Kei-ai Los Angeles Healthcare Center
KEI-AI LOS ANGELES HEALTHCARE CENTER in LOS ANGELES, CA — inspection on February 20, 2026.
Found 13 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 13's Verification of Informed Consent for Psychotropic Medication dated 1/31/2023 for lamotrigine, the consent indicated the resident was provided information and the risks were discussed and reviewed.
The consent had not been renewed since 2023.
During a review of Resident 13's Verification of Informed Consent for Psychotropic Medication dated 2/21/2024 for trazadone, the consent indicated the resident was provided information and the risks were discussed and reviewed.
During a review of Resident 13's Verification of Informed Consent for Psychotropic Medication dated 12/10/2024 for aripiprazole, the consent indicated the resident was provided information and the risks were discussed and reviewed.
During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool) dated 1/9/2026, the MDS indicated Resident 13 was alert and oriented with good recall.
The MDS indicated Resident 13 had bipolar disorder and schizophrenia.
During a concurrent interview and record review on 2/19/2026 at 2:42 PM with Licensed Vocational Nurse (LVN) 8, Resident 13's consent for lamotrigine was reviewed. LVN 8 reviewed Resident 13's electronic chart for consent for lamotrigine but could not locate the document in the chart. LVN 8 stated consents were needed and the risk to Resident 13 would be the resident would not be informed of the risks and benefits of the medication. LVN 8 reviewed the consents for Trazadone and Aripiprazole and noted the consents had not been renewed.
LVN 8 stated she (LVN 8) was unsure when consents needed to be renewed.
During an interview on 2/19/2026 at 2:54 PM, with the Assistant Director of Nursing (ADON), the ADON stated that consents need to be renewed every six months.
The ADON was not sure if the facility's policy indicated if consents needed to be renewed every six months.
During an interview on 2/19/2026 at 3:45 PM with the Director of Nursing (DON), the DON stated that consents for psychotropic medications were a requirement and the resident and or their representative (unspecified) needed to be informed of the risks and benefits of the psychotropic medication.
The DON stated that consents needed to be updated every six months.
The DON stated Resident 13 could have been deprived of the opportunity to give consent and participate in the plan of care and be informed of the medications. A review of the facility's policy and procedures (P&P) titled, Informed Consent Policy, dated 4/2025, the P&P indicated no mention of the time frame when the psychotropic consent should be renewed. A review of the facility's policy and procedures (P&P) titled, Psychotropic Medication Use, dated 4/2025, the P&P indicated no mention of the time frame when the psychotropic consent should be renewed. A review of the All Facilities Letter (AFL, an official bulletin or memo sent by a government agency [most commonly the California Department of Public Health (CDPH)] to keep healthcare facilities informed about new rules, safety alerts, or changes in the law) dated 2/3/2026, the AFL indicated Facilities had to renew the Informed Consent form every six months during which the resident received a psychotherapeutic drug (used to manage mood, behavior, and thoughts).
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During a review of Resident 308's Discharge Instructions dated 1/2/2026 at 1:41 PM, the Discharge Instruction indicated Resident 308 was discharged to home with medical equipment arrangements for a hospital bed with Low Air Loss mattress (a specialized therapeutic mattress used in healthcare to prevent and treat pressure ulcers), wheelchair, walker and bathroom handrails.
During a review of Resident 308's nurses' notes dated 1/2/2026 at 5:23 p.m., the notes indicated Resident 308 was discharged home by Gurney (a wheeled cot, stretcher, used in hospitals and ambulances to transport patients who are unable to walk) and explained discharge instructions.
During a concurrent interview and record review on 2/19/2026 at 2:25 p.m. with Minimum Data Set Licensed Vocational Nurse (MDSLVN), Resident 308's order summary report was reviewed.
The MDSLVN stated the order dated 1/2/2026 indicated Resident 308's discharge orders were to home with family. Resident 308's nurses' notes dated 1/2/2026 were reviewed.
The notes indicated Resident 308 was discharged home.
The MDSLVN stated that Resident 308's daughter was given discharge instructions.
The MDSLVN reviewed Resident 308's MDS and stated the MDS indicated Resident 308 was discharged to Short-Term General hospital (a medical center that specializes in the short-term medical treatment of patients).
The MDSLVN confirmed by stating the discharge status of Resident 308 was incorrectly documented on the MDS.
The MDSLVN stated the MDS should have indicated discharged to home instead of discharged to Short-Term General Hospital.
The MDSLVN stated that MDS assessment had to be accurate.
The MDSLVN stated it was an incorrect assessment and reimbursement submission.
During an interview on 2/29/2026 at 3:13 p.m. with the Administrator (ADM), the ADM stated the MDS was an assessment process to determine the clinical picture of residents.
The ADM stated the MDS needed to be accurate.
The ADM stated the MDS reflected the quality of care and clinical status of Residents.
During a concurrent interview and record review on 2/19/2026 at 3:18 p.m. with the ADM, Resident 308's MDS dated [DATE] and nurses' notes dated 1/2/2026 were reviewed.
The ADM stated the MDS discharge status indicated that the resident was discharged to a short-term General Hospital.
The ADM stated Resident 308 was discharged home on 1/2/2026.
The ADM Stated the MDS did not reflect accurate discharge status of Resident 308.
The ADM stated the inaccuracy potentially affected financial reimbursement and accurate assessment of Resident 308.
During a review the facility's policy and procedure (P&P) titled, Certify Accuracy of the Resident Assessment, dated 4/2025, the P&P indicated Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment.
The P&P indicated The information captured on the assessment reflects the status of the resident during the observation period (the specific timeframe during which staff review a resident's care, treatments, and behavior to fill out their assessment accurately to identify the resident's usual condition and to guide care planning and reimbursement) for the assessment.
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
policy and procedure (P&P) titled, Support Surface Guidelines dated 4/2025, the P&P indicated Review
4/10/2025, the P&P indicated A comprehensive, person-centered care plan that includes measurable
developed and implemented for each resident.
The P&P indicated The comprehensive, person-centered care plan will incorporate risk factors associated with identified problems, reflect treatment goals, timetables and objectives in measurable outcomes.
The P&P indicated The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).
The P&P indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During a review the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive (complete) Person-Centered, dated 3/2025, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
The P&P indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
The P&P indicated The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition;b. when the desired outcome is not met;c. when the resident has been readmitted to the facility from a hospital stay; andd. at least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set - a resident assessment tool) assessment.The P&P indicated The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments.
Such refusals are documented in the resident's clinical record in accordance with established policies.
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During a review of Resident 193's Minimum Data Set (MDS, a resident assessment tool) dated
understand, and reason).
The MDS indicated Resident 193 was dependent on the staff (helper does all of the effort) for toileting hygiene, lower body dressing, lying to sitting on the side of the bed, and chair/bed to chair transfer.
The MDS indicated Resident 193 was at risk of developing pressure ulcers/injuries.
The MDS indicated Resident 193 utilized a pressure reducing device for bed.
During a review of Resident 193's Weights and Vitals Summary, the Weights and Vitals Summary indicated the resident weighed 118 pounds (lbs., a unit of weight) on 2/17/2026.
During a concurrent observation and interview on 2/17/2026 at 12:08 PM, with Licensed Vocational Nurse (LVN)1, in Resident 193's room, Resident 193 was observed on a Drive LALM with settings set between 320 and 350 lbs. LVN 1 confirmed Resident 193's LALM settings were set at 320 to 350 lbs.
LVN 1 stated the LALM settings were based on the Resident 146's weight. LVN 4 stated Resident 146's LALM settings at 350 lbs. were incorrect. LVN 1 verified Resident 193' weight in the medical record and stated Resident 193 current weight was 118 lbs. and stated the resident could have developed a pressure injury due to the mattress having been too hard for the resident.
During an interview on 2/18/2026 at 11:45 PM, with the Director of Nursing (DON), the DON stated LALMs were set up based on a resident's weight to provide appropriate pressure.
The DON stated if the LALM was too firm or too soft it could have been uncomfortable for the residents.
The DON stated residents that had potential for pressure injuries with a LALM set at the incorrect weight, and would impact the benefit of having a LALM in place.
During a review of the facility's policy and procedure (P&P) titled, Support Surface Guidelines dated 4/2025, the P&P indicated Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction.
During a review of the user manual titled Med-Aire Assure 5 Air +3 Foam Base Alternating Pressure and Low Air Loss Mattress System dated 3/22/2021, the user manual indicated .intended to help reduce the incidence of pressure ulcers while optimizing patient comfort.
The user manual indicated Turn the pressure adjust knob to set a comfortable pressure level using the weight scale as a guide.
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During an observation in Resident 79's room and interview on 2/17/2026 at 12:43 PM with Certified Nurse Assistant 5 (CNA 5), Resident 79's bed was observed to be in a high position. CNA 5 stated Resident 79's bed was in a high position and Resident 79 could fall out of bed.
During an interview on 2/172026 at 12:47 PM with Licensed Vocational Nurse 11 (LVN 11), LVN 11 stated if Resident 79's bed position was set too high, Resident 79 could be at risk for fall.
During an interview on 2/17/2026 at 12:57 PM with Registered Nurse 2 (RN 2), RN 2 stated if Resident 79's bed was not in a low position, Resident 79 could fall and have an injury. RN 2 stated staff should have placed Resident 79's bed in a low position.
During an interview on 2/19/2026 at 2:39 PM with the Director of Nursing (DON), the DON stated if Resident 79's bed was not in the low position, Resident 79 could fall and have an injury.
The DON stated Resident 79's bed should have been positioned to the lowest position.
During a review of the facility's policy and procedure (P&P) titled Falls - Clinical Protocol, dated 12/2025, the P&P indicated the facility would identify pertinent (relevant) interventions to try to prevent subsequent (following or additional) falls.
During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, dated 4/2025, the P&P indicated Our facility strives to make the environment as free from accident hazards as possible.
Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
The P&P indicated Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.
The P&P indicated risk factors included bed safety.
During a review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, dated 4/2025, the P&P indicated staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
The P&P indicated incorrect bed height, delirium (a sudden, temporary state of severe confusion and rapid mental decline ) and other cognitive impairment (having trouble with thinking, memory, focus, or decision-making that is more noticeable than normal aging), lower extremity weakness, and balance and gait disorders as a factors that could contribute to a resident's (in general) risk for fall.
The P&P indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During a review of Resident 120's Minimum Data Set (MDS - a resident assessment tool) dated 12/10/2025, the MDS indicated Resident 120 rarely/never had the ability to make herself (Resident 120) understood and rarely/never had the ability to understand others.
During a review of Resident 120's History and Physical (H&P) dated 10/17/2025, the H&P indicated Resident 120 was only oriented to person (means that a person knows who they are) due to dementia.
During a review of Resident 120's care plan dated 1/18/2026, the care plan indicated Resident 120 had impaired (decrease in ability) respiratory function r/t (related to) desaturation (drop in your blood oxygen levels below normal), tachycardia (an abnormally fast resting heart rate, generally defined as exceeding 100 beats per minute), fever pneumonia per x-ray result.
The care plan had an intervention to change tubing and oxygen humidifier bottle (small, reusable container filled with distilled water that attaches to an oxygen machine to prevent dry air from causing nosebleeds, throat irritation, and dry nasal passage) when in use per facility protocol (standardized set of rules, procedures, or instructions that dictate how communication, actions, or tasks are carried out, ensuring consistency and safety).
During a review of Resident 120's Nurses Notes dated 2/3/2026, the Nurses notes indicated Resident 120 was S/P (status post - after or following) antibiotic for pneumonia (an infection/inflammation in the lungs).
During a review of Resident 120's Order Review History Report dated 2/20/2026, the Order Review History Report indicated a physician order written on 1/18/2026 to change Resident 120's oxygen cannula tubing every 2 weeks on Sundays and as needed for soilage (the act of making something dirty, stained, or contaminated).
During a concurrent observation in Resident 120's room and interview on 2/17/2026 at 2:47 PM with Licensed Vocational Nurse 6 (LVN 6) and Certified Nursing Assistant 1 (CNA 1), Resident 120's oxygen nasal cannula tubing was observed touching the floor while Resident 120 was using the oxygen nasal cannula. CNA 1 stated the oxygen nasal cannula tubing on the floor could cause a tripping hazard. LVN 6 stated Resident 120 could get an infection from the oxygen nasal cannula tubing touching the floor and Resident 120's oxygen nasal cannula tubing would need to be changed right away.
During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, dated 1/2026, the P&P: indicated the facility would change oxygen tubing every 2 weeks or as needed.
During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated 4/2025, the P&P indicated the facility would provide residents (in general) with a clean, sanitary (free from germs), and orderly environment.
During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 3/27/2025, the P&P indicated An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections (when germs are spread from one person to another).
The P&P indicated the facility would educate staff on adhering (sticking) to proper infection prevention techniques and procedures.
The P&P indicated the facility would institute (put into place) prevention of infection measures to avoid complications and dissemination (spread).
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During a medication storage area inspection and interview on 2/18/2026 at 11:36
faxed to the pharmacy and then the form was put back inside of the Ekit and sent with the Ekit to the
controlled Ekits, Injectable Ekits, and non-controlled Ekits, such as oral and antibiotic medications.
During an interview on 2/18/2026 at 4:49 PM with the DON, the DON stated the facility did not have a process to monitor or track Ekit usage in the facility. A review of the facility's undated P&P titled, Emergency Medication Supply Procedures, indicated Medications will be available for administration to residents in emergency situations and situations requiring immediate administration of a medication 24 hours/ day, 7 days/week.Separate kits may be maintained according to routes of administration or storage needs.The nurse removing the medication from the emergency kit also enters a record of the medication withdrawn in the emergency medication administration record (log book) that is kept in the vicinity of the emergency kit.
The record shall include the name and dose of each medication being used, the name of the resident to whom the medication is being administered, the time and date of medication administration, and the signature of the person who administers the medication.
This emergency medication administration record must be retained as a permanent record .The pharmacist consultant monthly inspects the kits for expiration dating and integrity.
Discrepancies are reported to the director of nursing services. 4a.
During a concurrent medication storage area inspection and interview on 2/18/2026 at 3:39 PM of Station 1 MedCart B with LVN 4, a form titled, Controlled Drugs Inventory, was reviewed, and the spaces for nurses' signature In and Out for the 3 PM to 11 PM shift on 3/18/2026 was blank. LVN 4 stated that she was the incoming nurse and that she counted the controlled medications in the medication cart with the outgoing nurse for Station 1 MedCart B, but they both forgot to sign and the outgoing nurse had already left for the day.
LVN 4 stated it was important to sign the Controlled Drugs Inventory form with two nurses to ensure the controlled count was correct, complete, and to prevent diversion (misuse) of controlled medications. 4b.
During a concurrent medication storage area inspection and interview on 2/18/2028 at 4:10 PM of Station 1 MedCart A with LVN 5, a form titled Controlled Drugs Inventory,' was reviewed, and the space for nurses' signature Out for the 11 PM to 7 AM shift on 2/18/2026 was initialed/signed. LVN 5 stated that she accidentally signed the shift change (Controlled Drugs Inventory) form ahead of time before the end of the shift and before the next nurse arrived. LVN 5 stated it was important to sign together with the incoming nurse to prevent medication discrepancies especially for controlled medications.
During a concurrent interview and review of the Controlled Drugs Inventory for Station 1, MedCart A, and Station 1, MedCart B on 2/18/2026 at 4:22 PM with the Assistant Director of Nursing (ADON), the ADON stated that when the next shift nurse arrives for Station 1 MedCart A, both the incoming and outgoing nurses were required to count the controlled medications together.
The ADON stated that after counting, both nurses were required to sign the Controlled Drugs Inventory form together.
The ADON stated that signing the Controlled Drugs Inventory form confirmed the controlled count was accurate and that the outgoing nurse was endorsing (formally handing over responsibility for) the medication cart to the incoming nurse.
The ADON stated that failing to sign the form together could result in uncertainty about the accuracy of the controlled medications and could delay the discovery of any missing controlled medications. A review of the facility's P&P titled, Controlled Substances, dated 11/2025, indicated, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.The nurse coming on duty and nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During an interview on 2/17/2026 at 10:28 AM with CNA 1, in the
vital signs for Residents 260, 129, 8, and 83 before breakfast and once done provided the results to
usually relied on the vitals taken by the CNAs to determine to give or hold BP medications to the residents. LVN 6 stated she could not verify based on the undated and untimed form when the vitals, that included BP and HR were taken by CNA 1 on 2/17/2026. LVN 6 stated that it was important to recheck the residents BP and HR to make sure the BP and HR readings were accurate before administering BP medications with an ordered parameter. LVN 6 stated if BP medications were administered outside of the ordered parameters residents could experience symptoms that include low blood pressure, weakness, change in cognition and alertness, syncope (brief loss of consciousness), which could lead to hospitalization.
During an interview on 2/18/2026 at 5:09 PM with the Director of Nursing (DON), the DON stated residents' BP should have been checked prior to, and as close as possible to the medication administration time.
The DON stated that if a resident's BP and heart rate (HR) were checked two hours before medication administration, the licensed nurse had to recheck the resident's BP and HR immediately prior to administering the BP medication when there were ordered parameters, in order to prevent a decline in the resident's condition. A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2025, indicated, Medications are administered in accordance with prescriber orders.The following information is checked/verified for each resident prior to administering medications.b.
Vital signs, if necessary. A review of the facility's undated policy and procedure titled, Medication Administration Principles, indicated, Vital signs (blood pressure, pulse rate, respiration) or blood sugar levels required for medication orders with hold parameters are taken prior to the administration of the medication and recorded on the MAR.
During a review of the Food and Drug Administration (FDA)- approved prescribing information (package insert), revised 8/2024, the package insert for Lisinopril indicated, Hypotension: Patients with other heart or renal diseases have increased risk, monitor blood pressure after initiation.Patients at risk of excessive hypotension include those with the following conditions or characteristics: heart failure with systolic blood pressure below 100 mmHg.
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During a review of the Food and Drug Administration (FDA)- approved
tartrate tablets are contraindicated in severe bradycardia.systolic blood pressure less than 100.
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During a review of Resident 334's Minimum Data Set (MDS, a resident assessment tool), dated 11/5/2025, the MDS indicated Resident 334's cognitive skills (ability to think and reason) were intact.
During a review of Resident 334's History and Physical (H&P) dated 2/16/2026, the H&P indicated the resident did not have the capacity to make healthcare decisions.
During a review of Resident 334's Order Summary Report dated 2/18/2026, the Order Summary Report included an order for Advair Diskus (a medication that contains both an anti-inflammatory medicine (fluticasone propionate) and a long-acting bronchodilator (salmeterol), used to treat asthma and COPD) 250 micrograms ([mcg] - unit of measure of weight)/ 50 mcg, instructions indicated one inhalation orally two times a day for COPD, rinse mouth after each use, order date 2/13/2026.
During a concurrent observation and interview on 1/18/2026 at 12:10 PM with a Licensed Vocational Nurse (LVN) 3 on Nursing Station 3, MedCart C was inspected, and one oral inhaler was observed inside of the MedCart open without an open date for Advair (used to treat breathing difficulty) 250-50 mcg. LVN 3 stated there was no open date on the Advair labeled for Resident 334. LVN 3 stated without an open date the nurses would not accurately know when the medication was due to expire, and if administered after expiration the efficacy (effectiveness) might not have been as effective and the resident could have had an adverse reaction that included shortness of breath or respiratory symptoms (breathing problems such as coughing, wheezing, or chest tightness). LVN 3 stated she (LVN 3) administered a dose of Advair 250-50 mcg to Resident 334 on the date of interview, 2/18/2026.
During a concurrent interview and record review on 2/18/2026 at 12:31 PM with a Registered Nurse Supervisor (RN) 1, Resident 334's physician order dated 2/18/2026 and prescription label and packaging for Advair were reviewed. RN 1 stated there should have been an open date to know when the medication was first opened and used. RN 1 reviewed the manufacturer's labeling for Advair and stated, the medication expired one month after opening the foil pouch or when the counter read zero whichever comes first.
During a review of the manufacturer's labeling for Advair Diskus, dated 6/2023, indicated, Safely throw away ADVAIR DISKUS in the trash 1 month after you open the foil pouch or when the counter reads 0, whichever comes first.Write the date you opened the foil pouch in the first blank line on the label.Write the use by date in the second blank line on the label.That date is 1 (one) month after the date you wrote in the first line.
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During an interview with the Director of Nursing (DON) on 2/18/2026 at 12:40PM, the DON stated the refrigerator was not working and would be replaced immediately.
The DON stated that when the refrigerator temperature was not in range staff had to notify the maintenance supervisor. A review of the temperature log titled HACCP Refrigerator temperature Log-One Form Per Month for refrigerator Location: Nursing Station 1st Floor, dated 2/2026, indicated Maintain refrigerator temperature at 40F or below during stable times; complete corrective action column if temperature are not in proper ranges. A review of facility policy and procedure titled Food receiving and Storage with a revised date of 2017, the policy and procedure indicated, Food items and snacks kept on the nursing units must be maintained as indicated below: All food items to be kept below 41 degrees F must be placed in the refrigerator located at the nurses station and labeled with a use by date; Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines.
555438 02/20/2026
Kei-Ai Los Angeles Healthcare Center 2221 Lincoln Park Ave Los Angeles, CA 90031
During an interview on 2/20/2026 at 10:55 AM with LVN 12, LVN stated the safe infection control practice of EBP was to check the label next to the resident's name and use PPE when providing care.
LVN 12 stated Resident 292's safety was important. LVN 12 stated all staff had to wear PPE when residents were placed on EBP.
During a concurrent interview and record review on 2/20/2026 at 2:21 PM with the Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 1/8/2026, was reviewed.
The IP stated residents with EBP were at high risk of infection.
The IP stated PPE including gowns and gloves were worn during high contact care.
The IP stated the P&P indicated facility staff would wear a gown and gloves when performing high-contact resident care activities.
The IP stated an incontinent brief change was considered a high contact care activity.
The IP stated CNA 2 had potential contact with resident's soiled brief and CNA 2 should have worn the gown as indicated on the P&P.
During a concurrent interview and record review on 2/20/2026 at 2:25 PM with the facility Administrator (ADM), the facility's P&P titled, Enhanced Barrier Precautions, dated 1/8/2026, was reviewed.
The ADM stated the facility's priority was to practice and monitor infection control.
The ADM stated the EBP P&P indicated to wear PPE for high-contact resident care activities.
The ADM stated CNA 2 failed to wear the appropriate PPE and should have worn a gown when changing Resident 292's brief.
The ADM stated there was a potential risk of spreading infection.
During a review of the facility's P&P, titled Hand Hygiene, revised 10/2025, the P&P indicated To maintain the highest standards of infection prevention and control through hand hygiene adherence.Hand hygiene shall be performed under the conditions listed in, but not limited to, the attached hand hygiene reference table.before and after direct contact, after contact with surfaces or objects in immediate vicinity of patient.
During a review of the facility's P&P, titled Administering Medications, dated 4/2025, the P&P indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications, as applicable.
During a review of Resident 292's admission Record, the admission Record indicated the facility originally admitted Resident 292 on 12/31/2025 and re-admitted on [DATE] with diagnoses the included chronic left foot ulcer (an open, painful, crater-like sore that develops on the skin) and anemia ( a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues).
During a review of the facility's P&P titled Enhanced Barrier Precaution, last reviewed on 1/8/2026, the P&P indicated EBP was used in with standard precautions and expanded the use of PPE to putting on a gown and gloves during high contact resident care activities.
The P&P indicated facility staff were to perform hand hygiene and would put on a gown and gloves before performing the following high-contact resident care activities: Changing briefs or assisting with toileting.