Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gardena Convalescent Center during CMS and state inspections, most recent first.
Failure to Develop a Pain Care Plan: A resident admitted with left hip OA, a left hip artificial joint, and anxiety had an order for PRN Hydrocodone-Acetaminophen for moderate to severe pain and MDS findings of frequent pain and recent hip replacement. However, the Care Plan Report did not include a care plan for the resident’s left hip pain, and the RN stated there were no pain care plans in place.
Narcotic Destruction Logs Missing Required Signatures: The facility failed to ensure 36 of 36 narcotic destruction log sheets were signed by the DON and the pharmacy consultant. During interview and record review, the DON stated she did not sign 34 resident-controlled drug records during narcotic destruction with the RPH, even though the process required two signatures on the Controlled or Antibiotic Drug Record. The facility policy required disposal of controlled substances with signatures from at least two witnesses, including an RN and an authorized licensed pharmacy representative.
Unlabeled opened ipratropium with albuterol inhalation solution was found in Medication Cart 1 for three residents with active respiratory orders. LVN stated the foil packs had no opened date, and the DON confirmed medications need an open date so staff know the medication life span. The residents involved had diagnoses including COPD, CHF, pneumonia, DM, and atrial fibrillation, and the facility policy and manufacturer guidance required proper labeling and use or discard within two weeks of opening.
Expired corn tortillas and hot dog buns were found stored in the kitchen walk-in refrigerator and available for use. During observation, a staff member stated the items should not have been in refrigerated storage and should be thrown out. The DSS stated expired food could expose residents to foodborne illness, and the facility policy required refrigerated food to be monitored so it is used by its used-by date or discarded.
Call Light Not Within Reach: A resident with dementia, COPD, and CHF had a touch pad call light placed under her pillows and out of reach during observation. The resident was severely cognitively impaired and totally dependent for several ADLs, and the care plan directed staff to keep the call light within easy reach. The IPN and DON both stated the call light should be accessible to the resident at all times.
A facility failed to keep resident PHI private when meal tickets with resident names, room numbers, diet types, texture levels, liquid consistency levels, and likes/dislikes were found in the trash near the dishwashing area. An DA stated the tickets should not have been discarded in the trash, and the DSS stated the information was protected and should not be thrown away in the trash.
Late Completion of Quarterly MDS Assessment: A resident with CHF, atrial fibrillation, HTN, and no capacity to make medical decisions had a quarterly MDS assessment that was not completed within the required timeframe. The MDS Nurse confirmed the assessment remained incomplete past the 14-day deadline from the ARD, and the DON stated MDS assessments must be completed within 14 days to keep the resident’s assessment updated.
Inaccurate MDS Coding for ROM: A resident with CHF, atrial fibrillation, and HTN had an MDS that was coded incorrectly for lower extremity ROM. The MDSN stated section GG0115(B) should have been coded as no impairment based on the resident’s JMA and that inaccurate information was transmitted to CMS. The DOR confirmed the resident had no contractures or ROM limitation affecting ADLs, and facility policy required accurate assessments and supporting documentation.
A resident with pneumonia, COPD, and DM had broken teeth that bothered her and made chewing difficult. The dentist recommended obtaining a medical order clearance for tooth extraction, but the SSD and RN were unaware of the recommendation, and the DON confirmed there was no documentation that the physician was notified or that the clearance was obtained.
Failure to Use Ordered Elopement Alert Device: A resident assessed as an elopement risk was ordered to wear a ROAM Alert device on the left wrist, and the care plan identified constant seeking behavior and packing belongings. Despite the order and care plan, the resident was observed multiple times without the device, and the DON stated this created increased safety risk because the resident could elope without staff knowing.
Failure to use EBP for a resident with a PICC line. A resident admitted with pneumonia, UTI, and bacteremia had a PICC in the right upper arm and was receiving IV Unasyn. The IPN stated the resident was not placed on EBP because of the admission date, and noted gown and glove PPE should have been available outside the room. The DON stated residents with central lines and other medical devices should be placed on EBP immediately, and facility policy identified central lines as an indication for EBP.
A resident with hemiplegia and total dependence on staff for ADLs fell from bed during peri-care, resulting in injuries. The care plan lacked specific instructions on required staff assistance, and only one CNA was present during the incident. Staff interviews confirmed the resident was not centered in bed and that additional help should have been requested, contrary to facility policy and the resident's needs.
A CNA did not report a fall incident involving a resident with significant medical conditions, resulting in a delay in treatment and evaluation. The CNA only reported the resident's headache to the charge nurse, omitting the details of the fall, which was later discovered by nursing staff upon noticing an injury. Facility policy and staff interviews confirmed that all falls or near falls must be reported immediately for resident safety.
A resident with diabetes returned to the facility after an out on pass, but their blood glucose was not checked until four hours later, contrary to the facility's diabetes management policy. The resident's blood sugar was recorded at 333 mg/dl, indicating hyperglycemia, which could have posed a risk for further complications. The Director of Nursing acknowledged the oversight in the assessment process.
A facility failed to develop a care plan for a resident who did not comply with the recommended time frame for returning from out on pass (OOP). The resident, with a history of falls and diabetes, left the facility for extended periods without a care plan addressing this non-compliance. The DON acknowledged the oversight, noting the resident's high fall risk and need for insulin injections.
A facility failed to ensure a high-risk resident had a plan for continuous supervision while out on pass (OOP). The resident, with a history of falls and requiring supervision for transfers, was allowed to leave for 12 hours without adequate monitoring, exceeding the recommended OOP duration. The DON acknowledged the lack of documentation and monitoring, which posed a potential fall risk. Facility policies for therapeutic leave and fall management were not adhered to, failing to provide necessary supervision.
The facility failed to conduct monthly Medication Regimen Reviews (MRR) for four residents, including those with conditions like diabetes, dementia, and hypertension. The MRRs for October to December 2024 were missing, as confirmed by the DON, who noted that only five residents received an MRR in October. The facility's policy requires monthly MRRs to prevent adverse medication consequences, but this was not followed, risking unaddressed medication irregularities.
The facility failed to create individualized care plans for two residents, one requiring a plan for outings and another for managing a PICC line. This oversight could negatively impact their care. A resident frequently left the facility without a care plan for safety during outings, while another had a PICC line without a care plan for its management, risking complications. The facility's policy mandates comprehensive care plans, which were not followed.
A resident with decision-making capacity was not informed of a change in their attending physician due to a shift in care level. The facility's policies require residents to be informed and involved in such decisions, but there was no documentation of notification, violating the resident's rights.
A facility failed to report a resident's non-return after leaving on a pass, as required by their policy. The resident, with conditions including osteomyelitis and schizoaffective disorder, did not return, and the facility did not notify law enforcement or CDPH within 24 hours. The DON acknowledged the oversight, which could have led to serious harm.
A resident with multiple medical conditions left the facility and did not return, but the staff failed to report the absence to CDPH or other authorities. Despite the resident's history of leaving and returning, the facility did not document the absence or notify necessary parties, contrary to their policies. Interviews with the DON and ADM highlighted a lack of concern and adherence to reporting procedures.
A facility failed to complete a smoking safety assessment for a resident with multiple diagnoses, including nicotine dependence, and did not assess another resident before allowing them to go out on pass, despite their complex medical conditions. The Director of Nursing acknowledged the incomplete assessments and the potential safety risks involved.
A facility failed to accurately complete the MDS for a resident, potentially affecting their care plan. The resident, admitted with a pressure ulcer, sepsis, and COPD, had a physician's order for a low air loss mattress (LALM) for wound management. However, the MDS did not reflect the use of the LALM, as acknowledged by the MDS Nurse, which contradicted the facility's policy requiring accurate assessments.
A facility failed to conduct a necessary PASRR Level II evaluation for a resident with major depressive disorder and bipolar disorder, despite the resident's severe cognitive impairment and ongoing antidepressant treatment. The DON admitted to not following through with the evaluation, which is required by the facility's policy to ensure appropriate placement and care for residents with mental disorders.
A facility failed to obtain a Level 2 PASRR evaluation for a resident with schizoaffective disorder and other conditions, despite a Level 1 PASRR indicating the need for further assessment. The Director of Nursing acknowledged the oversight, which could delay necessary mental health care. Facility policy requires a Level II review for residents with mental disorders or intellectual disabilities experiencing significant changes.
A facility failed to carry out physician orders for a low air loss mattress for a resident with multiple medical conditions, risking incomplete care and skin breakdown. Additionally, the facility did not ensure smoking safety for another resident with nicotine dependence, as their smoking assessment was incomplete and lacked a physician's order for unsupervised smoking, posing a fire hazard risk.
A facility failed to assess and monitor a resident's smoking safety, leading to unsupervised smoking, and delayed processing of a pain management referral for another resident, resulting in unmanaged pain. The smoking assessment for a resident with multiple diagnoses was incomplete, and the pain management referral for a resident with a recent amputation was delayed by 18 days, causing significant discomfort.
A resident with a pressure ulcer was found lying on a low air loss mattress (LALM) set incorrectly at 350 pounds, despite weighing 132 pounds. This setting error, identified by a treatment nurse, risked worsening the resident's condition. The Director of Nursing confirmed that LALM settings should align with the resident's weight and ulcer severity, as per facility policy.
A resident with dementia and muscle weakness did not receive timely Restorative Nurse Assistant (RNA) services as ordered, which were intended to maintain and improve range of motion and mobility. RNA services were delayed by eight days and provided only three times a week instead of the prescribed five. Interviews with staff revealed that services should have started the day after the order, but no explanation was given for the delay or reduced frequency.
A facility failed to ensure adequate supervision and a hazard-free environment during smoke breaks for a resident with epilepsy and other conditions. The resident was allowed to keep smoking materials and smoke unsupervised, despite an incomplete smoking safety assessment. The DON confirmed the resident was considered an independent smoker, but acknowledged the risk of fire and safety issues due to the incomplete assessment. Facility policies required regular assessments and staff involvement in identifying hazards, which were not effectively implemented.
A resident did not receive necessary dental services, risking oral health issues. Additionally, the resident was administered 1.5 liters of oxygen instead of the 2 liters ordered by the physician, risking oxygen desaturation. The facility's policy required adherence to physician orders for oxygen therapy.
A facility failed to ensure a dialysis emergency kit was available at the bedside for a resident receiving hemodialysis. The resident, with end-stage renal disease and an arteriovenous graft, required the kit for potential bleeding emergencies. The Director of Nursing confirmed the responsibility of licensed nurses to check the kit's availability, as per facility policy.
A resident in an LTC facility experienced a medication error rate of 7.14% due to two errors during medication administration. An LVN failed to administer Calcium Carbonate with Vitamin D and did not check the pulse rate before giving Metoprolol Tartrate, as required by the physician's orders. The resident had conditions including atrial fibrillation and hypertension.
The facility failed to label an opened influenza vaccine vial and remove expired insulin vials from the medication storage room. A nurse admitted to not labeling the vaccine, and expired insulin vials for two residents with diabetes were found. Both residents had severe cognitive impairments and required assistance with daily activities. The facility's policy requires proper labeling and timely disposal of expired medications.
A resident with multiple diagnoses, including quadriplegia and bipolar disorder, did not receive requested dental services despite informing the Social Services Director. The resident's last dental visit was in November 2024, and the Social Services Director failed to document or follow up on the request, contrary to the facility's policy on dental services.
A resident with dementia and malnutrition did not receive a therapeutic diet as ordered, specifically fortified potatoes at lunch, which are crucial for weight gain. The RN confirmed the omission, and the Dietary Services Supervisor could not explain why the fortified potatoes were missing. This failure contravenes the facility's policies on therapeutic diets and weight management.
The facility failed to assess and manage pain in a timely manner for a resident with multiple diagnoses, including cellulitis and phantom limb syndrome. Despite a care plan and physician's orders for regular pain assessment, the resident reported severe pain and had been asking for medication for over two hours before receiving it. The staff's delay in addressing the pain caused the resident to experience anxiety and inadequate pain management.
Failure to Develop a Pain Care Plan
Penalty
Summary
The facility failed to develop a pain care plan for one resident who was admitted with diagnoses including unilateral primary osteoarthritis of the left hip, a left hip artificial joint, and an anxiety disorder. The resident’s physician order dated 5/18/2026 directed Hydrocodone-Acetaminophen 10-325 mg, one tablet by mouth every four hours as needed for moderate to severe pain. The resident’s MDS dated 5/24/2026 indicated intact cognition, substantial assistance needed for several activities of daily living, frequent pain, and a recent hip replacement. During a concurrent interview and record review on 5/29/2026, the resident’s Care Plan Report was reviewed and did not include a care plan for the resident’s left hip pain. The RN stated there were no care plans for the resident’s pain and that care plans should be initiated within 3 days of admission. The resident stated she had pain in her left hip after having left hip replacement surgery. The facility policy titled Develop-Implement Comprehensive Care Plans, dated 1/2026, stated the facility would develop a person-centered comprehensive care within seven days after completion of the comprehensive assessment.
Narcotic Destruction Logs Missing Required Signatures
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure 36 out of 36 narcotic destruction log sheets were signed by the DON and the facility's pharmacist consultant. During a concurrent interview and record review on 3/11/2026 at 10:32 a.m., the DON stated there were 34 individual residents-controlled drug records that she did not sign on 1/30/2026 during drug destruction with the RPH. She stated discontinued narcotics were kept in a locked drawer inside her office, and that when a narcotic was discontinued, a licensed nurse would come to her office and both would count the remaining medications. The DON also stated she performed monthly narcotic destruction with the pharmacy consultant, counting the narcotics together to verify the amount in the bubble pack matched the narcotic destruction log before placing the medications into a destruction bin. She stated the process required two signatures on the Controlled or Antibiotic Drug Record, one from the RPH and one from the DON, per State and Federal guidelines. The facility policy titled Medication Destruction, revised 1/2025, stated medications would be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous waste and controlled substances and include the signatures of at least two witnesses, including a registered nurse and an authorized licensed pharmacy representative.
Unlabeled Opened Respiratory Medications in Medication Cart
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles when three opened ipratropium with albuterol inhalation solution foil packs in Medication Cart 1 were found without an opened date. The deficiency involved Resident 16, Resident 20, and Resident 72, each of whom had active orders for ipratropium with albuterol inhalation solution for respiratory symptoms. The medication packs were observed stored at room temperature during a concurrent observation and interview with LVN 1. Resident 16 had diagnoses including pneumonia, COPD, and CHF, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognitive skills for daily decision making and substantial assistance was needed for eating, oral hygiene, and upper body dressing. Resident 20 had diagnoses including pneumonia, CHF, and DM, and the H&P stated the resident had the capacity to understand and make decisions; the MDS indicated independent cognitive skills for daily decision making and set-up assistance was needed for eating and oral hygiene. Resident 72 had diagnoses including COPD, CHF, and atrial fibrillation, and the H&P stated the resident had fluctuating capacity to understand and make decisions. LVN 1 stated that Residents 16, 20, and 72 each had one opened ipratropium with albuterol inhalation foil pack with no label showing an opened date. LVN 1 stated the pharmacy fill dates were on the packs and that all medications should be labeled with an open date so staff would know the expiration date. LVN 1 also stated that giving expired ipratropium with albuterol inhalation solution would no longer be effective in treating the residents' respiratory symptoms. The DON stated it is important to label all medications with an open date so staff would know the life span of the medication, and that giving expired medication would have a possibility of adverse reaction. The manufacturer's instructions stated opened foil packs should be used or discarded within two weeks of opening, and the facility policy stated drugs and biologicals are to be labeled in accordance with accepted professional principles, including the expiration date when applicable.
Expired Food Left in Kitchen Refrigerator
Penalty
Summary
Food items stored in the kitchen walk-in refrigerator were not maintained in a safe and sanitary manner when expired products were left available for use. During a concurrent observation and interview on 3/10/2026 at 8:40 a.m., an opened bag of [NAME] brand corn tortillas with an expiration date of 12/21/2025 and five bags of [NAME] Deli 16 count hot dog buns were observed in the refrigerator, including three bags with expiration dates of 1/31/2026 and two bags with expiration dates of 2/2/2026. The [NAME] stated the hot dog buns and tortillas should not be in the refrigerated storage and should be thrown out. During an interview on 3/10/26 at 11:09 a.m., the Dietary Services Supervisor stated that having expired food could expose residents to foodborne illness and make residents sick. Review of the facility policy titled Food Receiving and Storage, revised January 2026, indicated refrigerated food should be monitored so it is used by its used-by date or discarded.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for one resident, Resident 39. Resident 39 was initially admitted to the facility and later readmitted, and had diagnoses including dementia, COPD, and CHF. The H&P dated 8/30/2025 indicated Resident 39 did not have the capacity to understand and make decisions. The MDS dated 12/10/2025 indicated the resident's cognitive skills for daily decision-making were severely impaired and that the resident was totally dependent on staff for oral hygiene, toileting hygiene, and upper and lower body dressing. Resident 39's care plan, revised 1/12/2026, included an intervention to maintain the call light within easy reach and answer promptly. During a concurrent observation and interview on 3/10/2026 at 9:45 a.m., the IPN found Resident 39's touch pad call light under her pillows and stated the resident could not reach it. The IPN stated the call light should be in the resident's reach to allow the resident to call for help and assistance. During an interview on 3/12/2026 at 12:07 p.m., the DON stated all staff are responsible for monitoring residents' call lights and that the call light should be within reach at all times so staff could anticipate residents' needs.
Failure to Protect Resident Meal Ticket Information
Penalty
Summary
The facility failed to protect residents' personal information when meal tickets containing resident names, room numbers, diet types, texture levels, liquid consistency levels, and likes and dislikes were observed in the trash by the dishwashing machine area. During interview, the Dietary Aide stated the meal cards contained patient information such as names, diet type, and room number and should not have been thrown in the trash, but should have been shredded or given to the supervisor. The Dietary Service Supervisor stated the meal tickets contain resident names, diet, and room numbers, that this information is protected, and that personal privacy information should not be thrown in the trash can. Review of the facility policy titled Privacy and Confidentiality dated 1/2025 stated that the resident has a right to personal privacy and confidentiality of his or her personal and medical records.
Late Completion of Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that one resident’s quarterly MDS assessment was completed within the required timeframe. Resident 2 was initially admitted to the facility and later readmitted, and the record review noted diagnoses of CHF, atrial fibrillation, and HTN. The resident’s H&P dated 9/11/2025 stated that Resident 2 lacked the capacity to make medical decisions. During a concurrent interview and record review on 3/11/2026, the MDS Nurse reviewed Resident 2’s quarterly MDS assessment dated 2/20/2026 and stated it had not yet been completed. The MDS Nurse stated the assessment should have been completed by 3/6/2026, 14 days from the ARD, and that MDS assessments should be completed in a timely manner to capture unnecessary changes in a resident’s condition. During an interview on 3/12/2026, the DON stated MDS assessments should be completed within 14 days from the ARD and that failure to complete the MDS in a timely manner means the resident’s assessment is not updated and there is a possibility the resident’s care would not be met. The facility policy titled Resident Assessment, dated 1/2026, stated the facility shall complete MDS assessments within required federal timeframes.
Inaccurate MDS Coding for ROM
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident. The resident was admitted and later readmitted to the facility and had diagnoses including CHF, atrial fibrillation, and HTN. The resident's H&P stated that the resident lacked the capacity to make medical decisions. In the MDS assessment dated 11/21/2025, the resident was coded as having severely impaired cognitive skills for daily decision making and requiring moderate assistance with toileting hygiene, lower body dressing, and personal hygiene. Review of the resident's JMA records dated 8/29/2025, 9/9/2025, 12/15/2025, and 2/20/2026 showed no impairment in ROM for the upper or lower extremities. During interview, the MDSN stated the MDS was completed inaccurately because section GG0115(B) for lower extremity ROM should have been coded as 0 rather than 1, and that the facility transmitted inaccurate information to CMS. The DOR also stated the resident had no contractures and no limitation in ROM affecting ADLs, and the DON stated accurate completion of the MDS is important to provide the resident's needs. Facility policy required comprehensive, accurate resident assessment and supporting source documentation for MDS coding.
Failure to Obtain Medical Clearance for Recommended Tooth Extraction
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice for one sampled resident by not obtaining a medical order clearance for a tooth extraction that the dentist recommended. Resident 3 was admitted and later readmitted to the facility with diagnoses including pneumonia, COPD, and DM. The resident’s H&P stated she did not have the capacity to understand and make decisions, while the MDS indicated she was independent in cognitive skills for daily decision making and required substantial assistance with eating and oral hygiene. During interview, Resident 3 stated she needed surgery to remove broken teeth, that the broken teeth bothered her, and that she was not able to chew food properly. Review of the Dental Visit Summary and Dental Notes showed the dentist recommended obtaining a medical order clearance for tooth extraction, but facility staff did not document that the physician was notified or that the clearance was obtained. The SSD stated she was not aware of the dentist’s recommendation, RN 1 stated she did not check the Dental Visit Summary and was not aware of the recommendation, and the DON confirmed there was no documentation that the physician was notified or that the medical order clearance was obtained.
Failure to Use Ordered Elopement Alert Device
Penalty
Summary
The facility failed to ensure that one of two sampled residents, Resident 36, wore the physician-ordered ROAM Alert device on the left wrist for elopement risk. Resident 36 was admitted with diagnoses including homelessness, syncope and collapse, and DM. The resident’s MDS dated 2/6/2026 indicated independence in cognitive skills of daily decision making and independence in several functional abilities, with minimal assistance needed for personal hygiene, showering, and oral hygiene. An elopement risk note dated 2/6/2026 documented a score of 4, and the H&P dated 2/23/2025 stated the resident had fluctuating capacity to understand and make decisions. The physician orders dated 3/2/2026 included a ROAM Alert to the left wrist for elopement risk and ROAM Alert monitor function to the right wrist every shift. The care plan dated 12/3/2023 identified elopement risk related to constantly seeking behavior and packing belongings, with an intervention added on 5/9/2024 for the resident to wear the ROAM Alert device on the left wrist. During observations on 3/10/2026, 3/11/2026, and 3/12/2026 at 8:00 a.m., 11:00 a.m., 2:00 p.m., and 4:00 p.m., Resident 36 was observed without a ROAM Alert device on the wrist. The DON stated on 3/12/2026 that being without the device put the resident at increased safety risk because the resident could easily elope without staff knowing and be at risk for injury or harm.
Failure to Use EBP for Resident With PICC Line
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure Enhanced Barrier Precautions were used for one sampled resident with a PICC line. Resident 39 was admitted with diagnoses including pneumonia, UTI, and bacteremia, and the H&P documented that he had the capacity to understand and make decisions. The physician ordered Unasyn 3 grams IV three times daily for UTI treatment, and during observation the resident was noted to have a PICC line in the right upper arm. During a concurrent observation and interview, the IPN stated EBP is practiced for residents with medical devices like a PICC line, but Resident 39 was not placed on EBP because he had been admitted to the facility on [DATE]. The IPN stated this was an oversight and that PPE supplies such as gown and gloves should have been outside the room for staff to use when providing care. The DON stated residents with medical devices such as central lines, gastrostomy tubes, and foley catheters should be placed on EBP immediately to prevent cross contamination and spread of infection. Facility policy stated EBP are indicated for residents with indwelling medical devices including central lines and require gown and glove use during high-contact resident care activities.
Failure to Provide Adequate Supervision and Individualized Care Plan During Resident ADL Care
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis following a stroke, muscle wasting, and abnormal gait, who was totally dependent on staff for activities of daily living (ADLs), fell from bed while receiving care. The resident was observed with swelling and discoloration on the right cheek and a dime-sized abrasion on the right elbow. The resident was unable to move the right upper and lower extremities and had slurred speech but could communicate with simple words. The fall happened while a CNA was providing peri-care and turning the resident, during which the resident's weight shifted and resulted in a fall from the bed to the floor. Record review showed that the resident required maximum assistance with transfers and bed mobility and was dependent on staff for all ADLs. The care plan for the resident indicated the need for a safe and hazard-free environment but did not specify the type or number of staff assistance required during care. Interviews with staff revealed that the resident was not positioned in the center of the bed before being turned, and only one CNA was present during the incident. Staff acknowledged that the resident was totally dependent and should not have been turned alone, and that assistance should have been requested to ensure safety. Facility policies required periodic assessment of residents' needs for ADL care, monitoring and modifying care plans as necessary, and ongoing training on patient safety and fall prevention. However, the interventions in the resident's care plan were not individualized to specify the necessary assistance, and staff did not follow procedures to ensure the resident's safety during care, directly leading to the fall and resulting injuries.
Failure to Report Resident Fall Incident by CNA
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to report an incident involving a resident who rolled off the bed while being cleaned and subsequently complained of a headache. The resident, who had a history of a nondisplaced tibial fracture, traumatic subdural hemorrhage, and end stage renal disease, was dependent on staff for activities of daily living and had fluctuating capacity to make decisions. After the incident, CNA 1 picked up the resident, returned her to bed, and only reported the headache to the charge nurse, omitting the details of the fall or near fall. The facility's job description and policies required CNAs to promptly report any resident changes, injuries, or falls to licensed nursing personnel and to use proper techniques for lifting and repositioning residents. Interviews with other staff, including licensed vocational nurses and the Director of Nursing, confirmed that all falls or near falls must be reported immediately so that residents can be properly assessed for injuries. The facility's Fall Management Program and Patient Safety Plan also specified that any episode where a resident loses balance and would have fallen, if not for another person, is considered a fall and must be reported. The failure to report the incident resulted in a delay in the resident's treatment and evaluation. The incident was only discovered when a nurse noticed a bump on the resident's head and the resident reported the fall. The CNA's lack of reporting was identified as a deficiency in competency and adherence to facility policy, as confirmed by the Director of Staff Development and other staff interviews.
Failure to Monitor Blood Glucose After Resident's Return
Penalty
Summary
The facility failed to ensure that a resident's blood glucose level was checked promptly after returning from an out on pass (OOP). The resident, who has a history of diabetes mellitus, was admitted to the facility with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), and a history of falls. Upon returning to the facility at 1:48 a.m., the resident's blood sugar was not checked until 6:57 a.m., resulting in a delay of four hours. This oversight was identified during a review of the resident's progress notes and confirmed by the Director of Nursing (DON), who acknowledged that the blood sugar should have been checked as part of the assessment upon the resident's return. The facility's policy and procedure for diabetes management, dated March 2017, requires monitoring of blood glucose levels when a resident returns after a significant absence. Additionally, the facility's resident assessment policy, dated March 2023, mandates comprehensive assessments that include special treatments and procedures. The failure to adhere to these protocols resulted in the resident's blood sugar being recorded at 333 mg/dl, indicating hyperglycemia, which could have placed the resident at risk for further complications. The deficiency was noted as a failure to follow established guidelines for monitoring and assessing residents with diabetes upon their return to the facility.
Failure to Develop Care Plan for Resident Non-Compliance
Penalty
Summary
The facility failed to ensure that a care plan was developed for a resident who exhibited non-compliance by not returning to the facility within the recommended time frame after going out on pass (OOP). The resident, who was admitted with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, and a history of falls, was identified as a high fall risk and required insulin injections daily. Despite these needs, the resident left the facility for extended periods on two occasions, exceeding the recommended four to six hours, without a care plan addressing this non-compliance. The Director of Nursing (DON) acknowledged that a care plan should have been created to address the resident's non-compliance, especially given the resident's high fall risk and diabetes. The facility's policy requires comprehensive care plans to address medical, physical, mental, and psychosocial needs, including when a resident's choice to decline care poses a risk to their health or safety. However, no such care plan was in place for this resident, potentially placing them at risk for injury and inadequate monitoring of their diabetes.
Failure to Supervise High-Risk Resident on Therapeutic Leave
Penalty
Summary
The facility failed to ensure that a high-risk resident had a plan in place for continuous supervision and monitoring while out on pass (OOP). The resident, who was identified as having a high risk for falls due to a history of falls, diabetes mellitus, and chronic obstructive pulmonary disease, was cognitively intact and required supervision for transfers and walking. Despite these needs, the resident was allowed to leave the facility for 12 hours without adequate supervision or monitoring, exceeding the recommended OOP duration of four to six hours. This lack of supervision posed a potential risk for the resident to fall while outside the facility. The Director of Nursing (DON) acknowledged that the staff should have documented the resident's risk factors and monitored the resident's safety and supervision once the resident did not return within the recommended time. The facility's policy and procedure for Out on Pass Therapeutic Leave and Fall Management Program were reviewed, indicating that residents should be aware of the risks associated with leaving the facility and provided with necessary information and support. However, the facility did not adhere to these guidelines, failing to provide adequate supervision to minimize the risks associated with falls for the resident while OOP.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly Medication Regimen Review (MRR) for four of six sampled residents, specifically Residents 15, 30, 37, and 38. This deficiency was identified during a review of the facility's MRR binder, which showed that these residents did not have documented MRRs for the months of October through December 2024. The Director of Nursing (DON) acknowledged the oversight and noted that only five residents received an MRR for October, indicating a lapse in the facility's process to ensure all residents' medication regimens were reviewed monthly. Resident 15, admitted with diagnoses including diabetes mellitus, muscle weakness, and end-stage renal disease, had intact cognition and was dependent on staff for daily activities. Despite these conditions, there was no MRR documented for three consecutive months. Similarly, Resident 37, who had dementia, malnutrition, and muscle weakness, and Resident 38, with dementia, hypertension, and diabetes mellitus, also lacked MRR documentation for the same period. Both residents required significant assistance with daily activities and had varying levels of cognitive impairment. Resident 30, diagnosed with bipolar disorder, heart disease, hypertension, and muscle weakness, also did not have an MRR documented for October, November, and December 2024. The DON confirmed the absence of documentation and explained the facility's practice of having MRRs done monthly, with recommendations from the consultant pharmacist communicated to the physician. The facility's policy, revised in March 2024, mandates monthly MRRs to prevent adverse medication consequences, but this was not adhered to, placing the residents at risk of unaddressed medication irregularities.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized person-centered care plans for two residents, leading to potential negative impacts on their care. Resident 58, who was admitted with diagnoses including osteomyelitis, schizoaffective disorder, dysphagia, and acute kidney failure, frequently signed in and out of the facility on passes. However, there was no care plan in place to address the resident's needs and safety during these outings. The Director of Nursing acknowledged the absence of a care plan for Resident 58's outings, which could result in inadequate and incompetent care. Similarly, Resident 167, who was admitted with conditions such as atrial fibrillation, hypertension, polyneuropathy, and osteomyelitis, had a PICC line for intravenous medication administration. Despite this, the facility did not create a care plan to manage the PICC line, which posed a risk for complications. A registered nurse confirmed the lack of a care plan for the PICC line, emphasizing its importance for tracking the resident's progress and ensuring continuity of care among the interdisciplinary team. The facility's policy required comprehensive care plans to address residents' medical, physical, mental, and psychosocial needs, which was not adhered to in these cases.
Resident Not Informed of Physician Change
Penalty
Summary
The facility failed to ensure that a resident was involved in the decision-making process and was notified of a change in their attending physician. This deficiency was identified for a resident who had the capacity to understand and make decisions, as indicated by their History and Physical and Minimum Data Set assessments. The resident was not informed about the change of physician, which was made due to a shift in their level of care from skilled to custodial care. The resident expressed that they were unaware of the change and emphasized their right to be informed and to choose their own physician. During an interview, the Director of Nursing confirmed that there was no documentation indicating the resident was notified about the change of physician. The facility's policy and procedure on the choice of attending physician and resident rights clearly state that residents have the right to choose their physician and must be informed of any changes. The failure to notify the resident and involve them in the decision-making process violated their rights as outlined in the facility's policies and federal and state laws.
Failure to Report Resident's Non-Return
Penalty
Summary
The facility failed to implement its policy and procedures on reporting an unusual occurrence when a resident left the facility and did not return. The resident, who had been admitted with diagnoses including osteomyelitis, schizoaffective disorder, dysphagia, and acute kidney failure, had the capacity to understand and make decisions, as indicated in their History and Physical and Minimum Data Set. The resident required partial to moderate assistance with activities of daily living. The facility's out on pass log showed that the resident signed out but did not return, and the facility did not report this to law enforcement or the California Department of Public Health within 24 hours. During an interview, the Director of Nursing acknowledged that the resident left and did not return, and the facility failed to inform the appropriate authorities as required by their policy. The facility's policy, revised in March 2023, mandates reporting unusual occurrences that affect the welfare, safety, or health of residents within 24 hours. The failure to follow this policy had the potential to result in serious harm, injuries, or death for the resident.
Failure to Report Resident's Absence to Authorities
Penalty
Summary
The facility staff failed to report a resident's absence to the California Department of Public Health (CDPH) after the resident left the facility and did not return. The resident, who had diagnoses including osteomyelitis, schizoaffective disorder, dysphagia, and acute kidney failure, was noted to have intact cognitive skills and required partial to moderate assistance with activities of daily living. The resident frequently signed out of the facility on passes but did not return after leaving on a specific date. Despite the resident's history of leaving and returning, the facility did not notify the resident's primary physician, local law enforcement, or CDPH about the resident's failure to return. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility did not document the resident's absence or make necessary notifications. The DON acknowledged the risk of not reporting the resident's absence, while the ADM believed the resident's decision to leave did not impact facility operations. The facility's policies required attempts to contact the resident and documentation of such efforts, as well as reporting unusual occurrences to appropriate agencies. However, these procedures were not followed, resulting in a delay in the investigation by CDPH.
Incomplete Assessments for Smoking Safety and Out on Pass
Penalty
Summary
The facility failed to complete a smoking safety assessment for a resident who was admitted with diagnoses including epilepsy, schizoaffective disorder, nicotine dependence, and encephalopathy. The resident's Minimum Data Set (MDS) indicated intact cognitive skills and a need for partial to moderate assistance with activities of daily living. Despite having a care plan for tobacco use, the resident's smoking assessment was found incomplete. During an interview, the Director of Nursing (DON) acknowledged the incomplete assessment and noted the potential safety issues arising from unsupervised smoke breaks. Additionally, the facility did not conduct an assessment for another resident before allowing them to go out on pass, despite the resident having diagnoses such as osteomyelitis, schizoaffective disorder, dysphagia, and acute kidney failure. The resident's MDS indicated intact cognitive skills and a need for partial to moderate assistance with daily activities. The facility's out on pass log showed the resident frequently signed in and out, but no assessment was found to determine their ability to leave the facility. The DON confirmed the lack of assessment and highlighted the risk of serious harm or death without proper evaluation.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for one of the sampled residents, which had the potential to negatively affect the plan of care and delivery of services. The resident in question was admitted with diagnoses including a pressure ulcer in the sacral region, sepsis, and chronic obstructive pulmonary disease (COPD). The resident's MDS assessment indicated intact cognitive skills and a need for moderate assistance with upper body dressing and personal hygiene. However, the MDS assessment did not accurately reflect the use of a low air loss mattress (LALM) prescribed for wound management, as it was not marked under section M (Skin Condition) 1200B. During an interview and record review, the Minimum Data Set Nurse (MDSN) acknowledged the oversight, stating that the omission of the LALM on the MDS assessment resulted in providing incorrect information to the facility staff involved in the resident's care. This inaccuracy was contrary to the facility's policy and procedure, which mandates that assessments must accurately reflect the resident's status at the time of the assessment. The policy emphasizes the importance of qualified staff conducting assessments to ensure they represent an accurate picture of the resident's status during the observation period.
Failure to Conduct PASRR Level II Evaluation for Resident with Psychiatric Diagnosis
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) for a resident with an existing psychiatric diagnosis, which is a federal requirement to ensure appropriate placement and care for individuals with mental disorders or intellectual disabilities. The resident, who was readmitted to the facility with diagnoses including major depressive disorder and bipolar disorder, had a Minimum Data Set indicating severe cognitive impairment and was receiving antidepressant medication. Despite these indicators, the resident's PASRR Level I completed in 2019 did not acknowledge a mental illness, and no subsequent Level II evaluation was conducted. The Director of Nursing (DON) acknowledged the oversight in not following through with the necessary PASRR Level II evaluation, which is crucial for determining the appropriate placement and need for specialized services. The facility's policy, revised in March 2023, mandates the completion of PASRR for all residents upon admission and referral to the state for those with mental illness or intellectual disabilities. The policy also requires reporting significant changes in a resident's mental condition to the appropriate state mental health authority, which was not adhered to in this case.
Failure to Obtain Level 2 PASRR Evaluation
Penalty
Summary
The facility failed to ensure a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation was obtained for a resident who was admitted with diagnoses including epilepsy, schizoaffective disorder, nicotine dependence, and encephalopathy. The resident's Level 1 PASRR, dated 01/07/2025, indicated the need for a Level 2 PASRR evaluation, which was not completed. This oversight was identified during a review of the resident's face sheet and Minimum Data Set (MDS), which showed that the resident had intact cognitive skills and required partial to moderate assistance with activities of daily living. During an interview, the Director of Nursing (DON) acknowledged that the resident's Level 1 PASRR was positive for a mental illness and confirmed that a Level 2 PASRR should have been resubmitted. The DON stated that failing to resubmit the PASRR could result in a delay in necessary mental health care and services. The facility's policy, revised in 03/2023, requires a referral for a Level II resident review evaluation for individuals identified by PASRR to have a mental disorder, intellectual disability, or a related condition who experience a significant change.
Deficiencies in Physician Orders and Smoking Safety
Penalty
Summary
The facility failed to ensure physician orders were carried out for a resident who was dependent on activities of daily living and had intact cognitive skills. The resident was ordered to have a low air loss mattress for skin management due to their medical conditions, including spinal stenosis, chronic kidney disease, acute kidney failure, and embolism and thrombosis of the left lower extremity. Despite the order being in place since December 2024, the resident did not receive the mattress and reported the issue to staff members without resolution. The Director of Nursing confirmed the absence of the mattress and acknowledged the risk of incomplete care and potential skin breakdown due to this oversight. Additionally, the facility did not provide services meeting professional standards of quality regarding smoking safety for another resident with diagnoses including epilepsy, schizoaffective disorder, nicotine dependence, and encephalopathy. The resident's care plan included adherence to the facility's tobacco/smoking policies, but their smoking assessment was incomplete, and there was no physician's order for unsupervised smoking. The Director of Nursing noted that the incomplete smoking safety notes and lack of a physician's order posed a fire hazard risk. The facility's policy did not address low air loss mattresses or smoking safety.
Failure to Monitor Smoking Safety and Timely Process Pain Management Referral
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident's smoking safety, which could have resulted in serious harm. Resident 48, who was admitted with diagnoses including epilepsy, schizoaffective disorder, nicotine dependence, and encephalopathy, was observed smoking unsupervised on the facility's smoking patio. The resident's smoking assessment was incomplete, lacking information on whether supervision was required. The Director of Nursing acknowledged the incomplete assessment and the absence of Interdisciplinary Team meetings regarding the resident's smoking safety, which could lead to not knowing if supervision was necessary. Additionally, the facility did not process a pain management referral in a timely manner for Resident 49, who was admitted with conditions such as hypertension, a compression fracture of the spine, and a surgical amputation of the right lower leg. Despite having a physician's order for a pain management referral entered on 1/5/2025, the referral was not processed until 1/22/2025, resulting in unmanaged pain for the resident. Interviews with nursing staff revealed that the delay in processing the referral led to the resident experiencing excruciating pain, as the current pain medications were insufficient.
Incorrect LALM Setting for Resident
Penalty
Summary
The facility failed to ensure that a low air loss mattress (LALM) was set and maintained at the correct setting for a resident, which placed the resident at risk for worsening pressure ulcers and further skin breakdown. The resident, who was admitted with diagnoses including a pressure ulcer in the sacral region, sepsis, and COPD, was observed to be lying on an LALM set at 350 pounds, despite the resident's actual weight being 132 pounds. This incorrect setting was identified during an observation and interview with the treatment nurse, who acknowledged that the setting should be based on the resident's current weight to prevent discomfort and deterioration of the wound. The Director of Nursing confirmed that the LALM setting should be adjusted according to the resident's weight and the severity of the pressure ulcer as determined by the physician. The facility's policy and procedure for low air loss mattresses and treatment services to prevent or heal pressure ulcers emphasize following the manufacturer's guidelines and providing care consistent with professional standards to promote healing and prevent new pressure ulcers. However, the failure to adhere to these guidelines resulted in a deficiency in the care provided to the resident.
Failure to Provide Timely Restorative Nursing Services
Penalty
Summary
The facility failed to ensure that a resident received Restorative Nurse Assistant (RNA) services as ordered, which were intended to maintain and improve the resident's range of motion and mobility. The resident, who was admitted with diagnoses including dementia, malnutrition, and muscle weakness, was dependent on staff for various activities and required RNA services five times a week. However, RNA services were not initiated until eight days after the order was placed, and even then, the services were only provided three days a week instead of the prescribed five. Interviews with the Restorative Nursing Assistant and the Director of Rehab revealed that RNA services should have started the day after the order was placed, but neither could explain the delay or the reduced frequency of services. The facility's policy indicated that residents should receive restorative nursing care as needed, but this was not adhered to in the case of the resident, potentially leading to a decline in function or development of contractures.
Inadequate Supervision and Hazard Management During Resident Smoke Breaks
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment during smoke breaks for a resident, leading to a potential fire hazard. Resident 48, who was admitted with diagnoses including epilepsy, schizoaffective disorder, nicotine dependence, and encephalopathy, was observed to have a lighter and an empty pack of cigarettes on their bedside table. The resident stated they were allowed to keep smoking materials and smoke unsupervised on the smoking patio. However, the resident's smoking safety assessment was found incomplete, indicating a lack of proper evaluation of their ability to smoke safely. During an interview, the Director of Nursing (DON) confirmed that residents who were alert and oriented were permitted to possess smoking materials. The DON acknowledged that Resident 48 was considered an independent smoker, but the incomplete smoking safety assessment posed a risk of fire and safety issues. The facility's smoking policy required assessments to be completed on admission, quarterly, and as the resident's needs or capabilities changed, which was not adhered to in this case. Additionally, the facility's policy on accident hazards emphasized the importance of staff involvement in identifying potential hazards, which was not effectively implemented in this situation.
Failure to Provide Dental Services and Proper Oxygen Therapy
Penalty
Summary
The facility failed to ensure dental services were provided for a resident, identified as Resident 110, which had the potential to result in tooth decay, gum disease, bad breath, and cavities. Resident 110 was admitted with diagnoses including dependence on oxygen, thrombocytopenia, anemia, and benign prostatic hyperplasia. The Minimum Data Set (MDS) indicated that Resident 110 had intact cognitive skills but required substantial to maximal assistance with activities of daily living, such as toileting, showering, and dressing. Additionally, the facility did not administer oxygen therapy according to the physician's order for Resident 110. During an observation, it was noted that the resident was receiving 1.5 liters of oxygen via nasal cannula, whereas the physician's order specified 2 liters continuously. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN 2) who acknowledged the risk of not following the physician's order, which could lead to oxygen desaturation. The facility's policy on oxygen therapy required a physician order outlining administration, which was not adhered to in this instance.
Failure to Provide Dialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident requiring hemodialysis treatment. Specifically, the facility did not ensure that a dialysis emergency kit was readily available at the bedside of a resident with end-stage renal disease, hypertension, and anemia. The resident was scheduled to receive hemodialysis treatment three times a week and had an arteriovenous graft dialysis access site on the right upper arm. During an observation and interview, it was confirmed that the dialysis emergency kit, which should contain dry gauze, tape, alcohol pads, and a bandage, was not available at the bedside. This kit is essential for managing potential excessive bleeding from the dialysis site. The Director of Nursing stated that it was the responsibility of licensed nurses to check the availability of the dialysis emergency kit at the start of each shift and during huddle meetings. The facility's policy and procedure on dialysis management, dated March 2023, indicated that residents requiring dialysis care should receive services consistent with professional standards of practice. The absence of the emergency kit at the bedside was a deviation from these standards and posed a risk of uncontrolled bleeding, which could lead to severe consequences for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two errors out of 28 medication opportunities, resulting in a cumulative error rate of 7.14% for a resident. The errors involved the failure to administer Calcium Carbonate with Vitamin D as prescribed and the failure to monitor the pulse rate before administering Metoprolol Tartrate, as per the physician's orders. These deficiencies were observed during a medication administration task involving a resident with diagnoses including atrial fibrillation, hypertension, polyneuropathy, and osteomyelitis. During the medication pass observation, a Licensed Vocational Nurse (LVN) did not administer the prescribed Calcium Carbonate with Vitamin D due to the absence of the medication on the cart. Additionally, the LVN administered Metoprolol Tartrate without checking the resident's pulse rate, contrary to the physician's order to hold the medication if the systolic blood pressure was below 110 or the pulse rate was below 60. The facility's policy requires that medications be administered according to orders and that vital signs be checked prior to administration, which was not adhered to in this instance.
Medication Labeling and Expiration Management Deficiencies
Penalty
Summary
The facility failed to properly label and manage medications, leading to two deficiencies. In the first instance, a vial of influenza vaccine was found in the medication storage room refrigerator without an opened date label. During an observation and interview, a registered nurse acknowledged the absence of the label and the infection preventionist nurse admitted to opening the vial without labeling it. The facility's policy requires that multi-dose vials be dated when opened to ensure safe administration and storage. In the second instance, two unopened vials of expired insulin were found in the medication storage room refrigerator. One vial of Lispro insulin for a resident with diabetes and end-stage renal disease, and one vial of Levemir insulin for another resident with diabetes and chronic obstructive pulmonary disease, were both expired. A registered nurse confirmed the responsibility of licensed nurses to check expiration dates and stated that expired insulin should be discarded immediately. The facility's policy indicates that unopened vials should be discarded according to the manufacturer's expiration date. Both residents involved had severe cognitive impairments and required substantial assistance with daily activities. The failure to label the influenza vaccine and remove expired insulin vials posed a potential risk to the residents' health, as the effectiveness of the medications could be compromised.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for one of the six sampled residents, identified as Resident 6. Resident 6, who was admitted with diagnoses including bipolar disorder, quadriplegia, major depressive disorder, and insomnia, had intact cognitive skills and required partial to moderate assistance with activities of daily living. During an interview, Resident 6 reported that he had not received a dental cleaning from the facility's dentist as requested, despite having informed the Social Services Director months ago. The last dental visit for Resident 6 was in November 2024. The Social Services Director acknowledged responsibility for setting and following up on dental appointments for residents. She admitted to writing Resident 6's name on a list for a dental cleaning but was unable to locate the list. Furthermore, she did not document or follow up on Resident 6's request for dental services. The facility's policy, revised in December 2020, mandates that dental services be provided in accordance with professional standards of quality and timeliness. The failure to follow up on dental services had the potential to result in oral health issues for Resident 6.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for one resident, identified as Resident 37, during lunchtime. Resident 37, who was admitted with diagnoses including dementia, malnutrition, and muscle weakness, had an order for fortified potatoes to be served with lunch to address nutritional deficiencies and support weight gain. Despite this order, an observation on January 23, 2025, revealed that Resident 37's lunch tray did not include the fortified potatoes. This omission was confirmed by a Registered Nurse (RN) who acknowledged the importance of the fortified potatoes in preventing further weight loss for the resident. The Dietary Services Supervisor (DSS) was unable to provide an explanation for the absence of the fortified potatoes on Resident 37's lunch tray. The facility's policy on therapeutic diets, dated March 2023, mandates that residents receive foods with appropriate nutritive content to support their treatment and care plans. Additionally, the facility's weight management policy, dated December 2024, emphasizes the provision of therapeutic diets for residents with nutritional problems. The failure to adhere to these policies resulted in a deficiency that put Resident 37 at risk for further weight loss.
Failure to Timely Assess and Manage Pain
Penalty
Summary
The facility failed to assess and manage pain in a timely manner for Resident 3, who was admitted with diagnoses including cellulitis of the left lower limb, phantom limb syndrome with pain, and muscle weakness. Despite a care plan indicating the need for regular pain assessment and management, Resident 3 reported a pain level of 8 out of 10 and had been asking for pain medication since 9:00 a.m. on the day of the observation. The resident had undergone debridement on a right heel pressure ulcer and had pressed the call light multiple times to request pain medication. The Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) involved failed to promptly address the resident's pain, with the LVN admitting to not assessing the pain level before administering medication at 11:20 a.m., over two hours after the initial request. This delay in pain management caused the resident to experience anxiety due to unmanaged pain. Interviews with the Director of Nursing (DON) and a review of the facility's policy and procedure on pain assessment and management highlighted the requirement for proper pain assessment and timely treatment to maintain the resident's quality of life. The facility's policy emphasized the need for assessing pain characteristics, addressing underlying causes, and implementing appropriate pain management strategies. However, the staff's failure to adhere to these guidelines resulted in inadequate pain management for Resident 3, potentially affecting the resident's quality of life and ability to perform daily activities.
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What surveyors actually found near you
We read the 6,493 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gardena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kei-ai South Bay Healthcare Center | 0.2 mi | ★★★★★ | 17 | 0 |
| Rosecrans Care Center | 0.4 mi | ★★★★★ | 6 | 0 |
| Memorial Hospital Of Gardena D/p Snf | 0.6 mi | ★★★★★ | 13 | 0 |
| Clear View Convalescent Center | 0.8 mi | ★★★★★ | 4 | 0 |
| Clear View Sanitarium | 0.8 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.