&P) titled, Answering the Call Light, dated 3/2024, indicated, ensure that call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the door.

45523

2. A review of the admission record indicated Resident 26 was admitted to the facility on [DATE REDACTED], with diagnoses that included but not limited to encounter for palliative care (specialized medical care for people living with a serious illness), retention of urine (the inability to empty the urine from your bladder), pressure ulcer of sacral region (an area of the skin that has been damaged as a result of constant pressure), unstageable and hepatic (a large organ of in the human body that helps with important changes in many of

the substances contained in the blood) fibrosis (excessive connective tissue accumulates in the liver).

A review of the Physician History and Physical dated 4/5/2024 indicated Resident 26 does not have the capacity to understand and make decisions.

A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 4/10/2024, indicated Resident 26 was severely impaired in cognitive skills for daily decision making, and needed total assistance from the staff for the activities of daily living such as eating, oral and toilet hygiene, shower, and dressing.

A record review of Resident 26's Baseline Care plan (undated) indicated Resident 26's Nursing Interventions were to have the call light within reach.

During an observation on 6/4/2024 at 8:26 AM, Resident 26's call light was not within reach and was hanging from the top of the side rail (barrier attached to the side of bed) at the head of the bed.

During an interview with Licensed Vocational Nurse (LVN) 2 on 6/4/2024 at 9:50 AM, LVN2 stated the call light should be nearest where the resident can easily reach it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 39 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 0919 3. A review of the admission record indicated Resident 46 was admitted to the facility on [DATE REDACTED] and re admitted on [DATE REDACTED], with diagnoses that included but not limited to primary generalized osteoarthritis (a Level of Harm - Minimal harm or degenerative joint disease causing pain, stiffness, swelling, and decreased mobility), other unspecified potential for actual harm hypothyroidism (the thyroid is a small, butterfly-shaped gland in the front of your neck, when the thyroid gland doesn't make enough thyroid hormones [help control how cells and organs do their work] to meet the Residents Affected - Some body's needs), contracture of the left hand (one or more fingers to bend toward the palm of the hand. The affected fingers can't straighten completely), and unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities).

A review of the Physician History and Physical dated 5/7/2024 indicated Resident 46 does not have the capacity to understand and make decisions.

A review of the MDS dated [DATE REDACTED], indicated Resident 46 was severely impaired in cognitive skills for daily decision making, and needed total assistance from the staff for the activities of daily living such as eating, oral and toilet hygiene, shower, and dressing.

During an observation on 6/4/2024 at 9:06 AM, Resident 46 was laying in bed, and the resident's call light was on right side of bed wrapped around top part of the side rail and not within the resident's reach.

During a concurrent observation in Resident 46's room and interview with Restorative Nurse Assistant (RNA) 1 on 6/6/2024 at 9:54 AM, RNA1 stated, he (Resident 46) has a touch call light, he (Resident 46) can use it if you put within his reach but right now, I am not sure if he (Resident 46) can reach it I am not sure if he can use it since it was wrapped on the top side of rail. He (Resident 46) would not be able to use if it is on the side rail since he (Resident 46) cannot reach. The call light is important for the residents for any needs, any emergency the call light should be within the resident's reach at all times.

A review of the facility's Policy titled Answering the Call Light Revised 3/2024, indicated, The purpose of this procedure is to ensure timely responses to the residents requests and needs.

48143

4. A review of Resident 79's Admission Record indicated Resident 79 was admitted to the facility on [DATE REDACTED] with diagnoses that included ataxic gait (awkward, uncoordinated walking), thrombocytopenia (a condition that occurs when the platelet count in your blood is too low), and rickettsiosis (a group of diseases caused by closely related bacteria and spread to people through the bite of infected ticks and mites).

A review of Resident 79's History and Physical Examination (H&P), dated 8/24/2023, indicated Resident 79 have the capacity to understand and make decisions.

A review of Resident 79's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/29/2024, indicated Resident 79 was able to understand others and made herself understood. The MDS also indicated, Resident 79 required moderate physical assistance with bed mobility and transfer, and moderate physical assistance with toilet use (helper does less than half the effort) and moderate physical assistance with oral hygiene, toileting hygiene, lower body dressing, and personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 39 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 0919 During a concurrent observation in resident 79's room and interview with Maintenance Supervisor (MS) on 6/6/2024 at 5:26 PM, observed Resident 79 pressed on the call light, and the call light turned on but was Level of Harm - Minimal harm or turned off when the call light button was not pressed. MS stated the call light in Resident 79's room was not potential for actual harm working properly since the call light should have turned on after Resident 79 pressed on the call light one time. Residents Affected - Some

During interview with the DON on 6/7/2024 at 4:37 PM, the DON stated, the residents' call light should be working properly so staff will know when the resident called for help and/ or for assistance.

5. A review of Resident 55's Admission Record indicated Resident 55 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses that included pleural effusion (a condition in which this occurs when fluid builds up in the space between the lung and the chest wall), stroke ( a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off) , and COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).

A review of Resident 55's H&P, dated 4/30/2024, indicated Resident 55 can make needs known but cannot make medical decisions.

A review of Resident 55's MDS, dated [DATE REDACTED], indicated Resident 55 was assessed having moderately impaired cognition for daily decision making and required substantial/maximal assistance with toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, and sit to stand.

During an observation on 6/4/2024 at 09:52 AM in front of Resident 55's room, Certified Nurse Assistant (CNA) 6 pressed on Resident 55's call light to check if it was working, after pressing on the call light, the call light by the Resident 55's door lit up and turned off immediately.

During a concurrent observation at the second- floor nursing station and interview on 6/6/2024 at 3:50 PM with Registered Nurse (RN) 1, observe RN1 called first floor nursing station to check on which room was calling for service on the second floor. RN1 stated the whole call light panel on second floor is not working, it makes beeping noise, but there was only one room that has the light on for the whole call light panel and

they were unable to tell who is the resident that needs help or pressed the call light button.

During an interview with MS on 6/6/2024 at 5:26 PM, MS stated, the wall outlets are old and that could be

the reason why the call light on the second floor in Resident 79 and 55's room were not working properly, and the facility need to fix it.

During a review of the facility's policy and procedure titled, Maintenance Service, revised on March 2024, indicated, functions of maintenance personnel include, but are not limited to maintain the paging system in good working order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 39 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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48143

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure residents were provided a homelike environment for three of 13 sampled residents (Residents 79,76, and 55) for the environment care area by:

1. and 2. Failed to provide Resident's 79 and 76 with a clean and comfortable environment. The resident's room have unfinished patching, water marks and peeling paint on the ceilings and walls.

3. Failed to provide Resident's 55 a clean room by having white towels on the floor.

4. Failed to ensure ceiling in the resident's hallways in the first and second floor did not have water leak marks and brownish discoloration.

These deficient practices had the potential for an unsafe and unclean resident's environment and had the potential to negatively affect the resident's quality of life.

Findings:

1. A review of Resident 79's Admission Record indicated Resident 79 was admitted to the facility on [DATE REDACTED] with diagnoses that included ataxic gait (awkward and/ or uncoordinated walking), thrombocytopenia (a condition that occurs when the platelet count in your blood is too low), and rickettsiosis (a group of diseases caused by closely related bacteria and spread to people through the bite of infected ticks and mites).

A review of Resident 79's History and Physical Examination (H&P), dated 8/24/2023, indicated Resident 79 have the capacity to understand and make decisions.

A review of Resident 79's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/29/2024, indicated Resident 79 was able to understand others and made herself understood. The MDS also indicated, Resident 79 required moderate physical assistance with bed mobility and transfer, and moderate physical assistance with toilet use (helper does less than half the effort) and moderate physical assistance with oral hygiene, toileting hygiene, lower body dressing, and personal hygiene.

During an observation of Resident 79's room, on 6/4/2024, at 10:34 AM, Resident 79's room was observed to have multiple unfinished patching, watermarks, and holes in between the wall and the ceiling. Watermarks are mostly on the left side of the wall to Resident 79's bed.

During an interview on 6/4/2024, at 10:35 AM in Resident 79's room, Resident 79 stated the watermarks from the wall were from the leak from the last rain around March of 2024. Resident 79 stated her room has been like that for a while.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 39 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 0921 2. A review of Resident 76's Admission Record indicated Resident 76 was initially admitted to the facility on [DATE REDACTED] with diagnoses that included ataxic gait, thrombocytopenia, unspecified psychosis (a collection of Level of Harm - Minimal harm or symptoms that affect the mind, where there has been some loss of contact with reality), and other lack of potential for actual harm coordination.

Residents Affected - Some A review of Resident 76's H&P, dated 2/7/2024, indicated Resident 76 have the capacity to understand and make decisions.

A review of Resident 76's MDS, dated [DATE REDACTED], indicated Resident 76 was independent and need very minimum assistance (resident completes the activity by themself with no assistance from a helper) with shower/bathe self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS also indicated Resident 76 required no assistance with toilet transfer, sit to stand, eating, oral hygiene, and toileting hygiene.

During an observation of Resident 76's room, on 6/4/2024, at 10:36 AM, Resident 76's room was observed to have unfinished patching on the ceiling located above the resident's bed.

During an interview with Maintenance Supervisor (MS), on 6/5/2024, at 3:33 PM, MS stated he was the one who supposed to fix Resident 79's room but there was nothing done so far. MS stated he did not know how long it has been like that and what cause it. MS stated the residents like it when everything in their room is fixed and being homelike.

During an interview with the Director of Nursing (DON), on 6/7/2024, at 9:21 AM, the DON stated the resident's rooms should be presentable and personalized to what the resident need and like. The DON stated it is important for the resident feel like they are at home. The DON stated when the residents have a nice room, they feel dignified and respected. The DON stated unfinished patching, peeling paint, and white patches on the walls is not considered a homelike environment. The DON stated the Maintenance Department is responsible for checking which rooms need to be repaired.

3. A review of Resident 55's Admission Record indicated Resident 55 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses that included pleural effusion (a condition in which this occurs when fluid builds up in the space between the lung and the chest wall), stroke ( a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off) , and COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).

A review of Resident 55's H&P, dated 4/30/2024, indicated Resident 55 can make needs known but cannot make medical decisions.

A review of Resident 55's MDS, dated [DATE REDACTED], indicated Resident 55 was assessed having moderately impaired cognition for daily decision making and required substantial/maximal assistance with toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, and sit to stand.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 39 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 0921 During a concurrent observation in Resident 55's room and interview with Certified Nurse Assistant (CNA6),

on 6/6/2024 at 8:28 AM, there were three white towels on the floor in between the wall and the headboard of Level of Harm - Minimal harm or Resident 55's bed. In addition, there was a white linen/ sheet on the floor of Resident 55's shared restroom. potential for actual harm CNA6 stated the towels, and the white sheet are not supposed to be left on the floor. CNA 6 also stated, it is housekeeper's responsibility to clean up and remove those white towels and white linen/ sheet. Residents Affected - Some

During an interview with the DON, on 6/7/2024, at 9:21 AM, the DON stated CNA is supposed to remove the towels and housekeeping are supposed to keep the area clean. The DON also stated the towels and white sheet are not supposed to be on the floor. The DON stated towels and linen, or sheets are not supposed to be on the floor, and it may cause infection to the resident, and this is not homelike environment if facility staff did not clean up the room.

A review of the facility's P&P titled, Maintenance Service, revised on March 2024, indicated, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The P&P further indicated, Functions of the Maintenance Department may include, but are not limited to maintaining the building in good repair and free from hazards.

45456

4. During an observation in the first-floor resident hallways on 6/6/2024 at 10:50 AM, the ceilings have water leak marks and has a brownish discoloration.

During a concurrent observation in the first - floor resident hallway and interview with the Maintenance Supervisor (MS) on 6/6/2024, at 11:10 AM, MS stated, the ceiling has leaks from the rain and air conditioning vents. When the ceilings get soaked, it leaves stain, and it does not look good. It can also form molds that can get the residents' sick.

During an observation in the second-floor resident hallways on 6/6/2024 at 5:50 PM, the ceilings have water leak marks and brownish discoloration in the resident hallways.

During an interview with the Director of Nursing (DON) on 6/7/2024, 9:24 AM, the DON stated, the environment it is what it is and there is nothing I can do in this old environment. Itis the maintenance job. It does not feel good to look at the old environment, it does not feel homelike.

A review of the facility's policy titled, Homelike Environment dated on 3/2024, indicated the facility provides residents with a safe and clean, comfortable, and homelike environment . The facility staff and management maximize, to the extent as possible, the characteristics of the facility that reflect a personalized, homelike setting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 39 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48395 potential for actual harm Based on observation, interview, and record review, the facility failed to have an effective pest control Residents Affected - Some program for gnats' (small, winged insect) infestation, which affected three (3) of 24 sampled residents (Residents 2, 70, and 89).

This deficient practice had the potential to cause itchy, painful bites to Residents 2, 70, and 89, which could result to open sores (an ulcer) that are susceptible to bacterial infection. This also had the potential for transmission of infectious diseases to other residents.

Findings:

1. During a review of Resident 2's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] with diagnoses of paroxysmal (an attack or sudden increase or recurrence of symptoms) atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the [NAME]] fire rapidly at the same time), and cerebral infarction (damage to the tissues in the brain due to a loss of oxygen in the area).

During a review of Resident 2's H&P, dated 9/16/2024, the H&P indicated the resident has the capacity to understand and make decisions.

During a review of Resident 2's MDS , dated 3/22/2024, the MDS indicated the resident had intact cognitive skills of daily decision making. Resident 2 needed supervision or touching assistance (helper set up or cleans up; resident completes activity) with walking 50 feet and making 2 turns and dressing (how a resident puts on, fastens and takes off all items of clothing), needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) transferring from bed-to-chair, going from a sit to stand position, personal hygiene and eating.

During a concurrent observation and interview on 6/4/2024 at 1:09 PM with Resident 2 in her room, multiple little black flies were observed on the privacy curtain, crawling around on the floor, and flying around the resident's bedside. Resident 2 stated that she tries to not keep fruit or food out but stated that the little flies were always there.

During an observation on 6/5/2024 at 7:50 AM in Resident 2's room, a small black fly was observed on the resident's privacy curtain.

2. During a review of Resident 70's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] with diagnoses of malignant (a term for diseases in which abnormal cells divide without control and can invade nearby tissues) neoplasm (an abnormal mass of tissue that forms when cells grow and divide more than they should or do not die when they should) of endometrium (the layer of tissue that lines the uterus [the hollow, pear-shaped organ in the female pelvis]), and spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord).

During a review of Resident 70's H&P, dated 4/24/2024, the H&P indicated the resident has the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 39 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 0925 During a review of Resident 70's MDS dated [DATE REDACTED], the MDS indicated the resident had intact cognitive skills for daily decision making. Resident 70 needed supervision or touching assistance with bed-to-chair Level of Harm - Minimal harm or transfers, going from a sitting to a standing position, upper body dressing and personal hygiene and needed potential for actual harm setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating.

Residents Affected - Some During a concurrent observation and interview on 6/4/2024 at 12:54 PM with Resident 70 in her room, multiple small little black flies were observed flying around her bedside. Resident 70 stated that the little flies are everywhere and that they bother her. Resident 70 stated she had to buy her own bug spray to prevent her from getting bitten.

3. During a review of Resident 89'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 weakness and low back pain.

During a review of Resident 89's H&P, dated 4/13/2024, the H&P indicated the resident has the capacity to understand and make decisions.

During a review of Resident 89's MDS, dated [DATE REDACTED], the MDS indicated the resident had intact cognitive skills of daily decision making. Resident 89 needed substantial/maximal assistance (helper does more than half the effort) with rolling left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed) and with lower body dressing, needed partial/moderate assistance (helper does less than half the effort) with upper body dressing and needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating.

During a concurrent observation and interview on 6/4/2024 at 8:40 AM with Certified Nursing Assistant 1 (CNA 1), multiple small little black flies were observed flying around Resident 89's bedside. CNA 1 stated that there were a lot of little black flies flying around the resident.

During an interview on 6/4/2024 at 11:25 AM with Maintenance Supervisor (MS), MS stated that it was important that the building be free of insects to prevent contamination, infection, and disease.

A review of the facility's Policy and Procedure (P&P), Pest Control, dated 3/2024, the P&P indicated, the facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure that the building is kept free of insects, and rodents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 39 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.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 39 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 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, Level of Harm - Minimal harm or chair, wheelchair, standing position), lower body dressing and personal hygiene, and needed setup or potential for actual harm clean-up assistance (helper set up or cleans up; resident completes activity) with eating.

Residents Affected - Few 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.

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 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 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 39 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, 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 Level of Harm - Minimal harm or includes the use of verbal, written or gestured communication, or sounds, to residents within hearing potential for actual harm distance, regardless of age, ability to comprehend, or disability and Examples of mental and verbal abuse include, but are not limited to: Residents Affected - Few 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.

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 agencies listed below via telephone within two (2) hours of the suspected abuse incident. Follow the steps below to report:

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 8 of 39 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: