Kei-ai Los Angeles Healthcare Center

F-F656

Findings:

a. A review of Resident 197's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (one-sided muscle weakness), dementia (a progressive state of decline in mental abilities), and muscle weakness.

A review of Resident 197's Minimum Data Set (MDS, a standardized assessment and care screening tool) completed on 10/15/2024, indicated Resident 197 had mild cognitive (a person's ability to think, learn, remember, use judgement, and make decisions) impairment and was moderately dependent with bed mobility, transfer, dressing, feeding, toileting, personal hygiene, and bathing. The MDS indicated it was very important for Resident 197 to perform favorite activities.

A review of Resident 197's History and Physical dated 10/10/2024, it indicated that the resident did not have

the capacity to understand or make medical decisions.

A review of Resident 197's care plan related to activities initiated on 10/31/2024, indicated that resident enjoys social and recreational involvement with minimal levels of participation. The interventions included to make activity adaptations to accommodate the residents change in abilities and condition.

During various observations on 1/9/2025 from 08:30 AM to 3:00 PM, Resident 197 was observed in bed with

the television (TV) on, no activity materials were observed in the resident's room, and no activity staff were observed at the resident's bedside.

b. A review of Resident 530's face sheet indicated that Resident 530 was admitted to the facility on [DATE REDACTED], with diagnoses that included depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities) and muscle wasting.

A review of Resident 530's MDS completed on 1/3/2025, indicated Resident 530 had no cognitive impairment and was moderately dependent with bed mobility, transfer, dressing, feeding, toileting, personal hygiene, and bathing. The MDS indicated it was important for Resident 530 to do things with groups of people.

A review of Resident 530's History and Physical dated 12/29/2024, indicated the resident had the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0679 A review of Resident 530's care plan related to activity dated on 12/28/2024, indicated to determine resident's activity of choice and encourage resident to engage in individual and group activity. Level of Harm - Minimal harm or potential for actual harm During various observations on 1/9/2025 from 8:30 AM to 3:00 PM, Resident 530 was observed in bed with

the television (TV) on, no activity materials were observed in the resident's room, and no activity staff were Residents Affected - Some observed at the resident's bedside.

During an interview on 1/9/2025 at 1:45 PM with Resident 530, Resident 530 stated that the activities staff had not gone to the resident's room that day (1/9/2025). Resident 530 stated the activities staff would visit

the resident, but not consistently.

During a concurrent interview and record review on 1/9/2025 at 1:22 PM with the Activities Director (AD), the AD stated there were activity aides who were assigned to specific floors and units. The AD stated the aides would see residents who were bed bound or requested to be seen in their rooms. The AD stated residents were seen by activity aides 3 times a day 9am, 11:30 am, and 3pm. The AD stated activity visits were logged

on a form titled Monthly Time Sheet (MTS) for each resident. The AD reviewed the Monthly Time Sheet for December 2024 for Resident 197 and Resident 530. The AD stated according to the Monthly Time Sheet, Resident 197 was not seen by an activity's aide on December 15, 19, 21, 22, 25, and 27 and Resident 530 was not seen by an activity's aide on December 25, 27, 28, and 29. The AD was unsure as to why no visits were done during those days. The AD stated that not consistently having activities and social interaction could affect the resident's psychosocial well-being and could cause residents to experience loneliness and depression.

A review of the facility's policy and procedure (P&P) titled Activity Programs-Staffing and revised November 2023, indicated sufficient activity personnel were on duty to meet the needs of the residents and the functions of the activity programs.

49881

c. A review of Resident 44's Admission Record indicated the facility admitted the resident on 3/03/2021 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

A review of Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 3/07/2024, indicated while in the facility it was somewhat important to participate in religious services or practices and do her favorite activities.

A review of Resident 44's Activity Assessment Form dated 3/08/2024, indicated the resident's preferences included turning on television or music, Christian service 1x week, and bingo games at bedside. The assessment indicated the residents desired outcome from involvement within the activity program was pleasure and comfort.

A review of Resident 44's Activity Monthly Time Sheet dated 10/2024, indicated the resident watched television 29 days, had conversation/social contact 27 days, was provided activity materials three days, played bedside bingo three days, and had a spiritual religious video chat one day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0679 A review of Resident 44's Activity Monthly Time Sheet dated 11/2024, indicated the resident watched television 28 days, had conversation/social contact 20 days, was provided activity materials five days, played Level of Harm - Minimal harm or bedside bingo five days, played bingo in a group three days, and had a spiritual religious video chat one day. potential for actual harm

A review of Resident 44's Activity Monthly Time Sheet dated 12/2024, indicated the resident watched Residents Affected - Some television 28 days, had conversation/social contact 21 days, was provided activity materials one day, and played bingo in a group one day.

A review of Resident 44's MDS dated [DATE REDACTED], indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was dependent (helper does all of the effort) with personal, oral, and toilet hygiene and eating.

During a concurrent observation and interview on 1/06/2025 at 1:38 PM in Resident 44's room, Resident 44 was observed laying on her bed and watching television. Resident 44 stated she liked to play bingo and go to church but stayed in the room all day watching television.

During an interview on 1/09/2025 at 11:19 AM with the Activities Director (AD), the AD stated Resident 44's preferences included daily one to one contact, television or music, Christian service 1x week, and bingo games.

During a concurrent record review and interview on 1/09/2025 at 11:47 AM with the AD, Resident 44's Activity Monthly Time Sheet from October 2024 to December 2024 were reviewed. The AD confirmed Resident 44 received spiritual services once in October 2024 and November 2024, and no spiritual services

in December 2024. The AD confirmed Resident 44 played bingo three days in October 2024, played bingo eight days in November, and played bingo one day in December 2024. The AD stated Resident 44' preferences such as Christian service once a week and playing bingo were not being followed. The AD stated it was important to follow the resident's preferred activities because the activities were beneficial for

the resident and can help prevent depression.

During a concurrent record review and interview on 1/10/2025 at 9:07 AM with the Director of Nursing (DON), Resident 44's Activity Monthly Time Sheet for October 2024, November 2024, and December 2024 were reviewed. The DON stated Resident 44's preferences such as playing bingo and church once a week were not being followed. The DON stated it was important to follow and provide residents preferences because it could impact a resident's psychosocial well-being.

A review of the facility's P&P titled Activities Programs- Staffing, revised November 2023, indicated the activity programs were staffed with personnel who had appropriate training and experience to meet the needs and interest of each resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36943

Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide services to five of nine residents (Resident 37, 127, 44, 36, and 128) with limited range of motion ([ROM] full movement potential of

a joint [where two bones meet]) and mobility (ability to move) by failing to:

1. Provide Resident 37 with active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) to both arms, five times per week, in accordance with the physician's order, dated 12/26/2024.

2. Provide Resident 37 with sit-to-stand transfers using a front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking), five times per week, in accordance with the physician's order, dated 12/26/2024.

3. Provide Resident 127 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) to both legs, five times per week, from 11/2024 to 12/2024 in accordance with the physician's order, dated 5/9/2024.

4. Apply the Pressure Relief Ankle Foot Orthosis ([PRAFO] device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position) to Resident 127 left foot, seven times per week, from 11/2024 to 12/2024 in accordance with the physician's order, dated 5/9/2024.

5. Provide Resident 127 with a left-hand splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), five times per week, from 11/2024 to 12/2024 in accordance with the physician's order, dated 5/19/2024.

6. Provide Resident 127 with AROM to right arm, PROM to the left arm, and application of the left elbow splint, five times per week, from 11/2024 to 12/2024 in accordance with the physician's order, dated 8/16/2024.

7. Provide Resident 44 with PROM to both arms and legs, five times per week, during 9/2024, 12/2024, and 1/2024.

8. Apply the resting hand splint (splint secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist and prevent contractures [a stiffening/shortening at any joint that reduces the joint's range of motion]) to Resident 36's left hand from 10/2024 to 1/2024 in accordance with

the physician's order, dated 10/15/2024.

9. Provide Resident 36 with PROM to both arms and legs, three times per week, during 12/2024 in accordance with the physician's order, dated 10/15/2024.

10. Ensure Resident 128 was properly assessed for the application of both knee splints for one-and-a-half (1. 5) hours in accordance with professional standards of practice for Physical Therapy ([PT] profession aimed

in the restoration, maintenance, and promotion of optimal physical function).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0688 These failures had the potential for Resident 37, 127. 44, and 36 to experience a decline in ROM and mobility, including the development or worsening of contractures (a stiffening/shortening at any joint that Level of Harm - Minimal harm or reduces the joint's range of motion). These failures also had the potential to damage Resident 128's skin potential for actual harm integrity (relating to skin health), including but not limited to redness and development of pressure sores (injuries to the skin and underlying tissue caused by prolonged pressure on the skin). Residents Affected - Some Findings:

a. During a review of Resident 37's Admission Record, the facility admitted Resident 37 on 9/18/2024 with diagnoses including B-cell lymphoma (cancer that affects white blood cells that helps with the body's immune system), Type II Diabetes Mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), muscles weakness, and unsteadiness on feet.

During a review of Resident 37's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 9/19/2024, the OT Evaluation indicated Resident 37 had impaired ROM (unspecified) in both shoulders. The OT Evaluation indicated Resident 37 required moderate assistance ([MOD-A] requires 25 to 50 percent [%] physical assistance) for upper body dressing and maximum assistance ([MAX-A] requires 50 to 75% physical assistance) for lower body dressing.

During a review of Resident 37's PT Evaluation and Plan of Treatment, dated 9/19/2024, the PT Evaluation indicated Resident 37 had ROM within functional limits ([WFL] sufficient movement without significant limitation) in both legs. The PT Evaluation indicated Resident 37 required MAX-A for walking 10 feet using an FWW.

During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool), dated 9/22/2024 and 12/23/2024, the MDS indicated Resident 37 expressed ideas and wants, clearly understood verbal content, and had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 37 required partial/moderate assistance (helper does less than half the effort) for upper body dressing and substantial/maximal assistance (helper does more than half the effort) for lower body dressing, rolling from lying on the back to either side, transfers from lying to sitting on the side of the bed, sit to stand transfers, and chair/bed-to chair transfers.

During a review of Resident 37's OT Discharge Summary, dated 12/26/2024, the OT Discharge Summary indicated Resident 37 required set-up assistance for upper body dressing and MOD-A for lower body dressing. The OT Discharge Summary indicated recommendations for the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to provide Resident 37 with AROM exercises to both arms.

During a review of Resident 37's PT Treatment Encounter Note, dated 12/26/2024, the PT Treatment Encounter indicated Resident 37 required MOD-A for bed mobility and transfers using an FWW. The PT Treatment Encounter Note indicated Resident 37 did not walk due to weakness and fatigue (extreme tiredness).

During a review of Resident 37's physician's orders, dated 12/26/2024, the physician's orders included for

the RNA to provide Resident 37 with AROM to both arms, five times per week as tolerated, and sit to stand using the FWW, five times per week as tolerated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0688 During a review of Resident 37's Document Survey Report (record of tasks) for RNA, dated 12/2024, the Documentation Survey Report included an RNA task to assist Resident 37 with sit to stand using FWW but Level of Harm - Minimal harm or did not include AROM to both arms. The Documentation Survey Report for the RNA task was blank for potential for actual harm 12/26/2024, 12/30/2024, and 12/31/2024.

Residents Affected - Some During a review of Resident 37's Documentation Survey Report for RNA, dated 1/2024, the Documentation Survey Report included an RNA task to assist Resident 37 with sit to stand using FWW but did not include AROM to both arms. The Documentation Survey Report for the RNA task was blank for 1/1/2025, 1/2/2025, and 1/3/2025.

During a concurrent observation and interview on 1/8/2025 at 8:16 AM in Resident 37's room, Resident 37 was lying in bed with the head-of-bed elevated eating breakfast. Resident 37 lifted both arms overhead. Resident 37 bent each hip and knee while lying in bed. Resident 37 stated he usually received arm exercises and walked with a walker with a staff member (unknown). Resident 37 stated he had not received any arm exercises and had not walked with a walker for over a week.

During an observation on 1/8/2025 at 9:47 AM in Resident 37's room, Resident 37's RNA treatment was observed with Restorative Nursing Aide 5 (RNA 5) and RNA 8. RNA 5 and RNA 8 assisted Resident 37 with transferring from lying in the bed to sitting at the edge of the bed. RNA 5 placed a gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 37's waist. Resident 37 was observed requiring RNA 5's physical assistance to perform three repetitions of sit to stand transfers using the FWW. RNA 5 and RNA 8 assisted Resident 37 with transferring from sitting at the edge of the bed to lying in bed.

During an interview on 1/8/2025 at 10:03 AM with RNA 5, RNA 5 stated Resident 37 performed sit to stand transfers using the FWW. RNA 5 stated Resident 37's RNA program included AROM to both arms, twice per week, and sit to stand using the FWW, five times per week. RNA 5 stated Resident 37 did not receive AROM exercises to both arms on date of interview (1/8/2025) since it was the Resident 37's day off from the arm exercises.

During an interview on 1/8/2025 at 12:26 PM with RNA 5, RNA 5 stated Resident 37 was likely not seen for over one week because the RNAs were usually pulled from RNA assignments to perform Certified Nursing Assistant (CNA) duties.

During an interview on 1/10/2025 at 12:06 PM with the Director of Staff Development (DSD), the DSD stated

the purpose of the RNA program included maintaining the resident's physical function and mobility.

During a concurrent interview and record review on 1/9/2025 at 8:54 AM with the Director of Rehabilitation (DOR), Resident 37's OT Discharge Summary, dated 12/26/2024, was reviewed. The DOR stated Resident 37's OT Discharge recommendations included for the RNA to perform ROM to both arms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0688 During a concurrent interview and record review on 1/10/2025 at 12:26 PM with the Director of Staff Development (DSD), the DSD reviewed Resident 37's physician orders for RNA, dated 12/26/2024, and Level of Harm - Minimal harm or Documentation Survey Reports, dated 12/2024 and 1/2025. The DSD stated the physician's orders indicated potential for actual harm for RNA to provide Resident 37 with AROM to both arms, five times per week, and sit to stand using the FWW, five times per week. The DSD stated Resident 37's Documentation Survey Reports for the RNA tasks Residents Affected - Some were blank for 12/26/2024, 12/30/2024, 12/31/2024, 1/1/2025, 1/2/2025, and 1/3/2025. The DSD stated there was no documentation the RNAs provided Resident 37 with treatments during those dates. The DSD stated Resident 37 could develop a decline in ROM, development of contractures, and decline in mobility if RNA was not provided. The DSD stated the RNAs were occasionally pulled from RNA treatment to perform CNA duties but were provided overtime pay to provide RNA treatment.

b. During a review of Resident 127's Admission Record, the facility admitted Resident 127 on 4/24/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left non-dominant side, muscle weakness, and dysarthria (difficulty speaking due to weak speech muscles).

During a review of Resident 127's OT Evaluation and Plan of Treatment, dated 4/25/2024, the OT Evaluation indicated Resident 127 had WFL ROM in the right arm and impaired ROM (unspecified) with contracture (at unspecified joint) in the left arm.

During a review of Resident 127's PT Evaluation and Plan of Treatment, dated 4/25/2024, the PT Evaluation indicated Resident 127 has WFL ROM in both legs.

During a review of Resident 127's PT Discharge Summary, dated 5/9/2024, the PT Discharge Summary included recommendations for the RNA to provide Resident 127 with PROM to both legs and apply the left PRAFO.

During a review of Resident 127's physician's orders, dated 5/9/2024, the physician's orders indicated for the RNA to provide PROM to both legs, five times per week or as tolerated, and to apply the PRAFO to the left ankle for four to six hours, seven times per week or as tolerated.

During a review of Resident 127's OT Discharge Summary, dated 5/19/2024, the OT Discharge Summary indicated recommendations for the RNA to provide Resident 127 with PROM to both arms and apply a splint (unspecified type).

During a review of Resident 127's physician's orders, dated 5/19/2024, the physician's orders indicated for

the RNA to apply the left hand/wrist splint for four to six hours or as tolerated, five times per week.

During a review of Resident 127's Documentation Survey Report for RNA, dated 5/2024, the Documentation Survey Report included an RNA task to provide Resident 127 with PROM of the left arm and active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) of the right arm, five times per week, beginning on 5/21/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0688 During a review of Resident 127's Rehab Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 7/31/2024, the JMA indicated Resident 127 had severe Level of Harm - Minimal harm or (more than 50% limitation) ROM limitations in the left shoulder, left elbow, left wrist, and left hand. potential for actual harm

During a review of Resident 127's OT Evaluation and Plan of Care, dated 7/31/2024, the OT Evaluation Residents Affected - Some indicated Resident 127 was referred to OT for contracture management due to decreased ROM in the left arm.

During a review of Resident 127's OT Discharge Summary, dated 8/15/2024, the OT Discharge Summary included recommendations for the RNA to apply a left elbow splint for four hours per day and ROM exercises.

During a review of Resident 127's physician's orders, dated 8/16/2024, the physician's orders indicated for

the RNA to perform AROM on the right arm and PROM on the left arm, five times per week as tolerated. Another physician's orders, dated 8/16/2024, indicated for the RNA to apply an elbow splint on Resident 127's left arm for up to four hours, five times per week or as tolerated.

During a review of Resident 127's Documentation Survey Report for RNA, dated 11/2024, the Documentation Survey Report included RNA tasks for AROM of the right arm, five times per week; PROM of

the left arm, five times per week; PROM of both legs, five times per week; application of the left hand roll splint (splint positioned in the palm of the hand and secured with straps), five times per week; application of

the left elbow splint up to four hours per day, five times per week; and application of the PRAFO on the left ankle for four to six hours, seven times per week. The Documentation Survey Report was blank for RNA tasks on 11/1/2024, 11/4/2024, 11/8/2024, 11/11/2024, 11/15/2024, 11/18/2024, 11/18/2024, 11/20/2024, and 11/25/2025.

During a review of Resident 127's Documentation Survey Report of RNA, 12/2024, the Documentation Survey Report included RNA tasks for AROM of the right arm, five times per week; PROM of the left arm, five times per week; PROM of both legs, five times per week; application of the left hand roll splint, five times per week; application of the left elbow splint up to four hours per day, five times per week; and application of

the PRAFO on the left ankle for four to six hours, seven times per week. The Documentation Survey Report was blank for RNA tasks on 12/2/2024, 12/6/2024, 12/16/2024, 12/20/2024, 12/23/2024, 12/25/2024, 12/26/2024, 12/30/2024, and 12/31/2024.

During a review of Resident 127's MDS, dated [DATE REDACTED], the MDS indicated Resident 127 expressed ideas and wants, clearly understood verbal content, and had moderately impaired cognition. The MDS indicated Resident 127 had ROM limitations in one arm and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for dressing, bathing, toileting, rolling from lying on the back to either side, transferring from lying in the bed to sitting on the side of

the bed, and chair/bed-to-chair transfers.

During a concurrent observation and interview on 1/7/2025 at 12:30 PM in Resident 127's room, Resident 127 was lying awake in bed. Resident 127 stated the facility staff (unspecified) usually came every day but had not gone in that day (1/7/2025) to apply any splints or provide exercises. Resident 127 stated he was unable to move the left arm and has not walked since 2016. Resident 127 stated he had constant left shoulder pain and did not provide permission to view the left arm. Resident 127 provided permission to observe the RNA session for 1/8/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0688 During a concurrent observation and interview on 1/7/2025 at 3:57 PM in Resident 127's room, Resident 127 was lying awake in bed watching television. Resident 127 stated he did not receive any exercises and splints Level of Harm - Minimal harm or today. potential for actual harm

During an observation on 1/8/2025 at 10:08 AM in Resident 127's room, Resident 127's RNA session with Residents Affected - Some Restorative Nursing Aide 6 (RNA 6) was observed. Resident 127 had a splint already applied to the left hand. RNA 6 stood on the left side of Resident 127's bed. Resident 127 refused ROM to the left shoulder since the nurse (unknown) applied cream. RNA 6 walked to the right side of Resident 127's bed. RNA 6 demonstrated movements while Resident 127 performed AROM exercises on the left shoulder, elbow, wrist, and hand. Resident 127 was observed refusing ROM exercises to both legs due to pain.

During an interview on 1/8/2025 at 10:18 AM with RNA 6, RNA 6 stated he applied the left-hand splint in the morning and Resident 127 performed AROM on the right arm. RNA 6 stated Resident 127 refused ROM to

the left arm and both legs due to pain. RNA 6 stated the left elbow and left PRAFO were not applied due to Resident 127's pain. RNA 6 stated he would inform Resident 127's nurse of the pain and would offer ROM exercises again later during the day.

During a concurrent interview and record review on 1/10/2025 at 1:47 PM with the DSD, Resident 127's physician's orders for RNA, dated 5/9/2024 and 5/19/2024, and Documentation Survey Report for RNA, dated 11/2024 and 12/2024, were reviewed. The DSD stated a blank in the Documentation Survey Report for RNA indicated there was no evidence Resident 127 was seen for RNA services. The DSD stated Resident 127's did not receive RNA services in accordance with the physician's orders for 11/2024 and 12/2024. The DSD stated Resident 127 could develop a decline in ROM, development of contractures, and decline in mobility if RNA services was not provided.

c. During a review of Resident 44's Admission Record, the facility admitted Resident 44 on 8/28/2024 with diagnoses including schizophrenia (mental illness that is characterized by disturbances in thought), dysphagia (difficulty swallowing), functional quadriplegia (condition that causes a person to be completely unable to move due to a severe disease), and muscles weakness.

During a review of Resident 44's PT Evaluation and Plan of Treatment, dated 8/29/2024, the PT Evaluation indicated Resident 44 had both knee extension contractures (knees positioned in full extension and difficult to bend the knees) and both plantarflexion contractures (ankles positioned away from the body and difficult to bend the ankles toward the body).

During a review of Resident 44's OT Evaluation and Plan of Treatment, dated 8/29/2024, the OT Evaluation indicated Resident 44 had impaired ROM (unspecified) in both shoulders, elbows, and hands.

During a review of Resident 44's JMA, dated 8/29/2024, the JMA indicated Resident 44 had moderate (26 to 50% limitation) ROM limitations in both shoulders and the left hand and minimal (less than 25% limitation) ROM limitations in the left elbow and the right hand.

During a review of Resident 44's physician's orders, dated 8/30/2024 and 9/3/2024, the physician's orders indicated for RNA to provide Resident 44 with PROM exercises as tolerated in both arms and legs, five days per week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0688 During a review of Resident 44's Documentation Survey Report for RNA, dated 9/2024, the Documentation Survey Report included RNA tasks to provide Resident 44 with PROM of both arms, five times per week, and Level of Harm - Minimal harm or PROM of both legs, five times per week. The Documentation Survey Report was blank for RNA tasks on potential for actual harm 9/3/2024, 9/6/2024, 9/10/2024, 9/16/2024, 9/19/2024, 9/23/2024, and 9/26/2024.

Residents Affected - Some During a review of Resident 44's Documentation Survey Report for RNA, dated 11/2024, the Documentation Survey Report included RNA tasks to provide Resident 44 with PROM of both arms, five times per week, and PROM of both legs, five times per week. The Documentation Survey Report was blank for RNA tasks on 12/3/2024, 12/9/2024, 12/16/2024, 12/19/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, and 12/31/2024.

During a review of Resident 44's MDS, dated [DATE REDACTED], the MDS indicated Resident 44 expressed ideas and wants, clearly understood verbal content, and had moderately impaired cognition. The MDS indicated Resident 44 was dependent for eating, toileting, bathing, dressing, rolling from lying to either side of the bed, and chair/bed-to-chair transfers.

During a review of Resident 44's Documentation Survey Report for RNA, dated 1/2024, the Documentation Survey Report included RNA tasks to provide Resident 44 with PROM of both arms, five times per week, and PROM of both legs, five times per week. The Documentation Survey Report was blank for RNA tasks on 1/1/2025 and 1/6/2025.

During a concurrent observation and interview on 1/7/2025 at 12:04 PM in Resident 44's room, Resident 44 was awake while sitting up in a wheelchair with a high backseat. Resident 44 was observed moving both arms but stated having difficulty grasping items with both hands. Resident 44 was observed with both legs straight and elevated on the wheelchair's footrests. Resident 44 was observed moving both ankles but stated both knees were kind of locked in place. Resident 44 stated someone (unspecified) provided exercises to Resident 44's arms and legs every couple of weeks.

During an observation on 1/8/2025 at 10:28 AM in Resident 44's room, Resident 44's RNA session with Restorative Nursing Aide 7 (RNA 7) was observed. Resident 44 was observed lying in bed. RNA 7 provided PROM to both shoulders, elbows, wrists, and fingers. Resident 7's legs were observed extended on the bed. RNA 7 provided PROM to both hips, knees, ankles, and toes.

During an interview on 1/8/2025 at 10:54 AM with RNA 7, RNA 7 stated PROM to both arms and legs were provided to Resident 44. RNA 7 stated Resident 44 was seen for PROM exercises, five times per week, from Monday through Friday.

During a concurrent interview and record review on 1/10/2025 at 2:05 PM with the DSD, Resident 44's physician's orders for RNA, dated 8/30/2024 and 9/3/2024, and Documentation Survey Reports for RNA on 9/2024, 12/2024, and 1/2025 were reviewed. The DSD stated Resident 44 did not receive RNA services in accordance with the physician's orders for 9/2024, 12/2024 and 1/2025. The DSD stated the residents could develop a decline in ROM, development in contractures, and decline in mobility if RNA was not provided.

d. During a review of Resident 36's Admission Record, the facility admitted Resident 36 on 12/31/2018. The Admission Record indicated Resident 36's diagnoses included hemiplegia following cerebral infarction affecting the left non-dominant side, left-hand contracture, left-knee contracture, and muscle weakness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0688 During a review of Resident 36's PT Evaluation and Plan of Treatment, dated 10/8/2024, the PT Evaluation indicated Resident 36 had ROM limitations in both ankles, which were positioned in plantarflexion. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 36's OT Evaluation and Plan of Treatment, dated 10/14/2024, the OT Evaluation indicated Resident 36 had ROM limitations in both shoulders, left elbow, and left hand. Residents Affected - Some

During a review of Resident 36's physician's orders, dated 10/15/2024, the physician's orders indicated for

the RNA to provide PROM to both arms and legs, three times per week or as tolerated. Another of Resident 36's physician's order, dated 10/15/2024, indicated for the RNA to apply a left resting hand splint for up to four hours, three times per week or as tolerated.

During a review of Resident 36's Documentation Survey Report for RNA, dated 10/2024, the Documentation Survey Report included RNA tasks to provide Resident 36 with PROM on both arms and legs, three times per week. The Documentation Survey Report did not include a task to apply Resident 36's left-hand splint

during 10/2024.

During a review of Resident 36's Documentation Survey Report for RNA, dated 11/2024, the Documentation Survey Report included RNA tasks to provide Resident 36 with PROM on both arms and legs, three times per week. The Documentation Survey Report did not include a task to apply Resident 36's left-hand splint

during 11/2024.

During a review of Resident 36's Documentation Survey Report for RNA, dated 12/2024, the Documentation Survey Report included RNA tasks to provide Resident 36 PROM on both arms and legs, three times per week. The Documentation Survey Report did not include a task to apply Resident 36's left-hand splint. The Documentation Survey Report was blank for the RNA tasks on 12/3/2024, 12/7/2024, 12/19/2024, 12/24/2024, and 12/31/2024.

During a review of Resident 36's Documentation Survey Report for RNA, dated 1/2025, the Documentation Survey Report included RNA tasks to provide Resident 36 PROM on both arms and legs, three times per week. The Documentation Survey Report did not include a task to apply Resident 36's left-hand splint.

During an observation on 1/9/2025 at 7:58 AM in Resident 36's room, Resident 36's RNA session with Restorative Nursing Aide 9 (RNA 9) was observed. RNA 9 provided PROM to both shoulders, elbows, wrists, hands, hips, knees, ankles, and toes. RNA 9 applied Resident 36's left-hand resting hand splint.

During an interview on 1/9/2025 at 8:22 AM with Resident 36, Resident 36 used head gestures to communicate. Resident 36 gestured that the exercises felt good and was not in any pain.

During an interview on 1/9/2025 at 8:24 AM with RNA 9, RNA 9 stated Resident 36 received PROM to both arms and legs and applied the left-hand splint. RNA 9 stated the left-hand splint would be removed around 12:20 PM after four hours. RNA 9 stated he personally worked with Resident 36 once a month because RNA 9's assignment was usually rotated between multiple residents' rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0688 During a concurrent interview and record review on 1/10/2025 at 2:09 PM with the DSD, Resident 36's physician orders for RNA, dated 10/15/2024, and Documentation Survey Reports for RNA on 10/2024, Level of Harm - Minimal harm or 11/2024, 12/2024, and 1/2025 were reviewed. The DSD stated Resident 36's Documentation Survey potential for actual harm Reports for 10/2024, 11/2024, 12/2024, and 1/2025 did not include a task to apply the left resting hand splint.

The DSD stated Resident 36's Documentation Survey Report did not have any evidence Resident 36's left Residents Affected - Some resting hand splint was applied from 10/2024 to 1/2025. The DSD stated the RNAs did not report the missing task to the DSD. The DSD also stated Resident 36 did not receive RNA services in accordance with the physician's orders during 12/2024. The DSD stated Resident 36 could develop a decline in ROM, development of contractures, and decline in mobility if RNA was not provided.

e. During a review of Resident 128's Admission Record, the facility admitted Resident 128 on 3/7/2024 with diagnoses including hemiplegia following cerebral infarction the right dominant side, Type II DM, dysphagia, and right knee contracture.

During a review of Resident 128's PT Evaluation and Plan of Treatment, dated 3/18/2024, the PT Evaluation indicated Resident 128 had a chronic (long-standing) right knee contracture and had limited ROM in the left knee.

During a review of Resident 128's PT Treatment Encounter Note, dated 4/15/2024, the PT Treatment Encounter Note indicated Resident 128 wore both knee splints for one hour without any signs of pain or skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure).

During a review of Resident 128's PT Treatment Encounter Notes, dated 4/17/2024, 4/18/2024, 4/19/2024, 4/21/2024, 4/22/2024, 4/23/2024, 4/24/2024, 4/25/2024, 4/26/2024, and 4/28/2024, the PT Treatment Encounter Notes indicated Resident 128 refused to wear both knee splints.

During a review of Resident 128's physician's orders, dated 4/28/2024, the physician's orders indicated for

the RNA to apply splints on both knees for up to 1.5 hours, five times per week.

During a review of Resident 128's Documentation Survey Report for RNA, dated 4/2024, 5/2024, 6/2024, 7/2024, 8/2024, 9/2024, 10/2024, 11/2024, 12/2024, and 1/2025, the Documentation Survey Reports included an RNA task to apply splints to both of Resident 128's knees for 1.5 hours, five times per week.

During a concurrent observation and interview on 1/8/2025 at 7:52 AM in Resident 128's bedroom, Resident 128 was sitting at the edge of the bed while using the left hand to eat breakfast. Resident 128 stated Resident 128's pain level was determined when the facility staff (unspecified) performed exercises.

During an interview on 1/9/2025 at 12:08 PM with Physical Therapist 3 (PT 3), PT 3 stated a resident's skin and tissues need time to adapt to a splint. PT 3 stated the professional standard of practice for determining a resident's splint wearing tolerance included to apply the splint for 30 minutes and then gradually increase the wear time to determine if the splint was safe to provide.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0688 During a concurrent interview and record review on 1/9/2025 at 2:40 PM PT 3, Resident 128's PT Encounter Notes from 4/17/2024 to 4/28/2024 were reviewed. PT 3 stated both knee splints should not be applied when Level of Harm - Minimal harm or transitioning Resident 128 from PT services to RNA services because Resident 128 refused to wear both potential for actual harm knee splints for 10 treatment sessions prior to discharge. PT 3 stated the knee splints could cause pain and skin breakdown if the RNA applied the splints. Residents Affected - Some

During a review of the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, revised 11/2023, the P&P indicated residents with limited ROM and mobility will receive treatment and services to increase and/or prevent a further decrease in ROM and mobility.

During a review of a textbook titled, The Guide to Physical Therapist Practice, second edition, revised in 2003 by the American Physical Therapy Association, pages 76 and 77 of the textbooks indicated a PT used tests and measures to assess the need for orthotic (splint) devices in patients and evaluated the appropriateness and fit of the device. The Guide to Physical Therapy Practice textbook indicated physical therapists performed assessments to determine a patient's alignment and fit of the orthotic device, components of orthotic device, level of safety with device, and functional benefit of the device.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49881

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 238) identified as at risk for seizures was free from accidents by failing to ensure a physician's ordered bilateral (both sides) padded side rails were placed on Resident 238's bed.

This deficient practice placed Resident 238 at increased risk for falls injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed, causing seizures/convulsions).

Findings:

A review of Resident 238's Admission Record indicated the resident was originally admitted to the facility on [DATE REDACTED] with diagnosis including epilepsy and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting left non-dominant side and aphasia (a disorder that makes it difficult to speak).

A review of Resident 238's Minimum Data Set (MDS- a resident assessment tool) dated 11/27/2024, indicated the resident was severely impaired in cognitive skills (ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making and was dependent (helper does all the help) from the staff for activities of daily living.

A review of Resident 238's physician's order dated 9/20/2024, indicated an active physician's order for bilateral 1/2 padded siderails.

A review of Resident 238's care plan revised on 10/26/2024, indicated the resident was at risk for recurrent seizure episodes. The care plan indicated interventions which included padded side rails on bed as indicated.

During a concurrent observation and interview on 1/06/2025 at 2:13 PM with Licensed Vocation Nurse 8 (LVN 8) in Resident 238's room, LVN 8 confirmed Resident 238 only had one padded side rail on the bed and needed two padded side rails. LVN 8 stated it was important both side rails were padded to prevent injury during a seizure.

During an interview on 1/09/2025 at 2:23 PM, with the Director of Nursing (DON), the DON stated seizure precautions included padded side rails to prevent injury during a seizure.

During an interview on 1/10/2025 at 11:01 AM, the DON stated the facility did not have a policy for seizure precautions that indicated padded siderails. The DON stated resident 238 had a seizure care plan that indicated padded side rails as needed, which meant the resident needed both side rails padded. The DON stated it was important to follow the resident's care plan interventions because it guided the needs of the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0689 A review of Seizure Safety and Precautions by the American Association of Neuroscience Nurses, undated,

it indicated management strategies/nursing implications include proper set-up of the patient room like Level of Harm - Minimal harm or padded side rails to prevent any danger or harm should be assessed and completed with each interaction. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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** 50391 potential for actual harm Based on observation, interviews, and record reviews, the facility failed to ensure one of eight sampled Residents Affected - Few residents (Resident 96) had physician orders to receive oxygen therapy via nasal cannula as needed for shortness of breath.

This deficient practice had the potential to cause complications associated with oxygen therapy.

Findings:

A review of Resident 96's admission record indicated Resident 96 was originally admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with diagnoses that include emphysema (chronic lung condition), cachexia (general stated of ill health involving great weight loss and muscle loss, and chronic kidney disease (Long lasting disease of kidneys leading to kidney failure).

A review of Resident 96's initial Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 11/11/24, indicated Resident 96's cognition (level for daily decision making) was not intact. The MDS indicated the resident required extensive assistance from staff in transfers, bed mobility, and dressing.

During a concurrent observation of Resident 96's room and interview on 1/9/25, at 9:37AM, Resident 6 was observed in the presence of the License Vocational Nurse 6 (LVN 6), the was observed lying in his bed, receiving oxygen via nasal cannula (a thin tube). LVN 6 checked the resident and stated Resident 96 was receiving oxygen at 5 liters per minutes. LVN 6 was not sure if there was an order for the resident to receive oxygen.

During a follow up interview on 1/9/25 at 2:00 p.m., LVN 6 admitted placing residents on oxygen without a physician's order was a practice facility staff was used to doing. A review of Resident 96's physician's order dated 1/9/25, 1:57pm, indicated that an order for oxygen therapy had just been placed while interviewing LVN 6.

During an interview with the Director of Nursing (DON) on 1/10/25 at 9:45AM, the DON stated an order should have been placed before administering oxygen therapy to resident 96. The DON stated it was a dangerous move because unnecessary oxygen could be just as bad as not receiving oxygen when needed.

The DON stated the resident could really become ill from administering oxygen without orders. The DON stated, all medication administration requires an MD order to administer.

A review of Resident 96's care plan for at risk for altered respiratory status/difficulty breathing related to emphysema (chronic lung condition) dated 1/10/25, indicated a goal of not having shortness of breath. The care plan listed interventions which included to administer oxygen at two liters per minute as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 A review of the facility's undated policy titled Oxygen Administration indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this Level of Harm - Minimal harm or procedure. Review the physician's orders or facility protocol for oxygen administration. After completing the potential for actual harm oxygen set up or adjustment, the following information should be recorded in the resident's medical record such as, the rate of oxygen flow, route, and rationale. All assessment data obtained before, during, and after Residents Affected - Few the procedure.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49881

Residents Affected - Few Based on interview and record review, the facility failed to ensure:

1. Two of five staff (Licensed Vocational Nurses [LVN 6] and 1 Registered Nurse [RN 3]) had a completed annual performance evaluation.

2. One of five staff (Registered Nurse [RN 4]) had a completed annual competency evaluation.

3. One of five staff (Certified Nursing Assistant [CNA 7]) had an active certified nursing assistant certification.

This deficient practice had the potential for all 294 residents to not receive appropriate services.

Findings:

During a review of LVN 6's employee file, LVN 6's employee file indicated a hire date of [DATE REDACTED]. The employee file indicated LVN 6's competency evaluation was last completed on [DATE REDACTED]. No performance evaluation was noted on file.

During a review of RN 3's employee file, RN 3's employee file indicated a hire date of [DATE REDACTED]. No performance evaluation was noted on file.

During a review of RN 4's employee file, RN 4's employee file indicated a hire date of [DATE REDACTED]. No annual competency evaluation was noted on file.

During a review of CNA 7's employee file, CNA 7's employee file indicated a hire date of [DATE REDACTED]. The employee file indicated CNA 7 had a Nursing Assistant Certification that expired on[DATE REDACTED]. The employee file indicated CNA 7 had a Counseling/Disciplinary Notice dated [DATE REDACTED] via phone for suspension, pending investigation, subject to discharge due to CNA 7's expired certification.

During a concurrent record review and interview on [DATE REDACTED] at 3:15 PM, with the Director of Staff Developer (DSD), CNA 7's employee file was reviewed. The DSD confirmed CNA 7's Nursing Assistant Certification was expired. The DSD stated during the annual skill evaluation, the Director of staff Developer was responsible for verifying employees' certifications were up to date. The DSD stated CNA 7 last worked on [DATE REDACTED] from 7 AM to 3 PM and was suspended the day prior to the interview ([DATE REDACTED]) via phone after the DSD discovered her certification was expired. The DSD stated it was important the certification was up to date for safety reasons to ensure that the staff were licensed and/or certified. The DSD stated there was a potential for harm that can lead to potential abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0726 During a concurrent interview and record review on [DATE REDACTED] at 8:17 AM with the DSD, the DSD reviewed employee files for LVN 6, RN 3, and RN 4. The DSD confirmed LVN 6, and RN 3 did not have a completed Level of Harm - Minimal harm or annual performance evaluations and RN 4 did not have a completed annual competency evaluation. The potential for actual harm DSD stated it was important staff had an annual performance evaluation, to ensure staff knew how they were performing and to address issues like attendance and call offs with the employee. The DSD stated it was Residents Affected - Few important to complete the competency evaluation annually to make sure staff were following proper procedure with skills performed on residents like medication administration, physical assessment, and charting.

During an interview on [DATE REDACTED] at 2:12 PM with the Director of Nursing (DON), the DON stated certified nursing assistants, licensed vocational nurses, and registered nurses had to have a performance evaluation completed annually. The DON stated it was important for staff to have a performance evaluation because if

an employee was not performing well, the employee could need coaching to ensure they were keeping up with the job requirements and tasks. The DON stated at a minimum the validation of competency skills was done annually. The DON stated competency evaluations were important because it was a requirement to ensure staff were providing quality of care to the resident and adhering to the standard of care. The DON stated it was important that certified nursing assistants had an active certification because the CNA's work directly impacted the residents.

A review of the facility's P&P titled Performance Evaluations, revised [DATE REDACTED], indicated the job performance of each employee shall be reviewed and evaluate at least annually.

A review of the facility's P&P titled Competency of Nursing Staff, revised [DATE REDACTED], the policy statement indicted all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by the state law. The policy indicated facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.

A review of the facility's Certified Nursing Assistant Job Description, dated 2023, experience included: must be a licensed Certified Nursing Assistant in accordance with laws of this state.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 49881 potential for actual harm Based on interview and record review, the facility failed to ensure one of six Certified Nursing Assistants Residents Affected - Few (CNA 5) had a completed annual performance evaluation as per facility policy and procedures titled Performance Evaluations, revised June 2010.

This deficient practice had the potential for all 294 residents to not receive appropriate services.

Findings:

During a review of CNA 5's employee file, it indicated that their date of hire was 7/26/2022. No performance evaluation was noted in CNA 5's employee file.

During a concurrent interview and record review of CNA 5's employee file on 1/9/2025 at 8:17 AM with the Director of Staff Developer (DSD), CNA 5's employee file was reviewed. The DSD confirmed CNA 5 did not have a completed annual performance evaluation. The DSD stated it was important staff had an annual performance evaluation, so the staff knew how there were performing and issues like attendance and call offs were addressed with the employee.

During an interview on 1/9/2025 at 2:12 PM with the Director of Nursing (DON), the DON stated certified nursing assistants were to have a performance evaluation completed annually. The DON stated it was important staff had a performance evaluation because if an employee was not performing well, the employee would need coaching to ensure they were keeping up with their job requirements and tasks.

A review of the facility's policy and procedures titled Performance Evaluations, revised June 2010, indicated

the job performance of each employee shall be reviewed and evaluate at least annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49130

Residents Affected - Few Based on observation, interview, and record review, the facility failed to:

1. Administer medication as per physician's orders for two of three sampled residents (Resident 256 and Resident 205). By failing to:

a. Ensure Resident 256's Lidocaine External Patch (a medication applied topically to relieve pain) 4 percent (% - a unit of measurement for strength), apply to left knee topically one time a day for pain management and remove per schedule, order date 11/24/2024, and Lidocaine External Patch 4%, apply to right knee topically one time a day for R knee pain and remove per schedule, order date 10/27/2024 were removed on 1/6/2025 and new patches applied as per physician's orders.

b. Resident 256's psyllium husk powder (a fiber laxative used to relieve constipation) give 1 scoop by mouth one time a day for gastrointestinal (GI) regularity mix with 8 ounces (oz - a unit of measurement for volume) of water or juice was administered in 8 ounces of water or water as per physician's orders dated 10/24/24.

c. Ensure LVN 4 did not document Resident 205's Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of bloodflow to a part of the brain]) enteric coated (EC) tablet delayed release 81 milligram (mg - a unit of measurement for mass), give 1 tablet by mouth one time a day for stroke prophylaxis (prevention), order date 11/24/2024 as given when LVN 4 held the medication during medication administration observation on 1/7/2025.

2. Clarify Resident 205's orders for Lidocaine External Patch, apply to affected area topically as needed for pain management, order date 7/20/2024, and Nasal spray nasal solution (Oxymetazoline hydrochloride [HCl], 1 spray in both nostrils as needed for dry nostrils, order date 1/3/2025, to ensure both orders had a frequency of administration.

These failures of not administering medications to Resident 256 and 205 in accordance with the physician orders or professional standards of practice had the potential to result in hospitalization due to adverse effects such as abnormal breathing, numbness, tingling, abnormal heartbeat, choking, rebound nasal congestion, heart attack and stroke.

Findings:

1. During a review of Resident 256's admission record dated 1/8/2025, the admission record indicated the facility admitted Resident 256 on 10/9/2024 with diagnoses including generalized muscle weakness.

During a review of Resident 256's History and Physical (H&P) dated 10/10/2024, the H&P indicated Resident 256 had the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0755 During a review of Resident 256's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 10/15/2024, the MDS indicated Resident 256's cognition (mental action or process of Level of Harm - Minimal harm or acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated potential for actual harm Resident 256 needed cleanup assistance from facility staff for eating, needed moderate assistance for oral hygiene, personal hygiene and upper body dressing, and maximal assistance to being dependent for Residents Affected - Few toileting, showering and lower body dressing.

During a review of Resident 256's Order Summary Report (a list of all currently active medical orders) dated 1/8/2025, the order summary report indicated the following (but not limited to) physician orders: Lidocaine External Patch 4 percent (% - a unit of measurement for strength), apply to left knee topically one time a day for pain management and remove per schedule, order date 11/24/2024, start date 11/25/24, Lidocaine External Patch 4%, apply to right knee topically one time a day for R knee pain and remove per schedule, order date 10/27/2024, start date 10/28/2024, and Psyllium Husk Powder, give 1 scoop by mouth one time a day for gastrointestinal (GI) regularity mix with 8 ounces (oz - a unit of measurement for volume) of water or juice, order date 10/24/24, start date 10/25/24.

During a concurrent medication administration observation and interview on 1/7/2025 between 8:46 AM and 9:25 AM with Licensed Vocational Nurse (LVN) 10 in Resident 256's room, LVN 10 prepared medications for Resident 256. LVN 10 removed one lidocaine patch from the resident's left knee dated 1/5/25, then removed one patch from the resident's right knee dated 1/5/25. LVN 10 applied one patch to each knee (left and right) dated 1/7/25 and with LVN 10's initials. LVN 10 then administered the following medications:

1. One tablet of carbidopa-levodopa (a combination medication used to treat Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]) 25 milligrams (mg - a unit of measurement for mass) - 100 mg

2. One tablet of Biktarvy (a medication used to treat viral infection) 50-200-25 mg

3. Three tables of divalproex (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 500 mg delayed release

4. Fluticasone nasal spray (a medication used to treat seasonal allergy related symptoms) to be given as one spray in both nostrils

5. Two patches of lidocaine 4%, one for left knee and one for right knee

6. One tablet of multivitamin with minerals

7. One tablet of oxybutynin (a medication used to treat symptoms of overactive bladder such as incontinence) extended release 10 mg

8. One tablet of probiotic 30 billion colony forming units (CFU)

9. One scoop of Reguloid (generic name - Natural Psyllium Husk) dissolved in 4 oz of water in a cup that was not graduated with measurement marking

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0755 10. One tablet of vitamin B12 (a vitamin used to treat low level of vitamin B12) 1000 microgram (mcg - a unit of measurement for mass) Level of Harm - Minimal harm or potential for actual harm 11. Five tablets of vitamin D (a vitamin used to treat low level of vitamin D) 25 mcg (1000 international units [IU - a unit of measurement for mass]) Residents Affected - Few 12. 17 grams (g - a unit of measurement for mass) of MiraLAX ([generic name - polyethylene glycol] a laxative used to relieve constipation) mixed with 4-8 oz of water.

LVN 10 stated she assumed the unmeasured water cup she was using to measure water and dissolve one scoop of psyllium was eight ounces. LVN 10 then used the small one-ounce medicine cup to measure eight-ounce water. LVN 10 stated she could only fit four ounces of water in the cup. LVN 10 stated the physician order required psyllium to be administered with eight-ounce of water so this would have been a wrong dose. LVN 10 then administered the one scoop of psyllium husk dissolved in four-ounce water, along with a cup of four-ounce water on the side to Resident 256. LVN 10 stated not using prescribed amount of water would have been a medication error and increased the risk for Resident 256 to not be treated for constipation. LVN 10 stated if the psyllium husk was not completely dissolved in prescribed eight ounces of water, there was a risk for Resident 256 to get side effects such as constipation or diarrhea. LVN 10 stated Resident 256's lidocaine patches labeled with date 1/5/25 should have been removed and after drug free period, new lidocaine patches should have been applied with date and nurse initials on 1/6/2025. LVN 10 stated excessive lidocaine could cause irregular heartbeat and hospitalization for Resident 256.

During a concurrent interview and record review on 1/7/2025 at 3:15 PM with LVN 16, the medication administration details of lidocaine 4% patch for Resident 256 were reviewed. The medication administration details indicated one lidocaine patch each was applied to left and right knee on 1/6/2025 at 9 AM and one lidocaine patch each was removed from left and right knee on 1/6/2025 at 9 PM. LVN 16 stated she forgot to apply new lidocaine patch for Resident 256 on 1/6/2025 because the Certified Nursing Assistant (CNA) was assisting the resident with changing and dressing, during which time LVN 16 forgot to return to Resident 256's room to apply lidocaine patch. LVN 16 stated she should only document medications that were administered and should not have documented lidocaine patch as administered on 1/6/2025 when it was not administered. LVN 16 stated the documentation on 1/6/25 was inaccurate and increased the risk of medication errors. LVN 16 stated Resident 256 received additional lidocaine because the patches dated 1/5/2025 were not removed from both knees on 1/6/2025.

During an interview on 1/8/2025 at 1:45 PM with Director of Nursing (DON), DON stated lidocaine patch should have been removed on 01/05/2025. DON stated nurses should have documented date and time when lidocaine patch was removed and applied. DON stated due to prolonged application of lidocaine patches, the medication could have been absorbed for a longer period which could increase the risk of dizziness, nausea, vomiting and ringing in the ear.

During an interview on 1/9/2025 at 4:13 PM with DON, DON stated the facility did not have graduated cups to measure volume of water accurately to dissolve medications. DON stated if the psyllium husk was not dissolved in the prescribed eight ounces of water, it would increase the risk of side effects such as abdominal pain, gas, nausea, and diarrhea. DON stated he was not aware that by taking psyllium without eight-ounce liquid choking could be caused.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0755 During a review of Resident 205's Admission Record, dated 1/8/2025, the admission record indicated the facility admitted Resident 205 on 07/31/2023 with diagnoses including (but not limited to) paroxysmal atrial Level of Harm - Minimal harm or fibrillation (a medical condition described as a type of irregular heartbeat), functional quadriplegia (a medical potential for actual harm condition described by inability to move due to severe disability), chronic pain, reduced mobility, and generalized muscle weakness. Residents Affected - Few

During a review of Resident 205's H&P dated 11/15/2024, the H&P indicated Resident 205 could make needs known but could not make medical decisions.

During a review of Resident 205's MDS dated [DATE REDACTED], the MDS indicated Resident 205's cognition was intact. The MDS indicated Resident 205 needed cleanup assistance from facility staff for eating, needed touching assistance for oral hygiene, toileting, personal hygiene and upper body dressing, and moderate assistance for showering and lower body dressing.

During a review of Resident 205's Order Summary Report dated 1/8/2025, the order summary report indicated the following (but not limited to) physician orders:

Monitor for excessive bleeding from the nose. If bleeding continues, hold Eliquis (generic name - apixaban, a medication used to prevent cerebrovascular accident [CVA] - stroke, loss of blood flow to a part of the brain), every shift, order date 10/22/2024, start date 10/22/2024, Aspirin enteric coated (EC) tablet delayed release 81 milligram (mg - a unit of measurement for mass), give 1 tablet by mouth one time a day for stroke prophylaxis (prevention), order date 11/24/2024, start date 11/25/24, and Eliquis 2.5 mg, give 1 tablet by mouth two times a day for deep venous thrombosis (DVT - a blood clot that forms in a deep vein, usually in

the leg or pelvis), order date 12/21/2023, start date 12/22/2023.

During a concurrent medication administration observation and interview on 1/7/2025 between 9:38 AM and 10:01 AM with LVN 4 in Resident 205's room, prepared the following medications to be administered.

1. One tablet of acetaminophen (a medication used to treat fever and pain) 500 mg

2. One tablet of aspirin 81 mg

3. One tablet of calcium (a supplement to treat low level of calcium) 600 mg plus vitamin D 10 mcg (400 IU)

4. One tablet of Eliquis 2.5 mg

5. One tablet of labetalol (a medication used to treat hypertension (HTN - high blood pressure) 100 mg

6. One tablet of magnesium oxide (a supplement used to treat low level of magnesium) 400 mg (elemental 240 mg)

7. One tablet of multivitamin with minerals

8. One tablet of nifedipine (a medication used to treat HTN) ER 60 mg

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0755 9. Two tablets of sennosides (a laxative used to relieve constipation) 8.6 mg

Level of Harm - Minimal harm or 10. One tablet of telmisartan (a medication used to treat HTN) 80 mg potential for actual harm

During medication administration, LVN 4 stated Resident 205 sometimes refuses to take aspirin due to nose Residents Affected - Few bleeds. LVN 4 administered all the medications except aspirin. LVN 4 stated Resident 205 refused to take aspirin because of nosebleed. LVN 4 did not visually check Resident 205 for signs and symptoms of nosebleed. LVN 4 stated she would inform the physician that aspirin was held for Resident 205 because of nosebleed.

During a medication reconciliation review on 1/7/2025 at 12:37 PM, Resident 205's order summary report with active physician orders dated 1/8/2025, medication administration observations on 1/7/2025 and medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/7/2025 were reviewed. The order summary report indicated there was no physician order that indicated holding aspirin for nosebleed. The order summary report indicated there was an active physician order that indicated, monitor for excessive bleeding from the nose. If bleeding continues, hold Eliquis. During the medication pass observation, LVN 4 administered Eliquis 2.5 mg to Resident 205 and held aspirin 81 mg. The MAR for 1/7/2025 indicated aspirin 81 mg was documented as administered although it was held during medication observation. The MAR for 1/7/2025 indicated Eliquis 2.5 mg was documented as administered.

During a review of Resident 205's MAR dated 1/1/2025 to 01/31/2025, the MAR indicated that LVN 4 documented No (N) for monitor for excessive bleeding from the nose, for 01/07/2025 day.

During a concurrent interview and record review on 1/8/2025 at 12:26 PM with LVN 2, Resident 205's medication administration history and details dated 01/07/2025 for aspirin EC 81 mg, progress note for aspirin EC 81 mg dated 01/07/2025 and administration history and details for Eliquis 2.5 mg dated 1/7/2025 were reviewed. The administration details for aspirin EC 81 mg and Eliquis 2.5 mg indicated LVN 4 documented both medications were administered on 01/07/2025 at 10:03 AM. The progress notes for aspirin EC 81 mg indicated, resident is refusing x3 (tried 3 times). Risk and benefits have been explained MD has been made aware. LVN 2 stated LVN 4 was not available at that time, but she could try answering questions. LVN 2 stated LVN 4 documented a progress note for aspirin EC 81 mg on 01/07/2025 indicating that aspirin was held but documented as administered.

During an interview on 1/8/2025 at 12:43 PM with LVN 2, LVN 2 stated there was a physician order to hold Eliquis if there was excessive bleeding from the nose and if bleeding continues and to monitor resident. LVN 2 stated there was no physician order to hold aspirin in case of nosebleed. LVN 2 stated Resident 205 should have also been assessed and monitored for low blood pressure, fast heart rate, bleeding in stool, bleeding in urine and check if there were abnormal vitals compared to resident's baseline, changes in level of consciousness when she complained of nosebleed. LVN 2 stated Resident 205 was at risk for stroke, DVT, hospitalization or even death. LVN 2 stated aspirin for Resident 205 was not documented accurately on 1/7/2025 10:03 AM which could cause medical errors and risk resident's wellbeing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0755 During an interview on 1/8/2025 at 1:45 PM with DON, DON stated facility staff were to notify the physician if

a resident was receiving an anticoagulant and experienced bleeding. DON stated LVN 4 should have Level of Harm - Minimal harm or assessed the Resident 205 for nosebleed by using a flashlight to visualize the nosebleed and check the back potential for actual harm of resident's throat to note any visible signs of bleeding. DON stated the resident would not benefit from aspirin to prevent stroke because it was not administered per physician's orders. Residents Affected - Few 2. During a medication reconciliation review on 1/7/2025 at 12:37 PM, Resident 205's active physician orders indicated oxymetazoline nasal spray to be administered as needed without any frequency.

During a review of Resident 205's Order Summary Report dated 1/8/2025, the order summary report indicated the following (but not limited to) physician orders:

Lidocaine External Patch, apply to affected area topically as needed for pain management, order date 7/20/2024, start date 7/30/2024 (no frequency), Nasal spray nasal solution (Oxymetazoline hydrochloride [HCl], 1 spray in both nostrils as needed for dry nostrils, order date 1/3/2025, start date 1/3/2025 (no frequency).

During a review of Resident 205's MAR dated 1/1/2025 to 1/31/2025, the MAR indicated there was no documented administration of lidocaine patch and oxymetazoline nasal spray to Resident 205.

During an interview on 1/9/2025 at 4:13 PM with DON, DON stated medication orders should include medication name, diagnosis or indication of use, dose, route, duration, end date and frequency. DON stated facility staff should have clarified frequency for oxymetazoline nasal spray. DON stated without a frequency, there was a risk that medication could cause side effects of blurred vision, fast irregular heart rate, dizziness, drowsiness if given more than necessary. DON stated the medication would not provide therapeutic benefit if given less frequently than needed.

During an interview on 1/10/2025 at 11:02 AM with DON, DON stated facility staff should have clarified physician's order for lidocaine patch without frequency. DON stated there was a risk for resident to experience side effects of dizziness, nausea, vomiting and ringing in the ear if lidocaine patch was administered more frequently than necessary and would not have provided resident with pain relief if it was administered less frequently than intended.

During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated 11/16/2023, the P&P indicated, Medications shall be administered in accordance with the orders, including any required time frame. The P&P indicated, The licensed personnel preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns if a dosage is believed to be inappropriate . or medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences. The P&P indicated, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document the applicable code for specific situation as indicated

on the eMAR . scheduled prescribed time.

During a review of the facility's P&P titled, Medication and Treatment Orders, dated 11/2023, the P&P indicated, Orders for medications must include: name and strength of the drug . dosage and frequency of administration .any interim follow-up .(pending culture monitoring, etc.).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49130 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain a medication error rate of Residents Affected - Few less than 5% (percent) during medication pass for two of three sampled residents (Residents 256 and 205) by failing to administer Resident 256's psyllium husk (a fiber laxative used to relieve constipation), and Resident 205's aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) in accordance with physician's orders.

These failures of medication administration error rate of 6.06% exceeded the five (5) percent threshold.

Findings:

a. During a review of Resident 256's Admission Record (a document containing demographic and diagnostic information), dated 1/8/2025, the facility admitted Resident 256 on 10/9/2024 with diagnosis including (but not limited to) generalized muscle weakness.

During a review of Resident 256's History and Physical dated 10/10/2024, the document indicated Resident 256 had the capacity to understand and make decisions.

During a review of Resident 256's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 10/15/2024, the MDS indicated Resident 256's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 256 needed cleanup assistance from facility staff for eating, needed moderate assistance for oral hygiene, personal hygiene and upper body dressing, and maximal assistance to being dependent for toileting, showering and lower body dressing.

During a review of Resident 256's Order Summary Report (a list of all currently active medical orders) dated 01/08/2025, the order summary report indicated the following (but not limited to) physician orders:

Psyllium Husk Powder, give 1 scoop by mouth one time a day for gastrointestinal (GI) regularity mix with 8 ounces (oz - a unit of measurement for volume) of water or juice, order date 10/24/24, start date 10/25/24

During a concurrent observation and interview on 1/7/2025 between 8:46 AM and 9:25 AM with Licensed Vocational Nurse (LVN) 10 in Resident 256's room, LVN 10 prepared and administered the following medications:

1. One tablet of carbidopa-levodopa (a combination medication used to treat Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]) 25 milligrams (mg - a unit of measurement for mass) - 100 mg

2. One tablet of Biktarvy (a medication used to treat viral infection) 50-200-25 mg

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0759 3. Three tables of divalproex (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 500 Level of Harm - Minimal harm or mg delayed release potential for actual harm 4. Fluticasone nasal spray (a medication used to treat seasonal allergy related symptoms) to be given as one Residents Affected - Few spray in both nostrils

5. Two patches of lidocaine 4%, one for left knee and one for right knee

6. One tablet of multivitamin with minerals

7. One tablet of oxybutynin (a medication used to treat symptoms of overactive bladder such as incontinence) extended release 10 mg

8. One tablet of probiotic 30 billion colony forming units (CFU)

9. One scoop of Reguloid (generic name - Natural Psyllium Husk) dissolved in 4 oz of water in a cup that was not graduated with measurement marking

LVN 10 stated she assumed the water cup she was using to measure water and dissolve one scoop of psyllium was eight ounces. LVN 10 then used the small one-ounce medicine cup to measure eight-ounce water. LVN 10 stated she could only fit four ounce of water in the cup. LVN 10 stated the physician order required psyllium to be administered with eight-ounce of water so this would have been a wrong dose. LVN 10 then administered the one scoop of psyllium husk dissolved in four-ounce water, along with a cup of four-ounce water on the side to Resident 256. LVN 10 stated not using prescribed amount of water would have been a medication error and increased the risk for Resident 256 to not be treated for constipation. LVN 10 stated if the psyllium husk was not completely dissolved in prescribed eight ounces of water, there was a risk for Resident 256 to get side effects such as constipation or diarrhea.

During an interview on 1/9/2025 at 4:13 PM with Director of Nursing (DON), DON stated facility did not have graduated cups to measure volume of water accurately to dissolve medications. DON stated if the psyllium husk was not dissolved in the prescribed eight ounces of water, it would increase the risk of side effects such as abdominal pain, gas, nausea, and diarrhea. DON stated he was not aware that by taking psyllium without eight-ounce liquid could cause choking.

b. During a review of Resident 205's Admission Record, dated 1/8/2025, the admission record indicated the facility admitted Resident 205 on 7/31/2023 with diagnoses including (but not limited to) paroxysmal atrial fibrillation (a medical condition described as a type of irregular heartbeat), functional quadriplegia (a medical condition described by inability to move due to severe disability), chronic pain, reduced mobility, and generalized muscle weakness.

During a review of Resident 205's History and Physical dated 11/15/2024, the document indicated Resident 205 could make needs known but could not make medical decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0759 During a review of Resident 205's MDS dated [DATE REDACTED], the MDS indicated Resident 205's cognition was intact. The MDS indicated Resident 205 needed cleanup assistance from facility staff for eating, needed Level of Harm - Minimal harm or touching assistance for oral hygiene, toileting, personal hygiene and upper body dressing, and moderate potential for actual harm assistance for showering and lower body dressing.

Residents Affected - Few During a review of Resident 205's Order Summary Report dated 1/8/2025, the order summary report indicated the following (but not limited to) physician orders:

Monitor for excessive bleeding from the nose. If bleeding continues, hold Eliquis (generic name - apixaban, a medication used to prevent cerebrovascular accident [CVA] - stroke, loss of blood flow to a part of the brain), every shift, order date 10/22/2024, start date 10/22/2024

Aspirin enteric coated (EC) tablet delayed release 81 milligram (mg - a unit of measurement for mass), give 1 tablet by mouth one time a day for stroke prophylaxis (prevention), order date 11/24/2024, start date 11/25/24

Eliquis 2.5 mg, give 1 tablet by mouth two times a day for deep venous thrombosis (DVT - a blood clot that forms in a deep vein, usually in the leg or pelvis), order date 12/21/2023, start date 12/22/2023

During a concurrent observation and interview on 1/7/2025 between 9:38 AM and 10:01 AM with LVN 4 in Resident 205's room, prepared the following medications to be administered.

1. One tablet of acetaminophen (a medication used to treat fever and pain) 500 mg

2. One tablet of aspirin 81 mg

3. One tablet of calcium (a supplement to treat low level of calcium) 600 mg plus vitamin D 10 mcg (400 IU)

4. One tablet of Eliquis 2.5 mg

5. One tablet of labetalol (a medication used to treat hypertension (HTN - high blood pressure) 100 mg

6. One tablet of magnesium oxide (a supplement used to treat low level of magnesium) 400 mg (elemental 240 mg)

7. One tablet of multivitamin with minerals

8. One tablet of nifedipine (a medication used to treat HTN) ER 60 mg

9. Two tablets of sennosides (a laxative used to relieve constipation) 8.6 mg

10. One tablet of telmisartan (a medication used to treat HTN) 80 mg

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0759 During medication administration, LVN 4 stated Resident 205 sometimes refuses to take aspirin due to nose bleeds. LVN 4 administered all the medications except aspirin. LVN 4 stated Resident 205 refused to take Level of Harm - Minimal harm or aspirin because of nosebleed. LVN 4 did not visually check Resident 205 for signs and symptoms of potential for actual harm nosebleed. LVN 4 stated she would inform the physician that aspirin was held for Resident 205 because of nosebleed. Residents Affected - Few

During a medication reconciliation review on 1/7/2025 at 12:37 PM, Resident 205's order summary report with active physician orders dated 1/8/2025, medication administration observations on 01/07/2025 and medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/7/2025 were reviewed. The order summary report indicated there was no physician order that indicated holding aspirin for nosebleed. The order summary report indicated there was an active physician order that indicated, monitor for excessive bleeding from the nose. If bleeding continues, hold Eliquis. During the medication pass observation, LVN 4 administered Eliquis 2.5 mg to Resident 205 and held aspirin 81 mg. The MAR for 1/7/2025 indicated aspirin 81 mg was documented as administered although it was held during medication observation. The MAR for 1/7/2025 indicated Eliquis 2.5 mg was documented as administered.

During a review of Resident 205's MAR dated 01/01/2025 to 1/31/2025, the MAR indicated that LVN 4 documented No (N) for monitor for excessive bleeding from the nose, for 1/7/2025 day.

During a concurrent interview and record review on 1/08/2025 at 12:26 PM with LVN 2, Resident 205's medication administration history and details dated 01/07/2025 for aspirin EC 81 mg, progress note for aspirin EC 81 mg dated 01/07/2025 and administration history and details for Eliquis 2.5 mg dated 01/07/2025 were reviewed. The administration details for aspirin EC 81 mg and Eliquis 2.5 mg indicated LVN 4 documented both medications were administered on 01/07/2025 at 10:03 AM. The progress notes for aspirin EC 81 mg indicated, resident is refusing x3 (tried 3 times). Risk and benefits have been explained MD has been made aware. LVN 2 stated LVN 4 was not available at that time, but she could try answering questions. LVN 2 stated LVN 4 documented a progress note for aspirin EC 81 mg on 01/07/2025 indicating that aspirin was held but documented as administered.

During an interview on 1/8/2025 at 12:43 PM with LVN 2, LVN 2 stated there was a physician order to hold Eliquis if there was excessive bleeding from the nose and if bleeding continues and to monitor resident. LVN 2 stated there was no physician order to hold aspirin in case of nosebleed. LVN 2 stated Resident 205 should have also been assessed and monitored for low blood pressure, fast heart rate, bleeding in stool, bleeding in urine and check if there were abnormal vitals compared to resident's baseline, changes in level of consciousness when she complained of nosebleed. LVN 2 stated Resident 205 was at risk for stroke, DVT, hospitalization or even death. LVN 2 stated aspirin for Resident 205 was not documented accurately on 01/07/2025 10:03 AM which could cause medical errors and risk resident's wellbeing.

During an interview on 1/8/2025 at 1:45 PM with DON, DON stated facility staff should always follow physician orders for medications. DON stated facility staff should notify physician if resident was receiving an anticoagulant and if they experienced bleeding. DON stated nurse should have assessed the resident for nosebleed by using a flashlight to visualize the nosebleed and check the back of resident's throat to note any visible signs of bleeding. DON stated the resident would not benefit from aspirin to prevent stroke because it was not administered per physician's orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0759 During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated 11/16/2023, the P&P indicated, Medications shall be administered in accordance with the orders, including Level of Harm - Minimal harm or any required time frame. The P&P indicated, The licensed personnel preparing or administering the potential for actual harm medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns if a dosage is believed to be inappropriate . or medication has been identified as having potential Residents Affected - Few adverse consequences for the resident or is suspected of being associated with adverse consequences. The P&P indicated, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document the applicable code for specific situation as indicated

on the eMAR . scheduled prescribed time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 49130 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of three sampled Residents Affected - Few residents (Resident 256) was free from significant medication errors by failing to administer Resident 256's lidocaine patch (a medication applied topically to relieve pain) in accordance with physician's orders.

This failure of not administering Resident 256's medication in accordance with the physician orders or professional standards of practice had the potential to result in hospitalization due to adverse effects such as abnormal breathing, abnormal heartbeat, numbness, and tingling.

Findings:

During a review of Resident 256's Admission Record (a document containing demographic and diagnostic information), dated 01/08/2025, the facility admitted Resident 256 on 10/09/2024 with diagnosis including (but not limited to) generalized muscle weakness.

During a review of Resident 256's History and Physical dated 10/10/2024, the document indicated Resident 256 had the capacity to understand and make decisions.

During a review of Resident 256's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 10/15/2024, the MDS indicated Resident 256's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 256 needed cleanup assistance from facility staff for eating, needed moderate assistance for oral hygiene, personal hygiene and upper body dressing, and maximal assistance to being dependent for toileting, showering and lower body dressing.

During a review of Resident 256's Order Summary Report (a list of all currently active medical orders) dated 01/08/2025, the order summary report indicated the following (but not limited to) physician orders:

Lidocaine External Patch 4 percent (% - a unit of measurement for strength), apply to left knee topically one time a day for pain management and remove per schedule, order date 11/24/2024, start date 11/25/24

Lidocaine External Patch 4%, apply to right knee topically one time a day for R knee pain and remove per schedule, order date 10/27/2024, start date 10/28/2024

During a concurrent observation and interview on 01/07/2025 between 8:46 AM and 9:25 AM with Licensed Vocational Nurse (LVN) 10 in Resident 256's room, LVN 10 prepared two patches of lidocaine 4% one for left knee and one for right knee to be applied. LVN 10 removed one lidocaine patch from left knee dated 1/5/25, removed one patch from right knee dated 1/5/25, applied one patch each with date 1/7/25 and initials to left and right knees. LVN 10 stated Resident 256's lidocaine patches labeled with date 1/5/25 should have been removed and after drug free period, new lidocaine patches should have been applied with date and nurse initials on 1/6/2025. LVN 10 stated excessive lidocaine could cause irregular heartbeat and hospitalization for Resident 256.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0760 During a concurrent interview and record review on 01/07/2025 at 3:15 PM with LVN 16, the medication administration details of lidocaine 4% patch for Resident 256 were reviewed. The medication administration Level of Harm - Minimal harm or details indicated one lidocaine patch each were applied to left and right knee on 01/06/2025 at 9:00 AM and potential for actual harm one lidocaine patch each were removed from left and right knee on 01/06/2025 at 9:00 PM. LVN 16 stated

she forgot to apply new lidocaine patch for Resident 256 on 01/06/2025 because the Certified Nursing Residents Affected - Few Assistant (CNA) was assisting the resident with changing and dressing, during which time LVN 16 forgot to return to Resident 256's room to apply lidocaine patch. LVN 16 stated she should only document medications that were administered and should not have documented lidocaine patch as administered on 01/06/2025 when it was not administered. LVN 16 stated this showed inaccurate documentation and increased the risk of medication errors. LVN 16 stated Resident 256 received additional lidocaine because

the patches dated 01/05/2025 were not removed from both knees on 01/06/2025.

During an interview on 01/08/2025 at 1:45 PM with Director of Nursing (DON), DON stated lidocaine patch should have been removed on 01/05/2025. DON stated nurses should have documented date and time when lidocaine patch was removed and applied. DON stated due to prolonged application of lidocaine patches, the medication could have been absorbed for a longer period which could increase the risk of dizziness, nausea, vomiting and ringing in the ear.

During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated 11/16/2023, the P&P indicated, Medications shall be administered in accordance with the orders, including any required time frame. The P&P indicated, The licensed personnel preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns if a dosage is believed to be inappropriate . or medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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** 49130 Residents Affected - Few Based on observation, interview, and record review, the facility failed to:

1. Ensure storage, labeling, and/or removal of expired, undated and/or discontinued medications including insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication), Calcitonin (a medication administered into the nostrils to treat osteoporosis [a bone disease with low bone mineral density]) salmon (synthetic origin) nasal spray, Zytiga (generic name - abiraterone acetate, a medication used to treat cancer [a disease caused by uncontrolled division of abnormal cells in a part of the body]) and Stiolto Respimat (generic name - a combination of two medications containing tiotropium bromide and olodaterol used to treat chronic obstructive pulmonary disease [COPD - a chronic lung disease causing difficulty in breathing]), in accordance with manufacturer requirements and facility's policy and procedure (P&P) titled, Discontinued Medications undated and Storage of Medications undated, affecting four residents (Residents 111, 184, 218, 481) in three of six inspected medication carts (First Floor Medication Cart A, First Floor Medication Cart B, First Floor Medication Cart C).

2. Ensure removal of expired vitamin D3 (also known as cholecalciferol, a vitamin used to treat low level of vitamin D) from medication room, and storage of refrigerated medications and vaccines that included Ozempic (generic name - semaglutide, a medication used to treat Type 2 Diabetes Mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]), Mounjaro (generic name - tirzepatide, a medication used to manage Type 2 Diabetes), Prevnar 20 (an injectable vaccine used to prevent pneumonia [an infection/inflammation in the lungs]), Tubersol (Tuberculin test used during tuberculosis [a contagious bacterial disease that usually affects lungs but can also affect other parts of the body]) and omega-3 fish oil (a medication used to treat high triglyceride [a type of fat that circulates in blood and is stored in fat cells]) levels, at temperature range of 2 to 8 degree Celsius [( C) is a unit of temperature] (36 -to-46-degree Fahrenheit [( F) is a unit of temperature], per manufacturer requirements, affecting five residents (Residents 10, 107, 109, 153, 174) and other facility residents in one of three inspected medication rooms (Station 2 Medication Room).

These failures had the potential to result in Residents 10, 107, 109, 111, 153, 174, 184, 218, 481 and other facility residents receiving medications and vaccines that were discontinued, expired, ineffective, and/or toxic due to improper storage or labeling possibly leading to health complications such as hyperglycemia (high blood glucose [simple sugar- the body's primary source of energy from food]), breathing problems, bone disease, pneumonia, heart complications and hospitalization .

Findings:

1a. During a concurrent inspection and interview on [DATE REDACTED] at 2:23 PM with Licensed Vocational Nurse (LVN) 10 of the First Floor Medication Cart A, the following medication was found expired:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 a. One opened Insulin Lispro Kwikpen 100 units (a unit of measurement for insulin) / milliliters (mL - a unit of measurement for volume) for Resident 111 labeled with an open date of ,d+[DATE REDACTED] and an expiration date of Level of Harm - Minimal harm or [DATE REDACTED]. potential for actual harm According to the manufacturer's product labeling, once opened / in-use or once stored at room temperature, Residents Affected - Few insulin lispro must be used within 28 days or be discarded. Resident 111's insulin lispro expired on [DATE REDACTED].

LVN 10 stated insulin lispro was expired and should have been removed from the medication cart and discarded. LVN 10 stated the quality and potency of an expired insulin are compromised and would not be safe to administer to Resident 111 to lower blood glucose and could cause hyperglycemia.

1b. During a concurrent inspection and interview on [DATE REDACTED] at 3:34 PM with LVN 11 of the First Floor Medication Cart B, the following medications were found either expired, discontinued, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:

a. One opened Lantus ([generic name - insulin glargine] Solostar 100 units/mL Pen for Resident 218 labeled with an open date of ,d+[DATE REDACTED] and an expiration date of ,d+[DATE REDACTED].

According to the manufacturer's product labeling, unopened / not in-use pen if stored at room temperature (a below 86 F [30 C]) and opened / in-use pen must be used within 28 days.

LVN 11 stated Lantus Solostar for Resident 218 expired on [DATE REDACTED] and should have been removed from the medication cart. LVN 11 stated an expired insulin may not work to control blood sugar for Resident 218 increasing the risk for high blood glucose, ketoacidosis and even hospitalization .

b. One unopened bottle of Zytiga (generic name - abiraterone acetate) 500 mg with 60 tablets, for Resident 218.

LVN 11 stated Zytiga for Resident 218 was discontinued on [DATE REDACTED] and should have been removed from the medication cart and provided to the Director of Nursing (DON) for appropriate disposal.

During a concurrent interview and record review on [DATE REDACTED] at 4:17 PM with LVN 11, the clinical physician orders for Zytiga 500 mg for Resident 218 were reviewed. The order for generic name - abiraterone acetate oral tablet 500 mg was discontinued with an end date of [DATE REDACTED] with the note dated [DATE REDACTED] that indicated, received doctor order to discontinue due to patient starting on chemotherapy. LVN 11 stated it was important for the medication to be removed from the medication cart to prevent any drug diversion, misuse, or medication errors.

c. One Calcitonin nasal spray for Resident 481 with no documented opened date.

According to the manufacturer's product labeling, medication bottle should be stored, if unopened in refrigerator between 2 C-8 C (36 F-46 F) and opened / in-use bottle at room temperature between 20 C-25 C (68 F-77 F) in an upright position, for up to 35 days and bottle should be discarded after 30 doses have been used.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 LVN 11 stated the container should have had an opened date to be able to determine expiration date and to prevent administering the expired medication to Resident 481. LVN 11 stated Calcitonin was used to treat Level of Harm - Minimal harm or osteoporosis and so if expired the medication would not be safe or effective to administer to Resident 481. potential for actual harm LVN 11 stated Resident 481 was discharged on [DATE REDACTED].

Residents Affected - Few 1c. During a concurrent inspection and interview on [DATE REDACTED] at 4:35 PM with LVN 12 of the First Floor Medication Cart C, the following medication was found with no open date as required by their respective manufacturer's specifications:

a. One package of Stiolto Respimat inhalation solution 2.5 micrograms (mcg - a unit of measurement for mass) / 2.5 mcg per actuation (spray) for Resident 184 with no documented open date. The cartridge was inserted into the inhaler device.

According to the manufacturer's product labeling, after assembly, the Stiolto Respimat inhaler should be discarded at the latest three months after first use or when the locking mechanism is engaged, whichever comes first.

LVN 12 stated Stiolto did not have an open date documented on the package. LVN 12 stated the package should have had an open date to be able to determine expiration date. LVN 12 stated Stiolto was used for Resident 184's COPD and breathing difficulties and would not be safe and effective for Resident 184's condition because it was not labeled properly.

2a. During a concurrent inspection and interview on [DATE REDACTED] at 11:04 AM with Registered Nurse (RN) 2 of the Station 2 Medication Room, the following medication was expired:

a. One unopened bottle of Vitamin D3 10 mcg (equivalent to 400 international units [IU - a unit of measurement for mass]), 100 tablets, with an expiration date of ,d+[DATE REDACTED].

RN 2 stated vitamin D3 was expired and should have been removed from medication stock and discarded. RN 2 stated expired medication would not be safe or effective to administer to facility residents and could have adverse health consequences.

2b. During a concurrent inspection and interview on [DATE REDACTED] at 11:04 AM with RN 2 of the medication refrigerator in Station 2 Medication Room, the thermometer in the refrigerator indicated temperature of 30 F.

The following medications were found stored in a manner contrary to their respective manufacturer's requirements:

a. One pen of Ozempic injection 2 milligrams (mg - a unit of measurement for mass) / 3 mL for Resident 174 labeled with an open date of [DATE REDACTED] and two doses of 0.25 mg documented as given on [DATE REDACTED] and [DATE REDACTED], and one dose of 0.5 mg documented as given on [DATE REDACTED].

According to the manufacturer's product labeling, Ozempic should be stored in a refrigerator between 36 F to 46 F (2 C to 8 C) prior to first use. The labeling indicated Ozempic should not be kept frozen and should not be used if it has been frozen. The labeling indicated Ozempic could be stored for 56 days at controlled room temperature (59 F to 86 F; 15 C to 30 C) or in a refrigerator (36 F to 46 F; 2 C to 8 C) after the first use.

b. One unopened package of four Mounjaro 10 mg/0.5 mL pens for Resident 109.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 According to the manufacturer's product labeling, Mounjaro should be stored in a refrigerator at 2 C to 8 C (36 F to 46 F). The labeling indicated if unrefrigerated, Mounjaro should be stored at temperatures not to Level of Harm - Minimal harm or exceed 30 C (86 F) for up to 21 days. The labeling indicated Mounjaro should not be used if frozen. potential for actual harm c. Partial vial of Tubersol labeled as house supply for facility labeled with an open date of [DATE REDACTED]. Residents Affected - Few According to the manufacturer's product labeling, Tubersol should be stored refrigerated at 2 C to 8 C (35 F to 46 F). The labeling indicated Tubersol should not be kept frozen, and product should be discarded if exposed to freezing.

d. One unopened Prevnar 20 single dose prefilled syringe for Resident 10

e. One unopened Prevnar 20 single dose prefilled syringe for Resident 107

According to the manufacturer's product labeling, Prevnar 20 vaccine should be stored refrigerated at 2 C to 8 C (36 F to 46 F). The labeling indicated Prevnar 20 vaccine should not be kept frozen, and it should be discarded if frozen.

f. One bottle of omega 3 fish oil for Resident 107 labeled with an open date of [DATE REDACTED]

g. One bottle of omega 3 fish oil for Resident 153 labeled with an open date of [DATE REDACTED]

According to the manufacturer's product labeling, omega 3 fish oil should be refrigerated after opening.

h. One unopened refrigerated emergency kit (e-kit - an emergency kit supplied by facility's pharmacy to be used for facility residents in case of an emergency) labeled as Facility, 2nd Floor Refrigerate E-kit, Ref-EKit#15

RN 2 stated the refrigerator temperature was at 30 F which was not in accordance with manufacturer requirements. RN 2 stated the medications and/or vaccines in refrigerator such as Ozempic, Mounjaro, omega 3 fish oil, E-kit, Tubersol and Prevnar 20 would not be safe and effective to be administered to Residents 174, 109, 10, 107, 153, and other facility residents because they were not stored according to manufacturer's labeling. RN 2 stated these medications would not be safe and effective for residents and could cause adverse health consequences such as pneumonia, hyperglycemia, failed weight management, cardiac complications, hospitalization or even death.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 an interview on [DATE REDACTED] at 1:00 PM with DON, DON stated the medications stored in refrigerator were not at the manufacturer required temperature range. DON stated these medications would not be safe and Level of Harm - Minimal harm or would not exhibit therapeutic benefit if administered to residents. DON stated discontinued medication Zytiga potential for actual harm should have been promptly removed from medication cart and appropriately destroyed because if someone did not pay attention, there was a risk for medication to be administered by mistake. DON stated expired Residents Affected - Few insulin would not control blood glucose for residents and increase risk for hyperglycemia. DON stated Calcitonin nasal spray and Stiolto should have an open date so that an expiration date could be determined when applicable. DON stated if the medication lost potency or safety, they could worsen resident's osteoporosis and COPD. DON stated there could be other negative effects from improperly stored medications.

During a review of the facility's P&P titled, Storage of Medications, undated, the P&P indicated, Medications shall be stored at appropriate temperatures. Medications required to be stored at room temperature shall be stored at a temperature of not less than 15 C (59 F) or more than 30 C (86 F). Medications requiring refrigeration shall be stored between 2 C (36 F) and 8 C (46 F). The P&P indicated, Discontinued medication containers shall be marked to indicate that the medication has been discontinued and shall be disposed of within 90 days of the date the medication was discontinued. The P&P indicated, Insulin - store in refrigerator, until it is opened. If may then be kept in the medication cart or the refrigerator. Insulin shall be discarded , d+[DATE REDACTED] days (per manufacturer guidelines) after it has been opened. Note: it is the responsibility of the nurse to be aware of the manufacturer guidelines prior to storing any medications.

During a review of the facility's P&P titled, Discontinued Medication, undated, the P&P indicated, discontinued .shall be given to the facility designate upon discontinuation (DON, etc) and placed in a secured location. Discontinued medication shall be disposed of within 90 days, or; returned to pharmacy within 30 days of the date . that time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38740

Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, by failing to:

1.Discard expired food and/or drinks.

a. One medium sized container of cottage cheese with dates ,d+[DATE REDACTED]-[DATE REDACTED] exceeding storage period for cottage cheese was stored in the reach in refrigerator.

b. Five expired single serve cartons of milk with dates [DATE REDACTED] were stored in the reach in refrigerator.

2. Label food taken from freezer with dates the foods were thawed.

a. Nutritional Supplement labeled store frozen with manufacturers instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after

this time frame.

b. One tray with 30 single serve cartons of mixed vanilla and chocolate flavored nutrition supplement were stored in the reach in refrigerator with no thaw date.

c. Individual juice cartons with manufacturers instruction indicating if frozen, thaw, refrigerate and use within 10 days, were not monitored for the date they were thawed to ensure expired juice were discarded.

d. One tray holding 5 apple flavored juice and one tray with 4 apple flavored single serve juice cartons were stored in the reach in refrigerator with no thaw date.

e. Two boxes with each containing 30 single serve juice cartons stored in the walk-in refrigerator with no thaw date.

3. Ensure kitchen staff did not store disposable kitchen towels in a bucket of water and reuse to clean and wipe food contact surfaces and food preparation equipment such as food storage carts and food prep counters.

4. Ensure kitchen staff did not store one open tube feeding bag in the resident refrigerator located next to the nurse's station in the nourishment room, with no date or label.

These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 287 out of 294 residents who received food from the facility, including 62 residents who received nutritional supplements, 30 residents who received juice, and residents who had food stored in the resident refrigerator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0812 Findings:

Level of Harm - Minimal harm or 1. During an observation in the kitchen on [DATE REDACTED] at 8:40AM, 5 single serve cartons of milk with an potential for actual harm expiration date of [DATE REDACTED] were observed stored in the reach in refrigerator.

Residents Affected - Few During a concurrent observation and interview with Dietary supervisor (DS), DS stated the milk was expired and should have been discarded. DS stated expired milk could cause GI problems.

During the same observation and interview on [DATE REDACTED] at 8:40AM, there was one open container of cottage cheese with dates [DATE REDACTED] to [DATE REDACTED] exceeding storage period for cottage cheese stored in the reach in refrigerator. DS stated the cottage cheese was expired and should have been discarded.

During an interview with Dietary Lead (DL) on [DATE REDACTED] at 8:45AM, DL stated cottage cheese was to be stored for 7 days after opening. DL stated the cottage cheese should have been discarded because the cottage cheese was expired. DL stated the kitchen staff over the weekend failed to discard food that was expired.

A review of facility policy and procedure titled Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods. (dated [DATE REDACTED]) indicated, Commercially processed foods that are not PH adjusted, must be dated when opened and are good for 7 days, or until the expiration date (such as milk, cottage cheese and soft cheese) the use by date or expiration date on the label is only valid if it comes before the 7th day.

2.During an observation in the kitchen on [DATE REDACTED] at 9:00AM, 30 single serve cartons of nutritional supplement (high calorie nutrition shakes for residents who will benefit from additional calories in their diet) were observed stored in the reach in refrigerator with no thaw date.

During a concurrent observation and interview on [DATE REDACTED] at 9:15AM, with DS, DS stated the shakes were stored in the freezer then removed from freezer and placed in refrigerator to thaw. DS stated confirmed there was no thaw date on the nutrition supplements. DS stated once thawed the product was safe for 14 days. DS stated expired nutrition shakes could cause GI problems and stomachache in residents.

During the same observation in the kitchen on [DATE REDACTED] at 9:15AM, 5 apple flavored single serve juice cartons

on one tray and 4 cranberry flavored single serve juice cartons on another tray were observed stored in the reach in refrigerator with no thaw date.

During and observation in the walk-in refrigerator on [DATE REDACTED] at 9:05 AM, two boxes with each containing 30 single serve juice cartons were observed stored in the walk-in refrigerator with no thaw date.

During an interview with DS and DL on [DATE REDACTED] at 9:15 AM DS stated the juices were delivered frozen and were stored in the refrigerator. DS stated the facility did not label the juices with a thaw date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0812 During a concurrent observation and review of the manufacturer's instructions for the storage of the juices on [DATE REDACTED] at 9:15AM, DS reviewed the manufacturer's instructions and stated the juices were stored frozen and Level of Harm - Minimal harm or once thawed they were good for 10 days. DS stated the juices and supplements should have been labeled potential for actual harm with a date to monitor date of thaw and when to discard.

Residents Affected - Few During a review of facility policy and procedure titled Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods. (dated [DATE REDACTED]) indicated, Health shakes usually have a 14-day refrigerated shelf life once thawed. They must be individually labeled or kept together in a bod or container that has date mark for use by date. The day they are pulled from freezer is day 1.

3.During an observation in the kitchen on [DATE REDACTED] at 9:45AM, [NAME] 2 was observed picking up one kitchen towel stored in a bucket of water, then wiping down the counters. There were additional towels stored in the same bucket of water. [NAME] 2 then sprayed the counters with a sanitizer spray and with the same kitchen towel wiped off the sanitizer on the surface.

During an interview on [DATE REDACTED] at 9:45AM, [NAME] 2 stated the bucket was filled with water to store kitchen cloth/towels. [NAME] 2 stated there was no detergent or sanitizer in the bucket and the bucket was filled with only water.

During a concurrent interview with DS on [DATE REDACTED] at 9:45AM, DS stated he had not provided in- service to staff on the use of the sanitizer spray.

During an observation in the kitchen on [DATE REDACTED] at 10:00AM, Dietary Aide (DA1) demonstrated the cleaning of food contact surfaces using the kitchen cloth and the sanitizer spray. DA1 picked up kitchen towel from the bucket. DA1 stated the bucket was filled with water only. DA1 then wiped visible stains and crumbs from the counter, then sprayed the counters with sanitizer. DA1 waited 60 seconds then wiped the counters with the same towel to wipe off the sanitizer. After DA1 was done cleaning and sanitizing, DA1 placed the towel back inside the bucket filled with water.

During a concurrent observation and interview with DS [DATE REDACTED] at 10:00AM DS stated staff should not use

the same cloth to wipe the sanitizer from the counters. DS stated staff should not store the used kitchen towels in the bucket of water. DS stated staff was contaminating the water in the bucket and could cause cross contamination of the counters and food contact surfaces and cause food borne illness.

During a review of the manufacturer instruction for the Foodservice Surface sanitizer it indicated, to sanitize hard Food contact surfaces, visible soil must be removed prior to sanitizing by pre cleaning. Wash surface and follow with a potable water rinse. Spray .this product with a cloth or sprayer device until surface is thoroughly wet .treated surface must remain visibly wet for 60 seconds. Wipe or allow to air dry, no rinse required.

A review of the 2022 U.S. Food and Drug Administration Food Code, Code ,d+[DATE REDACTED].14 Wiping Cloths, use Limitation, indicated, (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be:

(1) Held between uses in a chemical sanitizer solution at a concentration specified under S ,d+[DATE REDACTED].114; and (2) Laundered daily as specified under ,d+[DATE REDACTED].11(D).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0812 (C) Cloths in-use for wiping surfaces in contact with raw animal FOODS shall be kept separate from cloths used for other purposes. Level of Harm - Minimal harm or potential for actual harm 4. During an observation in the resident refrigerator located next to nurses' station on the first floor on [DATE REDACTED] at 1:40PM, one open tube feeding formula container (provides nutrition to people who cannot obtain nutrition Residents Affected - Few by mouth, are unable to swallow safely or need nutritional supplementation.) was observed stored in the refrigerator with no label or date.

During an interview with Licensed Vocational Nurse 16 (LVN 16) who was the charge nurse on [DATE REDACTED] at 1:45PM, LVN16 stated tube feeding formula was not to be stored in resident refrigerator for outside food. LVN16 stated there was also no label or date on the tube feeding bag and the bag had to be discarded. LVN16 stated it was not clear why the tube feeding container was stored in the refrigerator and storing the bag in the refrigerator for outside food could cause cross contaminate other resident food. LVN16 stated food items had to be dated to ensure the food items were discarded before expiration. LVN 16 stated once open food items were to be stored for 3 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 38740 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the trash stored in the Residents Affected - Few dumpster areas was maintained in sanitary manner.

One of five garbage dumpster was overfilled with trash bags and uncovered. The floor area around the trash dumpsters was not clean, there was disposable gloves, paper, and food.

This deficient practice had the potential for harborage and feeding of pests.

Findings:

During a concurrent observation and interview with DS and Facility Maintenance Manager (FMM) on 1/6/2025 at 2:00PM, one large dumpster outside of the food storage area was not covered. The dumpster was overfilled with trash bags and not covered. There was trash on the floor including disposable gloves and melted ice cream.

During a concurrent interview with DS, DS stated the dumpster lids should be covered and there should not be trash on the floor. DS stated everyone uses the trash bins and it's not only dietary staff.

During the same observation, FMM stated housekeeping cleans the area per shift and this must have happened after lunch shift. FMM stated trash bins should be covered and floors kept clean free of food debris to prevent attracting flies and pests in the facility.

A review of facility policy and procedures titled Trash Collection and Removal (dated 11/2023) indicated, Trash bags will be tightly closed, put into covered transport carts, and taken to the outdoor trash bins. Bags will be deposited into the trash bins/receptacles and lids will be closed.

A review of Food and Drug Administration (FDA) Food Code 2022 dated 1/18/2023, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that

they are inaccessible to insects and rodents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0825 Provide or get specialized rehabilitative services as required for a resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36943 potential for actual harm Based on observation, interview, and record review, the facility failed to provide therapy services, including Residents Affected - Some Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) and Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) to one of nine sampled residents (Resident 96) with range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns in accordance with Resident 96's physician signed care plans for OT and PT.

This failure resulted in Resident 96 not receiving OT and PT interventions from 10/9/2024 to 10/29/2024 to improve activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) and potentially contributed to Resident 96's further ROM limitations in both knees.

Findings:

During a review of Resident 96's Admission Record, the facility admitted Resident 96 on 3/7/2024 and readmitted on [DATE REDACTED]. The Admission Record indicated Resident 96's diagnoses including a history of falling and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).

During a review of Resident 96's census (record of hospitalization s, room changes, and payer source changes), the census indicated Resident 96 was discharged to the hospital on 10/4/2024 and readmitted to

the facility on [DATE REDACTED].

During a review of Resident 96's PT Evaluation and Plan of Treatment, dated 10/9/2024, the PT Evaluation indicated Resident 96 had poor appetite, less interactive, and tested positive for Coronavirus-19 (COVID-19,

an infectious viral disease that can cause respiratory illness) prior to hospitalization . The PT Evaluation indicated Resident 96 was referred to PT due to impaired mobility and impaired ability to safely ambulate (walk). The PT Evaluation indicated Resident 96 had within functional limits ([WFL] sufficient movement without significant limitation) ROM in both legs. The PT Plan of Treatment included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), gait training therapy (training for walking), and therapeutic activities (tasks that improve the ability to perform activities of daily living [ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility]), three times per week for four weeks. Resident 96's physician signed the PT Evaluation and Plan of Treatment on 10/11/2024.

During further review of Resident 96's PT Evaluation and Plan of Treatment, dated 10/9/2024, the PT Evaluation indicated Resident 96's short-term and long-term goals were changed on 10/29/2024 (20 days later). Resident 96's updated short-term and long-term goals included for Resident 96 to wearing both knee extension splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). Resident 96's physician signed the PT Evaluation and Plan of Treatment with the updated goals on 11/2/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0825 During a review of Resident 96's OT Evaluation and Plan of Treatment, dated 10/10/2024, the OT Evaluation indicated Resident 96 had a change in condition and hospitalization . The OT Evaluation indicated Resident Level of Harm - Minimal harm or 96 was referred to OT due to decreased strength, mobility, transfers, and reduced ADL participation. The OT potential for actual harm Evaluation indicated Resident 96 had within normal limits ([WNL] normal joint movement) ROM in both arms.

The OT Plan of Treatment included therapeutic activities, self-care management training, therapeutic Residents Affected - Some exercises, and neuromuscular reeducation, five times per week for 60 days. Resident 96's physician signed

the OT Evaluation and Plan of Treatment on 10/11/2024.

During a review of Resident 96's physician's orders, dated 10/14/2024, the physician's orders indicated for

the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to provide Resident 96 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) in both arms and legs, [NAME] times per week.

During a review of Resident 96's PT Treatment Encounter Notes, the PT Treatment Encounter Notes indicated Resident 96 received PT treatment on 10/9/2024 and then on 10/29/2024 (20-day gap).

During a review of Resident 96's OT Treatment Encounter Notes, the OT Treatment Encounter Notes indicated Resident 96 received OT treatment on 10/10/2024 and then on 10/29/2024 (19-day gap).

During a review of Resident 96's Minimum Data Set ([MDS] a resident assessment tool), dated 11/11/2024,

the MDS indicated Resident 96 expressed ideas and wants, clearly understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDs indicated Resident 96 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for oral hygiene, dressing, and moving from lying to sitting on the side of the bed.

During a concurrent observation and interview on 1/7/2025 at 2:10 PM in Resident 96's room, Resident 96's torso was tilted perpendicularly (90-degree angle) toward the left side of the bed. Certified Nursing Assistant 4 (CNA 4) came into Resident 96's room and stated Resident 96 should not be positioned this way in bed. CNA 4 removed the blanket to reposition Resident 96 toward the middle of the bed. Resident 96's hips and knees were observed fully bent. CNA 4 stated Resident 96's legs were bent all the time.

During an observation on 1/8/2025 at 11:00 AM with Physical Therapist 2 (PT 2) and Occupational Therapist 1 (OT 1) in Resident 96's room, Resident 96's PT and OT session was observed. PT 2 and OT 1 transferred Resident 96 to sitting at the edge of the bed. Both of Resident 96's hips and knees were bent while seated. PT 2 and OT 1 attempted to scoot Resident 96's body further back while seated at the edge of the bed. Resident 96 complained of pain since the back of Resident 96's right leg was pressed against the metal frame of the bed. PT 2 and OT 1 transferred Resident 96 back to lying down in bed. Both of Resident 96's hips and knees continued to be in bent positions while lying in bed. Resident 96 performed arm exercises and ADLs with OT 1. PT 2 adjusted and bent both knee splints prior to placing them on Resident 96's knees.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0825 During a concurrent interview and record review on 1/8/2025 at 12:46 PM with OT 1 and PT 2, Resident 96's PT Evaluation, dated 10/9/2024, PT Treatment Encounter Notes, dated 10/9/2024 and 10/29/2024, OT Level of Harm - Minimal harm or Evaluation, dated 10/10/2024, and OT Treatment Encounter Notes, dated 10/10/2024 and 10/29/2024, were potential for actual harm reviewed. PT 2 stated Resident 96 received a PT Evaluation on 10/9/2024, had WFL ROM in both legs, but did not perform transfers and gait (manner of walking) due to Resident 96 screaming in pain (unspecified Residents Affected - Some location) with bed repositioning. OT 1 stated the PT treatment plan was for three times per week for four weeks. OT 1 stated Resident 96 was not seen for PT and OT treatment until 10/29/2024. PT 2 stated Resident 96 could develop ROM limitations and decreased mobility if Resident 96 did not receive PT in accordance with the treatment plan.

During a concurrent interview and record review on 1/8/2025 at 1:35 PM with the Director of Rehabilitation (DOR), OT 1, and PT 2, Resident 96's PT and OT records and physician's orders for RNA, dated 10/14/2024, were reviewed. The DOR stated Resident 96 was readmitted (on 10/8/2024) with physician's orders to perform PT, OT, and Speech Therapy ([ST] or [SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) evaluations.

The DOR stated Resident 96's health insurance did not authorize any PT and OT services after the evaluations. The DOR stated Resident 96 received RNA on 10/14/2024 while the facility waited for insurance authorization for PT and OT services. OT 1 reviewed Resident 96's PT Evaluation, dated 10/9/2024, and stated PT added the goal for splints on 10/29/2024. PT 2 stated a knee splint goal usually indicated a resident needed a splint to prevent contractures.

During an interview on 1/10/2025 at 8:32 AM with Restorative Nursing Aide 3 (RNA 3), RNA 3 stated Resident 96 used to walk with a walker prior to contracting COVID-19. RNA 3 stated the RNAs performed PROM to both arms and legs after Resident 96 had COVID-19 because the resident developed contractures and could not walk anymore.

During an concurrent interview and record review on 1/10/2025 at 2:31 PM with the DOR and the Director of Nursing (DON), Resident 96's PT Evaluation, dated 10/9/2024, OT Evaluation, dated 10/10/2024, and facility policies and procedures (P&P) titled, Scope of Therapy Services - PT, OT, SLP, revised 11/16/2023, and Resident Mobility and Range of Motion, dated 11/2023. The DOR stated there was a time gap between the PT and OT Evaluations and treatment because the facility did not receive Resident 96's insurance authorization to provide PT and OT. The DON reviewed the PT Evaluation and OT Evaluations which were signed by Resident 96's physician on 10/11/2024. The DON stated the physician agreed with the PT and OT plans for treatment. The DON stated the facility needed to provide Resident 96 with the treatment. The DOR and DON stated the facility's P&Ps for Rehabilitation Services and Mobility and ROM did not indicate to wait for a resident's insurance authorization prior to providing treatment.

During a review of the facility's P&P titled, Scope of Therapy Services - PT, OT, SLP, revised 11/16/2023,

the P&P indicated the facility shall provide quality rehabilitation services to the residents they serve.

During a review of the facility's P&P titled, Resident Mobility and Range of Motion, dated 11/2023, the P&P indicated residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36943

Residents Affected - Some Based on interview and record review, the facility did not ensure four of nine sampled residents (Resident 96, 130, 44, and 37) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) had complete clinical records.

1. Resident 96's clinical records did not include the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge Summaries on 6/14/2024.

2. Resident 96's clinical records did not include the Occupational Therapy Discharge Summary on 11/2/2024 and PT Discharge Summary on 11/4/2024.

3. Resident 130's clinical record did not include the OT Discharge Summary on 10/14/2024 and PT Discharge Summary on 10/15/2024.

4. Resident 44's clinical record did not include the OT Discharge Summary on 9/12/2024 and PT Discharge Summary on 9/15/2024.

5. Resident 37's clinical record did not include a PT Discharge Summary on 12/26/2024.

These failures had the potential to prevent Resident 96, 130, 44, 37 from receiving the recommended services to maintain ROM and mobility after discontinuation of PT and OT services.

Findings:

a. During a review of Resident 96's Admission Record, the facility admitted Resident 96 on 3/7/2024 and readmitted on [DATE REDACTED]. The Admission Record indicated Resident 96's diagnoses including a history of falling and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).

1. During a review of Resident 96's OT Evaluation and Plan of Treatment, dated 3/8/2024, the OT Plan of Treatment included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), therapeutic activity (tasks that improve the ability to perform activities of daily living [ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility]), and self-care management training, five times per week.

During a review of Resident 96's PT Evaluation and Plan of Treatment, dated 3/8/2024, the PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), gait training therapy (training to walk), and therapeutic activities, five time per week for 60 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0842 During a concurrent interview and record review on 1/8/2025 at 12:21 PM with Occupational Therapist 1 (OT 1) and Physical Therapist 2 (PT 2), Resident 96's OT Evaluation and PT Evaluation, dated 3/8/2024, PT Level of Harm - Minimal harm or Treatment Encounter Notes, and OT Treatment Encounter Notes, were reviewed. OT 1 stated Resident 96's potential for actual harm last OT treatment was on 6/14/2024 but stated Resident 96's clinical record did not have a OT Discharge Summary. PT 1 stated Resident 96's last PT treatment session was on 6/14/2024 but stated Resident 96's Residents Affected - Some clinical record did not have a PT Discharge Summary. OT 1 stated the therapists were supposed to complete

a Discharge Summary on the last day of treatment.

During an interview on 1/9/2025 at 8:35 AM with the Director of Rehabilitation (DOR), the DOR stated the purpose of the therapy Discharge Summaries included ensuring the proper recommendations were carried out after a resident was discharged from therapy. The DOR stated it was best practice to complete the Discharge Summary on the date of discharge from therapy to ensure recommendations were completed.

During an interview on 1/10/2025 at 2:31 PM with the Director of Nursing (DON), the DON stated the resident's clinical records should be complete and accurate to reflect the resident's condition and care provided.

During a review of the facility's policy and procedure (P&P) titled, Resident/Patient Treatment Process for Rehabilitation Services revised on 11/16/2023, the P&P indicated the discharge summaries were included as part of the resident's final visit to justify the entire treatment period as medically necessary. The P&P also indicated the Discharge Summary lists the resident's discharge plan and will include any specific instructions, including follow-up care and prevention of physical dysfunction.

2. During a review of Resident 96's PT Evaluation and Plan of Treatment, dated 10/9/2024, the PT Evaluation indicated Resident 96 had poor appetite, less interactive, and tested positive for Coronavirus-19 (COVID-19, an infectious viral disease that can cause respiratory illness) prior to hospitalization . The PT Evaluation indicated Resident 96 was referred to PT due to impaired mobility and impaired ability to safely ambulate (walk). The PT Evaluation indicated Resident 96 had within functional limits ([WFL] sufficient movement without significant limitation) ROM in both legs. The PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, gait training therapy, and therapeutic activities, three times per week for four weeks.

During a review of Resident 96's OT Evaluation and Plan of Treatment, dated 10/10/2024, the OT Evaluation indicated Resident 96 had a change in condition and hospitalization . The OT Evaluation indicated Resident 96 was referred to OT due to decreased strength, mobility, transfers, and reduced ADL participation. The OT Evaluation indicated Resident 96 had within normal limits ([WNL] normal joint movement) ROM in both arms.

The OT Plan of Treatment included therapeutic activities, self-care management training, therapeutic exercises, and neuromuscular reeducation, five times per week for 60 days.

During a concurrent interview and record review on 1/8/2025 at 12:46 PM with OT 1 and PT 2, Resident 96's PT Evaluation, dated 10/9/2024, and OT Evaluation, dated 10/10/2024, were reviewed. OT 1 stated Resident 96's last OT treatment was on 11/2/2024. OT 1 stated Resident 96's OT Discharge Summary was started on 11/2/2024 but was not completed. OT 1 stated Resident 96's last PT treatment was on 11/4/2024. OT 1 stated Resident 96's PT Discharge Summary was started on 11/4/2024 but was not completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0842 During an interview on 1/9/2025 at 8:35 AM with the DOR, the DOR stated the purpose of the therapy Discharge Summaries included ensuring the proper recommendations were carried out after a resident was Level of Harm - Minimal harm or discharged from therapy. The DOR stated it was best practice to complete the Discharge Summary on the potential for actual harm date of discharge from therapy to ensure recommendations were completed.

Residents Affected - Some During an interview on 1/10/2025 at 2:31 PM with the DON, the DON stated the resident's clinical records should be complete and accurate to reflect the resident's condition and care provided.

During a review of the facility's P&P titled, Resident/Patient Treatment Process for Rehabilitation Services, revised on 11/16/2023, the P&P indicated the discharge summaries were included as part of the resident's final visit to justify the entire treatment period as medically necessary. The P&P also indicated the Discharge Summary lists the resident's discharge plan and will include any specific instructions, including follow-up care and prevention of physical dysfunction.

b. During a review of Resident 130's Admission Record, the facility admitted Resident 130 on 9/1/2023 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), history of falling, muscle weakness, malignant neoplasm of connective and soft tissue (cancerous tumor that develops in the body's muscles, fat, and ligaments) of the left arm including the shoulder.

During a review of Resident 130's PT Evaluation and Plan of Treatment, dated 8/3/2024, the PT Evaluation indicated Resident 130 required minimum assistance ([MIN-A] requires less than 25 percent [%] physical assistance to perform the task) for bed mobility (ability to move around in bed, including rolling, scooting, and moving from lying and sitting) and transfers (moving from one surface to another), and walking 30 feet (unit of measure) on level surfaces using a FWW. The PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, gait training therapy, and therapeutic activities, three times per week for 60 days.

During a review of Resident 130's OT Evaluation and Plan of Treatment, dated 8/4/2024, the OT Evaluation indicated Resident 130 had WFL ROM in both arms and required moderate assistance ([MOD-A] requires 26 to 50% physical assistance to perform the task) for upper body dressing, lower body dressing, and toileting.

The OT Plan of Treatment included neuromuscular reeducation, therapeutic exercises, and self-care management, three times per week for 60 days.

During a concurrent interview and record review on 1/8/2025 at 3:02 PM with OT 1 and PT 2, Resident 130's PT Evaluation, dated 8/3/2024, and OT Evaluation, dated 8/4/2024, were reviewed. PT 2 stated Resident 130's last PT treatment was on 10/15/2024 but stated Resident 130's clinical record did not have a PT Discharge Summary. OT 1 stated Resident 130's last OT treatment was on 10/14/2024 but stated Resident 130's clinical record did not have a OT Discharge Summary.

During an interview on 1/9/2025 at 8:35 AM with the DOR, the DOR stated the purpose of the therapy Discharge Summaries included ensuring the proper recommendations were carried out after a resident was discharged from therapy. The DOR stated it was best practice to complete the Discharge Summary on the date of discharge from therapy to ensure recommendations were completed.

During an interview on 1/10/2025 at 2:31 PM with the DON, the DON stated the resident's clinical records should be complete and accurate to reflect the resident's condition and care provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0842 During a review of the facility's P&P titled, Resident/Patient Treatment Process, revised on 11/16/2023, the P&P indicated the discharge summaries were included as part of the resident's final visit to justify the entire Level of Harm - Minimal harm or treatment period as medically necessary. The P&P also indicated the Discharge Summary lists the resident's potential for actual harm discharge plan and will include any specific instructions, including follow-up care and prevention of physical dysfunction. Residents Affected - Some c. During a review of Resident 44's Admission Record, the facility admitted Resident 44 on 8/28/2024 with diagnoses including schizophrenia (mental illness that is characterized by disturbances in thought), dysphagia (difficulty swallowing), functional quadriplegia (condition that causes a person to be completely unable to move due to a severe disease), and muscles weakness.

During a review of Resident 44's PT Evaluation and Plan of Treatment, dated 8/29/2024, the PT Evaluation indicated Resident 44 had both knee extension contractures (knees positioned in full extension and difficult to bend the knees) and both plantarflexion contractures (ankles positioned away from the body and difficult to bend the ankles toward the body). The PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, and therapeutic activities, five times per week for 60 days.

During a review of Resident 44's OT Evaluation and Plan of Treatment, dated 8/29/2024, the OT Evaluation indicated Resident 44 had impaired ROM (unspecified) in both shoulders, elbows, and hands. The OT Plan of Treatment included therapeutic exercises, therapeutic activities, and self-care management, five times per week for 60 days.

During an interview on 1/9/2025 at 8:35 AM with the DOR, the DOR stated the purpose of the therapy Discharge Summaries included ensuring the proper recommendations were carried out after a resident was discharged from therapy. The DOR stated it was best practice to complete the Discharge Summary on the date of discharge from therapy to ensure recommendations were completed.

During a concurrent interview and record review on 1/9/2025 at 10:03 AM with the DOR, Resident 44's PT Evaluation, dated 8/29/2024, and PT Treatment Encounter Notes were reviewed. The DOR stated Resident 44's last PT treatment was on 9/15/2024 but stated Resident 44's clinical record did not include a PT Discharge Summary.

During a concurrent interview and record review on 1/9/2025 at 10:14 AM with the DOR, Resident 444's OT Evaluation, dated 8/29/2024, and OT Treatment Encounter Notes were reviewed. The DOR stated Resident 44's last OT treatment was on 9/12/2024, but Resident 44's clinical record did not include a OT Discharge Summary. The DOR stated the resident's clinical record was not complete without the PT and OT Discharge Summaries.

During an interview on 1/10/2025 at 2:31 PM with the DON, the DON stated the resident's clinical records should be complete and accurate to reflect the resident's condition and care provided.

During a review of the facility's P&P titled, Resident/Patient Treatment Process for Rehabilitation Services, revised on 11/16/2023, the P&P indicated the discharge summaries were included as part of the resident's final visit to justify the entire treatment period as medically necessary. The P&P also indicated the Discharge Summary lists the resident's discharge plan and will include any specific instructions, including follow-up care and prevention of physical dysfunction.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0842 d. During a review of Resident 37's Admission Record, the facility admitted Resident 37 on 9/18/2024 with diagnoses including B-cell lymphoma (cancer that affects white blood cells that helps with the body's immune Level of Harm - Minimal harm or system), Type II Diabetes Mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor potential for actual harm wound healing), muscles weakness, and unsteadiness on feet.

Residents Affected - Some During a review of Resident 37's PT Evaluation and Plan of Treatment, dated 9/19/2024, the PT Evaluation indicated Resident 37 had WFL ROM in both legs. The PT Evaluation indicated Resident 37 required maximum assistance ([MAX-A] requires 50 to 75% physical assistance) for walking 10 feet using a FWW.

The PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, gait training therapy, and therapeutic activities, five times per week for 60 days.

During a concurrent interview and record review on 1/9/2025 at 8:35 AM with the DOR, Resident 37's PT Evaluation, dated 9/19/2024, and PT Treatment Encounter Notes were reviewed. The DOR stated Resident 37's last PT treatment was on 12/26/2024 but stated Resident 44's clinical record did not include a PT Discharge Summary. The DOR stated the purpose of the therapy Discharge Summaries included ensuring

the proper recommendations were carried out after a resident was discharged from therapy. The DOR stated

it was best practice to complete the Discharge Summary on the date of discharge from therapy to ensure recommendations were completed.

During an interview on 1/10/2025 at 2:31 PM with the DON, the DON stated the resident's clinical records should be complete and accurate to reflect the resident's condition and care provided.

During a review of the facility's P&P titled, Resident/Patient Treatment Process for Rehabilitation Services, revised on 11/16/2023, the P&P indicated the discharge summaries were included as part of the resident's final visit to justify the entire treatment period as medically necessary. The P&P also indicated the Discharge Summary lists the resident's discharge plan and will include any specific instructions, including follow-up care and prevention of physical dysfunction.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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** 36943 potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control practices Residents Affected - Few for 3 of 6 residents (Resident 96, 228, and 74) with infection control concerns by failing to ensure staff and visitors wore eye protection, including a face shield or eye goggles, while providing care to the residents, who were under observation for exposure to Coronavirus Disease 2019 (COVID-19, a highly contagious viral disease that can cause respiratory illness), in accordance to the signage posted upon entering the room and Federal guidance.

This failure had the potential to spread COVID-19 throughout the facility.

Findings:

a. During a review of Resident 96's Admission Record, the facility admitted Resident 96 on 3/7/2024 and readmitted on [DATE REDACTED]. The Admission Record indicated Resident 96's diagnoses including a history of falling and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).

During a review of Resident 96's care plan titled, Resident is at risk for s/s (signs and symptoms) of COVID-19, due to an exposure on 1/1/2025, dated 1/2/2025, the care plan intervention indicated to follow the facility protocol for COVID-19 precautions.

During a review of the facility's yellow COVID-19 posted sign, the yellow COVID-19 sign indicated to clean hands on room upon entry, wear a gown on room entry, wear a N-95 (a disposable face mask that covers

the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) mask, wear face shield or goggles, wear gloves on room entry, and clean hands upon exiting the room.

During an interview on 1/7/2025 at 1:42 PM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated the facility's yellow zone (resident rooms with an exposure to someone positive for COVID-19) included Resident 96's room.

During a concurrent observation of the entrance to Resident 96's room and interview on 1/7/2025 at 2:10 PM, a yellow COVID-19 sign was posted upon entrance to Resident 96's room. Resident 96 was observed with the torso tilted perpendicularly (90-degree angle) toward the left side of the bed. CNA 4 came into Resident 96's room and stated Resident 96 should not have been positioned that way in bed. CNA 4 removed the blanket to reposition Resident 96 toward the middle of the bed. CNA 4 was observed wearing a gown, N-95 respirator, and gloves but was not wearing any eye protection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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

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

F 0880 During an observation in Resident 96's room on 1/8/2025 at 11:00 AM with Physical Therapist 2 (PT 2) and Occupational Therapist 1 (OT 1) in Resident 96's room, Resident 96's PT and OT session was observed. PT Level of Harm - Minimal harm or 2 and OT 1 were observed wearing gown, gloves, and N-95 respirators but did not wear any eye protection. potential for actual harm PT 2 and OT 1 transferred Resident 96 to sitting at the edge of the bed. Both of Resident 96's hips and knees were bent while seated. PT 2 and OT 1 attempted to scoot Resident 96's body further back while Residents Affected - Few seated at the edge of the bed. Resident 96 complained of pain since the back of Resident 96's right leg was pressed against the metal frame of the bed. PT 2 and OT 1 transferred Resident 96 back to lying down in bed. Resident 96 performed arm exercises, hand washing, face washing, and grooming with OT 1.

During an interview on 1/9/2025 at 11:21 AM with OT 1, OT 1 stated precautions for working with a resident

in the yellow zone included to sanitizing hands and to wear a gown, gloves, N-95 mask, and face shield. OT 1 stated OT 1 did not see other facility staff wearing face shields in the yellow zone but stated face shields were to be worn during close contact with residents in the yellow zone.

b. During a review of Resident 228's Admission Record, the facility admitted Resident 228 on 3/18/2024 with diagnoses including displaced fracture (break in bone) of the right femur (hip bone) and history of falling.

During a review of Resident 228's physician's orders, dated 4/10/2024, the physician's orders indicated for

the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to assist Resident 228 to ambulate (walk) 20 feet (unit of measure) using a front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking).

During a review of Resident 228's care plan titled, Resident is at risk for s/s (signs and symptoms) of COVID-19, due to an exposure on 1/1/2025, dated 1/2/2025, the care plan intervention indicated to follow the facility protocol for COVID-19 precautions.

During a review of the facility's yellow COVID-19 posted sign, the yellow COVID-19 sign indicated to clean hands-on room upon entry, wear a gown on room entry, wear a N-95 wear face shield or goggles, wear gloves on room entry, and clean hands upon exiting the room.

During an interview on 1/7/2025 at 1:42 PM with CNA 3, CNA 3 stated the facility's yellow zone included Resident 228's room.

During an observation of Resident 228's door and interview on 1/7/2025 at 2:04 PM with RNA 2 and RNA 3,

a yellow COVID-19 sign was posted in front of Resident 228's door. RNA 2 and RNA 3 had a FWW and stated they were going to walk with Resident 228. RNA 2 and RNA 3 wore gowns, gloves, and N-95 masks but were not observed wearing eye protection.

c. A review of the admission record indicated Resident 74 was readmitted to the facility on [DATE REDACTED] with diagnoses including acute respiratory failure (your lungs suddenly can't provide enough oxygen to your body, causing severe shortness of breath) and dementia.

A review of Resident 74's History and Physical (H&P) report completed on 7/22/2024, indicated Resident 74 was positive for COVID.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 A review of Resident 74's Minimum Data Set (MDS - a resident assessment tool) dated 12/22/2024, indicated Resident 74 could make herself understood and understood others. The MDS indicated Resident Level of Harm - Minimal harm or 74 used a wheelchair and needed maximum assistance for toileting and bathing. potential for actual harm

A review of Resident 74's Order Summary Report dated 1/13/2025, indicated Resident 74 was to be Residents Affected - Few monitored for COVID.

A review of Resident 74's care plan for At Risk for signs and symptoms of COVID due to 1/1/2025 COVID exposure to Restorative Nursing Aide (RNA). The care plan intervention indicated the facility should have followed the protocol for screening and precautions for COVID. The care plan indicated the facility would educate family and visitors of COVID precautions. The care plan also indicated the facility would observe droplet precautions (precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets such as COVID).

During an observation outside Resident 74's room on 12025 at 1/9/2025 at 11:30 a.m., a yellow warning sign was observed posted on the wall indicating the need to see the nurse before entering the room. The yellow sign included instructions to clean hands when entering the room, to wear a gown, wear an N95 mask, gloves, and a face shield or goggles. Additionally, the family member of Resident 74 was observed in Resident 74's room, in close contact with Resident 74 helping the resident eat. The family member was observed wearing a gown, mask, and gloves but not wearing a face shield or protective eyewear.

During an interview on 1/9/2025 at 11:32 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 74's family member should have been educated to wear eye protection or face shield. During a concurrent interview, RNS 1 stated Resident 74's family member should have been educated to wear eye protection or face shield to protect anyone who was in contact with Resident 74 to prevent the spread of infections.

During a review of the Center for Disease Control (CDC) guidelines, updated 5/8/2023, the CDC guidelines indicated health care personnel who enter the room of a patient with suspected COVID-19 infection should use a N-95 respirator, gown, gloves, and eye protection, including goggles or a face shield that covers the front and the sides of the face.

A review of the facility's policy and procedure (P&P) titled, Isolation - Categories of Transmission-Based Precautions (TBP - additional precautions for patients with suspected or known transmissible infection, dated November 2023, indicated TBP was used to provide additional measures to protect staff, visitors, and other residents from being infected. The P&P indicated the signage used by the facility would inform the staff to the type of precautions and use of personal protective equipment (PPE - refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) to use along with instructions to see the nurse before entering a resident's room with this type of sign.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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

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

F 0880 During a concurrent interview and record review on 1/9/2024 at 12:25 PM with the Infection Prevention Nurse (IPN), the facility's yellow COVID-19 sign, and CDC guidance was reviewed. The IPN initially stated Level of Harm - Minimal harm or staff working with residents in the yellow zone needed to wear a N-95 mask, gown, gloves, and perform potential for actual harm handwashing. IPN stated the staff needed to wear eye protection, including face shield or goggles, if they were in direct contact with a symptomatic resident who were coughing and sneezing. IPN reviewed the Residents Affected - Few facility's yellow COVID-19 sign and CDC guidance. The IPN stated the CDC guidance did not specifically indicate eye protection should be worn with symptomatic residents. The IPN then stated staff needed to also wear eye protection when in direct contact with a resident.

During a review of the facility's policy and procedure (P&P) titled, Isolation - Categories of Transmission-Based Precautions (TBP - additional precautions for patients with suspected or known transmissible infection, dated 11/2023, the P&P indicated TBP was used to provide additional measures to protect staff, visitors, and other residents from being infected. The P&P indicated the signage used by the facility would inform the staff to the type of precautions and use of personal protective equipment ([PPE] refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) to use along with instructions to see the nurse before entering a resident's room with this type of sign.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 50296

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment, by failing to provide one of five sample resident (Resident 38) a stable toilet seat with side rails.

The deficient practice had the potential for Resident 38 to fall and sustain an injury.

Findings:

During an interview on 1/6/25 at 11:32 AM, Resident 38 reported having fallen in the bathroom on earlier that morning (1/6/25). Resident 38 stated she did not grab hold of the toilet seat side rails because they were loose. One is looser than the other.

During an observation in Resident 38's bathroom on 1/6/25 at 11:36 AM, the toilet seat side rails were attached by grey screws to the back of the toilet. The side rails raised up and down allowing a resident to grab hold to get up. The side rails moved freely but in the down position the railings did not adhere to the floor and were wobbly back and forth.

During an interview on 1/7/25 at 7:30 AM, in Resident 38 room, Resident 38 stated she felt confident getting up. Resident 38 stated she was sitting on the toilet and got up and started to sway back and forth and then fell . Resident 38 stated she could not grab onto the side rails attached to the toilet because the handles were wobbly. Resident 38 could not remember if she (Resident 38) reported this concern.

During an observation with the Maintenance Staff (MS) in the Resident 38's bathroom on 1/7/25 at 7:40 AM, Resident 38's toilet seat side rails were observed. The MS stated central supply installed the toilets with the side rails and maintenance would perform repairs. The MS stated the side rails were supposed be free to move up and down and not adhere to the floor. The MS stated Resident 38's toilet side rails were not 100% safe for the residents and would not prevent the residents from falling.

During an interview on 1/9/25 at 7:45 AM, the Maintenance Manager (MM) stated Resident 38's toilet was a standard seat provided to the facility. During a concurrent observation, the MM observed Resident 38's toilet side rails and confirmed the side rails were unstable when weight was applied. The MMD stated and agreed

the side rails would not prevent a resident from failing.

During an interview on 1/9/25 at 2:01 PM, the Director of Nursing (DON) stated he observed the toilet seat and We should get occupational therapy to assess the resident and get a bedside commode that is safe. The DON stated the risk to the residents would be falling and getting physically injured.

During a concurrent interview and record review on 1/9/25 at 2:15 PM, with the medical records staff, the Bathroom Maintenance policy was requested. The Bathroom Bedrooms, Maintenance Services, and Quality of Life policies were reviewed, but there was no indication regarding a stable toilet seat with side rails to prevent falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 76 555438

F-F679

Findings:

A review of Resident 197's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (one-sided muscle weakness), dementia (a progressive state of decline in mental abilities), and muscle weakness.

A review of Resident 197's Minimum Data Set (MDS, a standardized assessment and care screening tool) completed on 10/15/2024, indicated Resident 197 had mild cognitive (a person's ability to think, learn, remember, use judgement, and make decisions) impairment and was moderately dependent with bed mobility, transfer, dressing, feeding, toileting, personal hygiene, and bathing. The MDS indicated it was very important for Resident 197 to perform favorite activities.

A review of Resident 197's Activity Assessment Form dated 10/16/2024, indicated Resident 197 enjoyed reading magazines and books.

A review of Resident 197's History and Physical dated 10/10/2024, indicated the resident did not have the capacity to understand or make medical decisions.

A review of Resident 197's care plan related to activities initiated on 10/31/2024, indicated that resident enjoys social and recreational involvement with minimal levels of participation. The interventions included to make activity adaptations to accommodate the residents change in abilities and condition.

During a concurrent observation in Resident 197's room and interview on 1/6/2025 at 11:45 AM, Resident 197 was observed lying in bed awake with the television (TV) on. Resident 197 was able to make needs known but otherwise confused. Certified Nursing Assistant (CNA 8) stated Resident 197 liked to sit up in the chair and color or do activities with the activity aide.

A review of Resident 530's face sheet indicated that Resident 530 was admitted to the facility on [DATE REDACTED], with diagnoses that included depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities) and muscle wasting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0656 A review of Resident 530's MDS completed on 1/3/2025, indicated Resident 530 had no cognitive impairment and was moderately dependent with bed mobility, transfer, dressing, feeding, toileting, personal Level of Harm - Minimal harm or hygiene, and bathing. The MDS indicated it was important for Resident 530 to do things with groups of potential for actual harm people.

Residents Affected - Some A review of the Resident 530's Activity Assessment Form dated 1/3/2025, it indicated that Resident 530 enjoys watching TV.

A review of Resident 530's History and Physical dated 12/29/2024, indicated the resident had the capacity to understand and make decisions.

A review of Resident 530's care plan related to activity dated on 12/28/2024, indicated to determine resident's activity of choice and encourage resident to engage in individual and group activity.

During a concurrent observation in Resident 530's room and interview on 1/6/2025 at 1:30 PM, Resident 530 was observed lying in bed awake. Resident 530 stated she was not able to get up out of bed and preferred to stay in her room. Resident 530 stated she would prefer to do group activities but since she was unable to,

she preferred to watch television (TV) or listen to music. Resident 530 stated although she likes to watch TV

it could get boring and would like to sometimes listen to music. Resident 530 stated she mentioned wanted to listen to music to facility staff, but no one had updated the resident on the request.

During an interview on 1/8/2025 at 2:34 PM with the Activities Director (AD), the AD stated the resident's activity preferences were to be added to the care plan and updated if there were changes. The AD stated it was important for the care plan to reflect the resident's current interests.

A review of the facility's P&P titled Activity Evaluation and revised November 2023, it indicated that each resident's activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs. It further indicated that the activity evaluation is used to develop individual activities care plan that will allow the resident to participate in activities of his/her choice and interest.

49881

A review of Resident 44's Admission Record indicated the facility admitted the resident on 3/03/2021 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

A review of Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 3/07/2024, indicated while in the facility it was somewhat important to participate in religious services or practices and do her favorite activities.

A review of Resident 44's Activity Assessment Form dated 3/08/2024, indicated the resident's preferences included turning on television or music, Christian service 1x week, and bingo games at bedside. The assessment indicated the residents desired outcome from involvement within the activity program was pleasure and comfort.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0656 A review of Resident 44's MDS dated [DATE REDACTED], indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS Level of Harm - Minimal harm or indicated the resident was dependent (helper does all of the effort) with personal, oral, and toilet hygiene and potential for actual harm eating.

Residents Affected - Some During a concurrent observation and interview on 1/06/2025 at 1:38 PM in Resident 44's room, Resident 44 was observed laying on her bed and watching television. Resident 44 stated she liked to play bingo and go to church but stayed in the room all day watching television.

During a concurrent interview and record review on 1/09/2024 at 11:38 AM with the Activities Director (AD), Resident 44's electronic record was reviewed. The AD confirmed Resident 44 did not have an activity care plan. The AD stated it was important the resident had an activity care plan, so the staff were familiar with the resident's preferences. The AD stated it was important to have a care plan, so the resident did not become isolated while living in the facility.

During an interview on 1/10/2024 at 9:07 AM with the Director of Nursing (DON), the DON stated Resident 44 did not have an activity care plan. The DON stated it was important that all residents had an activity care plan because the care plan enabled the staff to determine what activities the resident liked to do.

A review of the facility's P&P titled Activities Programs- Staffing, revised November 2023, indicated the activity director/coordinator's responsibilities included ensuring that the activity goals and approaches were reflected in the resident's care plans and were individualized to match the skills, abilities, and interest/preferences of each resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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** 50714

Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 173's) care plan for alteration in comfort was updated quarterly.

This deficient practice had the potential to slow or stop Resident 173's progress toward achieving the highest practicable level of functioning.

Findings:

A review of the admission record indicated Resident 173 was admitted to the facility on [DATE REDACTED], with diagnoses including diabetes, dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and spinal stenosis (a narrowing of the spinal canal in the lower part of your back).

A review of Resident 173's History and Physical (H&P) report completed on 5/2/2024, indicated Resident 173 did not have the capacity to understand and make decisions.

A review of the Resident 173's Minimum Data Set (MDS - a resident assessment tool) dated 11/6/2024, indicated Resident 173 was able to identify the correct year, but not the month or day of the week. The MDS indicated the resident was able to recall words after cueing (prompting). The MDS indicated Resident 173 was able to understand others and was dependent on staff for toileting, upper body dressing, and putting on/taking off footwear.

A review of Resident 173's care plan titled, Alteration in Comfort, revised 5/18/2024, indicated the goal was for Resident 173 to be able to participate in care and activities of daily living (ADLs - eating, bathing, dressing, using the bathroom, getting in and out of bed, and moving around). The care plan did not indicate a quarterly review of the effectiveness of the interventions.

During an interview on 01/08/25 03:13 PM, Restorative Nursing Aide 11 (RNA 11) stated worked at the facility for 4 years and performed range of motion (ROM - movements you do to gently move each joint in your body as far as it can go) services for residents. RNA 11 stated if Resident 173 refused to get up out of bed, she would perform ROM at the very least. RNA 11 stated Resident 173 could have mobility and comfort problems if the resident did not get up or do ROM.

During an interview on 1/9/2025 at 8:23 a.m., Licensed Vocational Nurse (LVN) 9 stated if the care plan was not updated or revised, it would be difficult to see if the facility's care plan was effective or if Resident 173 was making progress toward the care plan goal. LVN 9 stated that a care plan was to be updated if the resident had a change in condition and the facility should have been checking monthly regarding the effectiveness of Resident 173's care plan.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 concurrent interview and record review on 1/9/2025 at 8:45 a.m., with Registered Nursing Supervisor 1 (RNS 1), the care plan titled Alteration in comfort revised on 5/18/2024 was reviewed. RNS 1 Level of Harm - Minimal harm or stated the care plan was not updated. The RNS 1 stated the care plan should have been reviewed by the potential for actual harm charge nurses during the weekly summary. RNS 1 stated if the care plan was not updated, it would be difficult for the facility to tell if Resident 173 was making progress or not. RNS 1 stated if Resident 173 was Residents Affected - Few not making any progress, the facility should have revised the care plan.

During an interview on 1/9/2025, at 9:37 a.m., the Director of Nursing (DON) stated care plans were to be updated quarterly and for any change in a resident's condition. The DON stated the last time the Resident 173's care plan for alteration in comfort was last revised was 5/18/2024. The DON acknowledged it would be difficult to see if Resident 173 was making progress on goals if the care was not updated.

A review of the facility's policy and procedure (P&P) titled, Care Planning (IDT) Policy, dated 11/16/2023, indicated residents will have a comprehensive care plan to meet their individual needs and would be reviewed and revised after subsequent assessments. The P&P also indicated care plans would be revised per the Resident Assessment Instrument (RAI - a detailed questionnaire used by nursing homes to thoroughly evaluate each resident's physical, mental, and social needs) schedule and as changes in a resident's condition dictated. The P&P indicated the facility would review clinical issues, along with dates of upcoming reviews.

A review of the facility's P&P titled, Resident Assessment Instrument, the RAI indicated the facility would

review the resident assessment schedule regularly and would review the resident's treatment plan with the physician during care conference or regularly schedule physician visit. The P&P also indicated the facility may complete during Initial, Quarterly, Annual and during episodes of significant change in condition an interdisciplinary progress and care plan when appropriate and in accordance with statutory and / or regulatory guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 76 555438 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555438 B. Wing 01/10/2025

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

Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031

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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49836 potential for actual harm Based on observations, interview, and record review the facility failed to provide consistent activities for three Residents Affected - Some of three residents (Resident 197, Resident 530, and Resident 44).

This deficient practice had the potential to decrease physical, cognitive, sense of belonging, and emotional health.

Cross Reference: