Kei-Ai South Bay Healthcare Center

In the surveyor’s words

From the most serious findings on record at Kei-Ai South Bay Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 19, 2024

  Based on interview and record review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 reassessed Resident 1 after a change of condition ([COC] a sudden or gradual change in a patient's physical, cognitive, behavioral, or functional status) of wheezing (when breathing becomes difficult due to narrowed or blocked airways in the lungs), vomiting, and sweating on [DATE] at 8:00 a.m. This deficient practice resulted in Resident 1's death, at 10:57 a.m., approximately 3 hours after she was observed with shortness of breath, wheezing, vomiting, and sweating. […]

• Actual harm, isolatedF684Apr 6, 2023

  Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent injury to one of three sampled residents (Resident 1), by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 did not make a homemade non-temperature regulated warm compress (method of applying heat to the body) and placed it on Resident 1's back. 2. Notify the charge nurse (Licensed Vocational Nurse [LVN] 1 that Resident 1 was having back pain. 3. Follow the facility's policy and procedure (P&P) titled, Compress or Soak, Applying Warm. As a result, CNA 1 prepared a compress that was hot, gave it to Resident 1 who had type 2 diabetes mellitus (a condition of high level of sugar in the blood) and applied it to Resident 1's mid-back (middle portion of the back). […]

• No harm, potential for more than minimal, widespreadF880Jan 6, 2021

  Based on interview and record review, the facility failed to adhere to its infection control policy and procedure to ensure visitors completed COVID-19 ( highly contagious [MEDICAL CONDITION] infection) screening upon entrance to the facility as per their mitigation plan to prevent the spread of COVID-19. This deficient practice had the potential to result in the transmission of COVID-19 among residents, staff, and visitors. Findings: On 12/15/2020 at 10 a.m., upon entry into the facility, the facility's COVID screening logbook indicated the screening was incomplete as follow; From 9/30/2020-10/31/2020 there was 61 incomplete entries on the assessemnt forms. From 11/1/2020-11/30/2020 indicated there were 36 incomplete entries on the assessment forms. […]

• No harm, potential for more than minimal, patternF812Jan 23, 2026

  Based on observation, interview, and record review, the facility failed to label a container of dehydrated mashed potatoes with a use by date and failed to properly sanitize (the process of keeping places free from dirt, infection, disease) cookware. This failure had the potential to result in the preparation and provision of expired food for the residents and the potential to result in the use of improperly sanitized cookware used to prepare food for the residents. Findings:During an observation on 1/20/2026, at 8:25 a.m., in the kitchen, on the counter, near the sink, a clear container labeled Mashed Potatoes did not have a use by date. During an interview on 1/20/2026, at 8:27 a.m., with DS1, DS1stated there should be a use by date once opened. […]

• No harm, potential for more than minimal, patternF919May 16, 2025

  Based on observation, interview and record review, the facility failed to place the call light buttons for 4 of 6 sampled residents (Residents 2, 4, 5 and 6), within their reach. This deficient practice placed Residents 2, 4, 5, and 6 at risk for not being able to call for help when needed and can result to needs not being attended to timely. This deficient practice had the potential to cause falls, other injuries, including hospitalization and death. Findings: During an inspection of the facility, on 5/16/25 at 10:45 am, the call light buttons in each residents ' room were inspected along with the Assistant Director of Nursing (ADON) for functioning and placement. […]