Kei-ai Los Angeles Healthcare Center

During an observation on 1/6/2025 at 11:07 AM in Resident 225's room, Resident 225's call light was not within reach.

During a concurrent observation and interview with LVN 2 on 1/6/2025 at 11:07 AM, LVN 2 confirmed Resident 225's call light was not within reach. LVN 2 immediately placed Resident 225's call light within reach. LVN 2 stated it was important the residents call light was in reach so the resident can call if they need assistance.

During an interview on 1/9/2025 at 2:26 PM, the DON stated a resident's call lights should always be within the resident's reach.

The DON stated it was important to have the call light within reach because it was the resident's primary way to communicate with staff and communicate their needs.

A review of the facility's policy and procedure (P&P) titled, Call Light Assistance, revised January 2024, indicated for the facility to provide the resident a means of communicating with nursing staff.

Procedures included leaving the resident comfortable and placing the call device within residents reach before leaving room.

555438 01/10/2025

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

During an interview on 1/10/2025 at 1:22 PM with the DSD, the DSD stated it was a nursing standard of practice to discuss the situation directly with the resident's physician and to receive orders from the resident's physician.

The DSD stated there would be a domino effect (situation in which a series of interconnected events are set off by a single initial event) if Resident 130 did not move which could lead to the development of pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).

The DSD stated Resident 130 developed a Sacro-coccyx wound on 1/4/2024.

During a telephone interview on 1/10/2025 at 1:40 PM with Resident 130's Hospice Physician (Hospice MD 1), Hospice MD 1 stated he was not physically near a computer but did not remember anything reported for Resident 130's RNA services.

During a concurrent interview and record review on 1/10/2025 at 2:55 PM with the Director of Nursing (DON), Resident 130's Documentation Survey Report for RNA, dated 12/2024, physician's orders to discontinue RNA, dated 12/20/2024, were reviewed.

The DON stated the Documentation Survey Report indicated Resident 130 last walked with RNA on 12/16/2024.

The DON stated the Documentation Survey Report did not indicate Resident 130 refused to participate in RNA prior to 12/20/2024.

The DON stated the nurse should have assessed Resident 130 to verify Resident 130 was unable to walk, completed SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) documentation due to Resident 130's change of condition, directly communicated with Resident 130's physician, and carried out the physician's orders and recommendations.

The DON stated it was the nursing standard of practice to contact the physician directly for orders and changes of condition.

The DON stated Resident 130 could experience a decline in mobility without walking, placing Resident 130 at increased risk for other conditions like skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure).

During a review of the facility's policy and procedure (P&P) titled, Change of Condition or Status, effective 11/16/2023, the P&P indicated the facility shall promptly notify the resident, the attending physician, and representative of changes in the resident's condition.

The P&P indicated the nurse will make detailed observations and gather relevant and pertinent information for the provider prior to notify the physician or healthcare provider.

555438 01/10/2025

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

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 admission MDS, dated [DATE], the MDS indicated Resident 37 was admitted to the facility on [DATE]. A review of Section Z of Resident 37's admission MDS indicated the facility staff completed the assessment sections on 9/22/2024, 9/28/2024, 10/5/2024, and 10/22/2024.

The MDS RN signed the assessment as completed on 10/22/2024.

During a review of the Resident Assessment Instrument User's Manual, revised 10/2023, page 2-17 indicated the admission MDS completion date should be no later than the 14th calendar date of the resident's admission to the facility.

During an interview on 1/10/2025 at 10:27 AM with the MDSC and the MDS RN, the MDSC stated the purpose of the MDS included gather data to summarize a resident's care at the facility.

The MDSC stated the admission MDS (in general) should be completed with the MDS RN's signature within 14 days of admission.

During a concurrent interview and record review on 1/10/2025 at 11:37 AM with the MDSC and MDS RN, Resident 37's admission MDS, dated [DATE], was reviewed.

The MDSC stated Resident 37's admission MDS was completed late on 10/23/2024 (35 days after admission on [DATE]).

The MDSC stated the Resident 37's admission MDS was late because the MDS staff were performing additional duties due to the absence of a director of nursing (DON).

The MDSC stated late completion of Resident 37's admission MDS led to its late submission to the Federal database.

555438 01/10/2025

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

During an interview on 1/10/2025 at 10:27 AM with the MDSC and the MDS RN, the MDSC stated the

develop the resident's care plans.

The MDSC stated the Quarterly MDS (in general) had to be completed with the MDS RN's signature within 14 days after the ARD.

During a concurrent interview and record review on 1/10/2025 at 10:32 AM with the MDSC and MDS RN, Resident 127's Quarterly MDS, dated [DATE], was reviewed.

The MDSC stated Resident 127's Quarterly MDS was completed on 10/13/2024 (21 days after the ARD).

The MDSC stated Resident 127's Quarterly MDS was late because the MDS staff were performing additional duties due to the absence of a DON.

The MDSC stated late completion of Resident 127's MDS led to its late submission to the Federal database.

meeting and the medications were continued.

The DON agreed that the psychotropic medications for

dated 11/23 indicated the psychotherapeutic medication order shall include the following information diagnoses for the medication.

A review of the facility's P&P titled, Resident Assessment Instrument, dated 10/1/23, indicated the MDS Nurse was responsible for the completion of Section I - Active Diagnoses.

The P&P indicated each discipline assigned to complete the designated section of the MDS assessment was responsible for the accuracy of the information following the RAI manual.

555438 01/10/2025

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

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.

555438 01/10/2025

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

Resident 173's care plan for alteration in comfort was last revised was 5/18/2024.

The DON

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.

555438 01/10/2025

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

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 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.

555438 01/10/2025

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

During a review of Resident 128's PT Treatment Encounter Note, dated 4/15/2024, the PT Treatment

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.

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 transitioning Resident 128 from PT services to RNA services because Resident 128 refused to wear both 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.

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.

555438 01/10/2025

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

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.

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 padded side rails to prevent any danger or harm should be assessed and completed with each interaction.

555438 01/10/2025

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

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.

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 procedure.

Review the physician's orders or facility protocol for oxygen administration.

After completing the 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 the procedure.

555438 01/10/2025

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

performance evaluation completed annually.

The DON stated it was important for staff to have a

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], 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], 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.

555438 01/10/2025

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

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.

555438 01/10/2025

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

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.).

555438 01/10/2025

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

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.

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.

555438 01/10/2025

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

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.

555438 01/10/2025

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

Note: it is the responsibility of the nurse to be

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.

555438 01/10/2025

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

for outside food. LVN16 stated there was also no label or date on the tube feeding bag and the bag

other resident food. LVN16 stated food items had to be dated to ensure the food items were discarded

555438 01/10/2025

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

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.

555438 01/10/2025

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

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.

555438 01/10/2025

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

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.

555438 01/10/2025

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

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.

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 staff working with residents in the yellow zone needed to wear a N-95 mask, gown, gloves, and perform 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 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.

555438 01/10/2025

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

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.

555438 01/10/2025

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

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], 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.

555438

Form Approved OMB

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

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], with diagnoses that included depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities) and muscle wasting.

555438

Form Approved OMB

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