Kei-ai Los Angeles Healthcare Center

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

1's feet were tied together with a flat sheet. CNA 1 stated the sheet was tied tight around Resident 1's feet so the resident could not move his feet. CNA 1 stated he (CNA1) immediately notified RN 1. CNA 1 stated

he (CNA1) was not sure who tied Resident 1. CNA 1 stated whoever tied Resident 1 probably did it so the resident could not move his legs. CNA 1 stated we don't do that; we don't tie the residents. CNA 1 stated tying Resident 1's legs was a restraint. CNA 1 stated Resident 1 could have hurt themselves when restrained. During a telephone interview on 9/23/2025 at 12:43 PM with RN 3, RN 3 stated on 9/11/2025 at around 11:15 PM he (RN3) was asked by RN 1 to come and see Resident 1 to be another witness. RN 3 stated he (RN3) saw Resident 1's legs wrapped in a long bedsheet which was tied to each end of the resident's bed. RN 3 stated the bed sheet was tied around Resident 1's legs. RN 3 stated Resident 1 could not move his legs. RN 3 stated Resident 1 was placed in a restraint. RN 3 stated Resident 1 being restrained was abuse because the resident could not move freely. RN 3 stated there was a potential for Resident 1 to have his skin broken and his circulation cut off because of the restraints. During an interview

on 9/23/2025 at 1:42 PM with the Director of Staff Development (DSD), the DSD stated wrapping a sheet around Resident 1's legs and then tying the sheet to the bed was considered a restraint because it limited and restricted the resident's movement. The DSD stated wrapping a sheet around a resident's legs and then tying the sheet to the bed was not a normal practice at the facility. The DSD stated, we don't do that here. The DSD stated restraints affect the resident's rights and dignity. During an interview on 9/23/2025 at 3:04 PM with the Director of Nursing (DON), the DON stated wrapping a resident's legs with a sheet and tying the sheet to the bed frame was a form of restraint. The DON stated that it was not a normal practice in

the facility. The DON stated, we don't do that here. The DON stated CNA 2 took it upon himself to restrain Resident 1. The DON stated CNA2 should not have tied the resident with a sheet. The DON stated restraining Resident 1 could have potentially resulted in an injury and affected the resident's mental well-being. During a review of the facility's Policy and Procedure (P&P) titled Use of Restraints dated 4/24/25, the P&P indicated Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including.Tucking sheets so tightly that a bed bound resident cannot move.Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor).

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

both of Resident 1's feet were tied with a sheet to the left and right side of the bed frame. CNA 1 stated Resident 1's feet were tied together with a flat sheet. CNA 1 stated the sheet was tied tight around Resident 1's feet so the resident could not move his feet. CNA 1 stated he (CNA1) immediately notified RN 1. CNA 1 stated he (CNA1) was not sure who tied Resident 1. CNA 1 stated whoever tied Resident 1 probably did it so the resident could not move his legs. CNA 1 stated we don't do that; we don't tie the residents. CNA 1 stated tying Resident 1's legs was a restraint. CNA 1 stated Resident 1 could have hurt themselves when restrained. During a telephone interview on 9/23/2025 at 12:43 PM with RN 3, RN 3 stated on 9/11/2025 at around 11:15 PM he (RN3) was asked by RN 1 to come and see Resident 1 to be another witness. RN 3 stated he (RN3) saw Resident 1's legs wrapped in a long bedsheet which was tied to each end of the resident's bed. RN 3 stated the bed sheet was tied around Resident 1's legs. RN 3 stated Resident 1 could not move his legs. RN 3 stated Resident 1 was placed in a restraint. RN 3 stated Resident 1 being restrained was abuse because the resident could not move freely. RN 3 stated there was a potential for Resident 1 to have his skin broken and his circulation cut off because of the restraints.During an interview

on 9/23/2025 at 2:12 PM with the Administrator (ADM), the ADM stated he (ADM) was the abuse coordinator. The ADM stated that he (ADM) was made aware of Resident 1 being found with his legs wrapped on 9/11/2025 at 11:30 PM. The ADM stated he (ADM) reported the incident involving Resident 1 to CDPH and the Ombudsman on 9/12/2025. The ADM stated he (ADM) did not report the incident to CDPH and the Ombudsman sooner because there was no serious bodily injury. During an interview on 9/23/2025 at 3:04 PM with the Director of Nursing (DON), the DON stated the ADM was the facility's abuse coordinator. The DON stated the ADM reported the incident involving Resident 1 and CNA 2 to CDPH and

the Ombudsman. The DON stated the incident was not reported within two hours because Resident 1 did not have any serious bodily injury. During a review of the facility's Policy and Procedure (P&P) titled Abuse Investigation and Reporting dated 4/10/2025, the P&P indicated All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. findings of abuse investigations will also be reported.An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has no resulted in serious bodily injury.

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