Kei-Ai Los Angeles Healthcare Center in Los Angeles: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

CDPH investigated a facility-reported incident about falls during an unannounced visit on February 19, 2025. According to the citation, Resident 1 had a history of falls, severe cognitive impairment and dementia, and needed staff help with transfers and toileting. The resident had an unwitnessed fall on November 25, 2024, when he slid from his wheelchair while reaching for crackers and hit his head. A physician then ordered visual checks every 30 minutes.

Inspectors found the facility did not follow that order. CDPH found that after a second fall on December 6, 2024, which left a skin tear and swelling on the resident's right ear, staff did not review and update the high fall risk care plan, and the interdisciplinary team did not add new interventions to prevent more falls. The department also determined the facility did not follow its own care planning and fall management policies. According to the citation, on February 3, 2025, Resident 1 fell a third time in the bathroom. He was sent to an acute care hospital and diagnosed with a hematoma (a pool of blood under the skin) on the head and a nondisplaced fracture of the left shoulder blade.

CDPH issued a Class A citation with a $25,000 penalty that was trebled to $75,000. The federal 2567 report for the same investigation cites F689, the rule on keeping residents free of accident hazards and providing adequate supervision, at severity G, which means actual harm.

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CDPH made an unannounced visit on September 10, 2024, to investigate a facility-reported incident. According to the citation, Resident 1 was an 85-year-old woman with vascular dementia, a prior pelvic fracture and a history of falls. A fall risk screen rated her at high risk. Her care plan called for 2:1 staff supervision (one certified nursing staff member for two residents) because of impulsive behavior and getting out of bed without help.

CDPH determined the facility did not develop an appropriate care plan for her dementia through an interdisciplinary team approach and did not provide the 2:1 supervision listed in her care plan. According to the citation, on August 20, 2024, she was in her wheelchair in the day room with other residents. CNA 1 was looking at charting and CNA 2 was at the door talking with another resident when the resident was found on the floor with a bump on the back of her head. She was sent to a hospital. Inspectors found that on August 24 she had right leg pain and swelling that had not been assessed before. On August 25 she went to a second hospital, where she was diagnosed with a dislocated right hip and treated under general anesthesia.

The department issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F744, the rule on treatment and services for residents with dementia, at severity G, which means actual harm.

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CDPH made an unannounced visit on July 31, 2024, while investigating a facility-reported incident. According to the citation, Resident 1 was a 91-year-old woman with Alzheimer's disease, dementia, hearing loss, impaired vision from glaucoma and a history of falls. A fall risk assessment in June 2024 rated her at high risk. Her care plans noted she had thrown herself off the bed in the past, but the department found there was no intervention for supervising her.

CDPH determined the facility did not give her care that met professional standards for residents at high risk of injury, did not provide needed behavioral health services, and did not keep her environment as free of accident hazards as possible. Inspectors found staff did not monitor her after a first fall on July 22, 2024, at 8:49 PM, and she fell again. The citation states the facility also did not develop a care plan that included supervision, did not update her care plan after changes in her condition, and did not follow its own fall risk policy on monitoring residents after falls.

According to the citation, Resident 1 had two falls within one hour on July 22 and complained of pain in her right thigh. She was sent to an acute care hospital and diagnosed with a fractured right hip, and surgery was recommended. CDPH issued a Class A citation, and the citation notice lists a $75,000 penalty. The federal 2567 report cites F689, covering accident hazards and supervision, at severity G (actual harm).

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CDPH made an unannounced visit on December 11, 2023, for a recertification survey and to investigate a facility-reported incident. According to the citation, Resident 1 was an 87-year-old woman admitted on November 30, 2023, after surgery for a broken left hip. She had Alzheimer's disease, dementia and repeated falls. Her physician ordered an abduction pillow (a pillow between the legs that keeps the hip in position while it heals) while in bed. Nurses' notes show she removed the pillow several times and tried to get out of bed on her own.

On December 4, 2023, a physician ordered a 1:1 sitter, and her care plan included one. CDPH determined the facility did not provide the 1:1 sitter as ordered and care planned, did not develop a care plan for her refusal to use the abduction pillow, and did not make sure a physician saw her within 72 hours of admission, as its own policies required.

According to the citation, on December 5, 2023, eight days after her original surgery, staff saw her left foot pointing inward. She was sent to an acute care hospital the next day, where she had a second dislocation of the left hip and needed a closed reduction under anesthesia. CDPH issued a Class A citation, and the citation notice lists a $75,000 penalty. The federal 2567 report cites F689, the accident hazards and supervision rule, at severity J, which means immediate jeopardy to resident health or safety.

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CDPH made an unannounced visit on June 13, 2023, to investigate a complaint about the quality of care for Resident 1. According to the citation, Resident 1 had Guillain-Barre Syndrome (an immune disorder that damages the nerves and can cause paralysis), generalized muscle weakness and a history of constipation. The resident depended on staff for nearly all daily care and could not walk. The care plan called for checking bowel movements every shift and checking for constipation after more than three days without a soft bowel movement.

CDPH found the facility did not assess Resident 1 for constipation before giving milk of magnesia (a laxative) at 9 PM on April 5, 2023, and did not monitor or document whether it worked. Inspectors found staff did not follow the physician's orders to give lactulose (a laxative) first, even though the resident had no soft bowel movement from April 3 to April 5. The department also determined the facility did not follow its own bowel disorder protocol.

According to the citation, Resident 1 was sent to an acute care hospital emergency department on April 6, 2023, for a neurology consult and complained of bloating, abdominal pain and constipation. On April 7 the resident had a large amount of stool in the rectum consistent with stercoral colitis (inflammation of the colon caused by hardened stool) and needed manual removal of the stool. The citation quotes the resident as saying, "I was in a lot of pain in my pelvic area and in my bottom." CDPH issued a Class A citation, and the notice lists a $75,000 penalty. The federal 2567 report cites F684, quality of care, at severity G (actual harm).

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The federal 2567 report states that Resident 1 had a gastrostomy tube (G-tube, a surgical opening in the stomach wall used for food and medication), quadriplegia (paralysis of all four limbs), diabetes and difficulty swallowing. The resident had severe cognitive impairment and depended on staff for eating. A physician's order called for cleaning and dressing the G-tube site every day and as needed.

Inspectors found the facility did not clean and treat the G-tube site on July 2, July 16 and July 24, 2023. According to the report, the nursing assignment sheets for those days showed no treatment nurse assigned. Inspectors also found the facility did not develop and carry out an effective care plan for the G-tube site, did not revise that plan after a change in condition on August 5, 2023, and did not order culture tests (lab tests that identify the germ causing an infection) until after the antibiotic was finished, which the facility's antibiotic stewardship policy calls for before treatment. The report also states the facility did not give the tube feeding as the physician ordered.

According to the 2567 report, these failures caused Resident 1 to develop redness and a foul smell at the G-tube site on August 5, 2023, which needed antibiotic treatment and raised the risk of more G-tube complications. The facility was cited under F693, the rule on tube feeding management and restoring eating skills, at severity G, which means actual harm.

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CDPH conducted an unannounced visit on March 29, 2023, to investigate a complaint about quality of care. According to the citation, Resident 2 had end stage kidney disease, received dialysis (a machine that filters the blood when the kidneys cannot) and had been treated at a hospital for sepsis (a severe body-wide response to infection) and an infected hip surgery wound. The hospital discharged the resident on February 23, 2023, with an order to continue IV vancomycin (an antibiotic given through a vein) for six weeks with dialysis. A physician's order at the facility called for the drug to be given at the dialysis center three times a week.

CDPH found the facility did not review the dialysis communication forms after treatments for missed medications or other concerns noted by the dialysis center. Inspectors found the facility did not carry out or follow up on the vancomycin order, and dialysis center records showed the drug was not given on February 28, March 2, March 4 and March 7, 2023. The citation states a facility note recorded on March 4 that the drug had been given, while the dialysis center's note did not show it. The department also determined staff did not perform or document post-dialysis assessments on March 4 and March 14.

According to the citation, on March 14, 2023, Resident 2 was sent to an acute care hospital and admitted to the intensive care unit for septic shock (a life-threatening drop in blood pressure caused by infection). CDPH issued a Class A citation, and the notice lists a $75,000 penalty. The federal 2567 report cites F698, the dialysis care rule, at severity G (actual harm).

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CDPH made an unannounced visit on February 13, 2023, to investigate a complaint about quality of care and a resident's death. According to the citation, Resident 111 was admitted on December 27, 2022, with a spinal epidural abscess (an infection in or near the spine), resistance to multiple antibiotics and other conditions. The hospital discharge plan called for two antibiotics, Rifampin and Bactrim, and an infectious disease appointment on January 20, 2023.

CDPH found the facility did not verify the admission orders with a physician, and the orders entered did not include Bactrim. The citation states there was no record that the resident received Bactrim in December or January, and the 2567 report states she did not get Rifampin on December 28, 29 or 30. Inspectors found no physician saw her within 72 hours of admission or every 30 days during the first 90 days. The department also determined the facility did not arrange transportation to the January 20 appointment or help reschedule it.

According to the citation, on February 7, 2023, Resident 111 developed flaccid paralysis (extreme weakness) in both legs with a new spinal infection at the T5 to T7 level and was sent to an acute care hospital. The resident died there on February 16, 2023. CDPH issued a Class AA citation with a $120,000 penalty. The federal 2567 report cites F684, quality of care, at severity J (immediate jeopardy), and F609, reporting of alleged violations, at severity D. Inspectors identified immediate jeopardy on February 15, 2023, and the report states it was removed after the facility submitted an acceptable removal plan that included staff training.

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CDPH made an unannounced visit on October 26, 2022, to investigate a complaint about quality of care and a resident's death. According to the citation, Resident 1 had dysphagia (difficulty swallowing), dementia, epilepsy and metabolic encephalopathy (a brain problem caused by chemical imbalances). His records noted that he pocketed food, meaning he kept food in his cheeks instead of swallowing it. His assessment called for extensive help and one person to assist him while eating.

CDPH determined the facility did not develop a care plan to address his dysphagia and food pocketing and did not provide the one-person help and monitoring during meals that his assessment called for. Inspectors found staff did not give him a speech therapy evaluation within 48 hours of a physician's order dated April 21, 2022. The citation also states staff did not properly assess him for emergency services at 5:30 PM on April 25, 2022, when he was weak, could not be woken and had a blood pressure of 80/41.

According to the citation, around 9:30 PM that day he had a change of condition and was found with food lodged inside his left cheek. The department found the facility called an ambulance service instead of 911, which delayed his transport. At a hospital, a chest x-ray showed findings likely from aspiration (food or liquid entering the lungs). He died on April 30, 2022, and was discharged with a diagnosis of septic shock from aspiration pneumonia. CDPH issued a Class AA citation with a $120,000 penalty.

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According to the federal 2567 report, inspectors found the facility did not protect two residents, Resident 2 and Resident 3, from physical abuse and misappropriation of property (use of a resident's belongings without consent) by Resident 1. The report states Resident 1 hit Resident 3 with a cane and took personal property belonging to Resident 2 and Resident 3 without permission.

The 2567 report states nurses' notes from 5:25 AM on January 5, 2023, describe an altercation in which Resident 1 hit Resident 3 with his cane. Resident 3 told staff he was hit on his back and both hands many times while trying to get back food that Resident 1 had taken from him. He reported arm pain of five out of 10 and was given Tylenol. According to the report, Resident 1 gave up the cane, was moved to another unit, and the police and his physician were notified. The physician ordered a transfer to an acute care hospital for a psychiatric evaluation.

Inspectors found that Resident 3 later developed a bruise on the inner arm measuring eight by four centimeters. The report states he said he felt scared and had severe pain in both arms and his shoulder that needed Tylenol. Resident 2 said he felt anxious and upset when he saw Resident 1 with his belongings. The facility was cited under F600, the rule on freedom from abuse and neglect, at severity G, which means actual harm.

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CDPH made an unannounced visit on November 1, 2022, to investigate a complaint about the quality of care for Resident 1. According to the citation, Resident 1 was admitted in September 2022 with ovarian cancer and a dehisced abdominal wound (a surgical wound whose edges had separated). A physician's order dated October 19, 2022, called for the wound to be cleaned, treated and packed every day shift and as needed.

CDPH found the facility did not have a care plan for the abdominal wound and did not follow the physician's order for daily wound care. Inspectors found no treatment nurse was assigned on October 29, 2022, and the treatment record for that day was blank. The citation states staff did not assess her pain before or after giving her Tramadol (an opioid pain medicine) on October 24, and did not assess her pain on October 29. The department also determined the facility did not follow its own care plan and pain management policies.

According to the citation, Resident 1 told inspectors she did not get wound care on a Saturday and that staff told her no one was available. She said the drainage stayed in the dressing for hours, caused a very bad odor and raised her pain to six out of 10, and that she felt embarrassed by the smell. CDPH determined she had more pain because the dressing was not changed. The department issued a Class A citation with a $25,000 penalty that was trebled to $75,000.

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