Health inspection·August 29, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) transfer summary was completed, and telephone report was called to the receiving facility, prior to discharge on [DATE], as indicated in the facility's policy and procedure (P&P) titled, Discharging the Resident. This failure caused Resident 1's discharge to the independent living facility (ILF, a community for active seniors who want to maintain their independence but desire the benefits of a maintenance-free lifestyle and community amenities, such as dining, fitness centers, housekeeping, and social activities) on 8/20/2025, who could not fully provide and accommodate the resident's needs and had the potential to affect the resident's highest practicable physical, mental and psychosocial well-being.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing,) hypertension (HTN-high blood pressure) and hyperlipidemia (a condition characterized by high levels of lipids (fats) in the blood, including cholesterol and triglycerides).During a review of Resident 1's History and Physical (H&P) dated 3/15/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Care Plan titled, Discharge Plan, dated 1/16/2025, the discharge plan indicated Resident 1 would remain in this facility long term. The discharge care plan goals indicated Resident 1 will be assisted post-discharge and the services required to meet needs before discharge. The discharge care plan interventions included identifying Resident 1's needs, discuss and address limitations, risk, benefits and needs for maximum independence. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/5/2025, the MDS indicated Resident 1 had intact cognition. The MDS indicated Resident 1 required supervision or touching assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer and mobility. During a review of Resident 1's Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting notes from 8/11/2025 to 8/20/2025, the notes did not indicate documented evidence that an IDT meeting was done prior Resident 1's discharge on [DATE]. During a review of Resident 1's Social Services (SS) progress notes dated 8/19/2025, the SS progress notes indicated the SS spoke to Resident 1 about possible discharge planning. The SS progress notes indicated Resident 1 was open to the idea of transitioning to a lower level of care facility. During a review of Resident 1's Physicians Orders dated 8/20/2025, the physician's order indicated to discharge Resident 1 to an independent living facility with home health services (an agency that provides skilled medical care to patients in their own homes to treat an illness or injury, often after a hospital stay or for chronic condition) and physical therapy. During an interview on 8/26/2025 at 11:20 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated part of a discharge process is to conduct an IDT Page 1 of 3 555306 555306 08/29/2025 Kei-Ai South Bay Healthcare Center 15115 S Vermont Ave Gardena, CA 90247

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meeting, one-week prior residents are being discharged . LVN 1 stated the purpose for an IDT meeting is to discuss Resident 1's needs and to make sure the new place was safe and could accommodate Resident 1's needs. During an interview on 8/26/2025 at 2:42 p.m. with the complainant, the complainant stated, I visited Resident 1 on 8/21/2025 at the ILF, the place was small, and Resident 1 stayed on a couch in the living room. The complainant stated there were 3 more people living at this place and Resident 1 did not have a room for him. The complainant stated this facility could not accommodate Resident 1's needs. During an interview on 8/27/2025 at 9:23 a.m. with the SS, the SS stated IDT meetings are done one-week prior to a resident's discharge. The SS stated Resident 1's IDT meeting was not scheduled prior to the discharge on [DATE]. The SS stated Resident 1's plan of care should have been reviewed to resolve any worries Resident 1 may have before discharge. The SS stated the discharge was only communicated with Resident 1 and the resident was open to the idea to be discharged . The SS stated on 8/20/2025, a discharge coordinator from the ILF called and stated Resident 1 had a room in the ILF. The SS stated Resident 1 was made aware and agreed with transfer to the ILF. The SS stated the communication about Resident 1's discharge was directly with the discharge planner and Resident 1 was discharged to the ILF on 8/20/2025. The SS stated, I was not sure if the place was safe for Resident 1. The SS stated, I failed to call and check with the independent living if they could accommodate Resident 1's needs, such as medications administrations, blood glucose (blood sugar level) checks and if the room was available for him. The SS stated the facility failed to provide Resident 1 a safe discharge to the ILF. During an interview on 8/27/2025 at 10:45 a.m. with the ILF owner (ILFO), the ILFO stated, on 8/19/2025, the discharge coordinator was instructed to provide Resident 1's weight, so the ILF would know if Resident 1 needed a bigger bed, but the weight was not provided. The ILFO stated Resident 1 arrived at the ILF on 8/20/2025. The ILFO stated that the ILF does not administer medications or check resident's blood glucose levels. During an interview on 8/27/2025 at 11:10 a.m. with the ILFO, the ILFO stated Resident 1's skilled nursing facility did not call the ILF to ask what services or accommodation the ILF can provide to the resident prior to the discharge on [DATE]. During an interview on 8/27/2025 at 11:34 a.m. with the Director of Nursing (DON), the DON the facility's protocol prior to discharge was to call the receiving facility (ILF) where Resident 1 will be discharged to make sure the ILF can accommodate Resident 1's needs. The DON stated the risk of not following this protocol can cause Resident 1 to not receive his medication and care on a daily basis. The DON stated it can jeopardize Resident 1's physical and psychological health. During an interview on 8/29/2025 at 1:00 p.m. with Resident 1, Resident 1 stated I was living at an apartment, but the place and the bed was small, so I slept on the couch, and I wanted to move out of that place. Resident 1 stated the ILF care giver reminded him about medications, but they do not administer insulin (a type of medication used to treat type 2 diabetes) shots. During a concurrent interview and record review on 8/29/2025 at 3:24 p.m. with RN 1, Resident 1's nurses notes dated 8/20/2025, discharge instructions summary dated 8/20/2025, were reviewed. RN 1 stated the discharge instructions were incomplete. RN 1 stated the discharge summary under special training instructions such as injections, blood sugar checks, blood pressure check, and special diet was not properly marked. RN 1 stated the discharge instruction summary did not include the last time Resident 1 received all his medications and the next doses due. RN 1 stated the licensed nurses should call the receiving facility to provide reports regarding resident's care needs, such as skin issues, medications to be administrated, ADL needs and status and if there were any behavioral issues. RN 1 stated Resident 1's receiving ILF was not called prior to the resident's discharge to provide the report. RN 1 stated it was important to call the receiving facility so they can prepare what Resident 1 needed prior to 555306 Page 2 of 3 555306 08/29/2025 Kei-Ai South Bay Healthcare Center 15115 S Vermont Ave Gardena, CA 90247

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discharge. RN 1 stated the SS notified nursing on 8/20/2025 that Resident 1 will be discharged on same day (8/20/2025), reason why Resident 1 was not provided education about his medications and how to administer insulin, at least 3 days prior to the discharge on [DATE]. RN 1 stated the danger of not properly discharging Resident 1 can cause Resident 1 to be at risk of hospitalization due to HTN crisis, hypoglycemia (low sugar level) or hyperglycemia (high blood sugar). During a review of the facility's undated P&P titled, Director of Social Services, the P&P indicated Social Services administrative functions duties and responsibilities are to participate in discharge planning, development and implementation of social care plan and resident assessment. The P&P indicated social services should schedule and announce departmental meeting times, dates, places. During a review of the facility's P&P titled, Discharging the Resident, dated 12/2016, the P&P indicated, if the resident was being discharged , the facility should ensure that resident and/or responsible party received teaching and discharge instructions. The P&P indicated if the resident was being discharge to another facility, the facility should ensure that a transfer summary is completed, and telephone report is called to the receiving facility. During a review of the facility's P&P titled, Discharge Summary and Plan, dated 12/2016, the P&P indicated the discharge summary should include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge. The P&P indicate the discharge summary shall include a description of the resident's: Nutrition's status and requirements Special treatments or procedures. Medication therapy 555306 Page 3 of 3