Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Memorial Hospital Of Gardena D/p Snf during CMS and state inspections, most recent first.
Food items in one walk-in refrigerator were found unlabeled, undated, and expired, including an unopened cheese danish and opened hot dog buns past their expiration date. Another walk-in freezer had no internal thermometer while storing meats, and a separate walk-in refrigerator storing dairy products was reading 50 degrees F. The DSS confirmed that food should be labeled and dated, expired items discarded, and that refrigeration units should have reliable thermometers and proper temperatures.
Inaccurate MDS Race Entry: A resident with respiratory failure, tracheostomy, quadriplegia, and sepsis had an MDS that listed the wrong race in Section A1010. The MDS Nurse stated the resident was Mexican, not White, and acknowledged the assessment was not completed accurately because the entry was not double-checked.
Failure to resubmit PASARR screening for a resident with mental illness. A resident with bipolar disorder, anxiety, and depression was receiving Klonopin and Zoloft via GT, but the facility relied on an older PASARR Level 1 screening from another facility that showed no serious mental illness and no psychotropic meds. The CM stated a new PASARR Level 1 screening under Resident Review should have been completed and resubmitted.
A resident with severe cognitive impairment and dependence for ADLs was found lying on a low air loss mattress set to a weight setting that did not match the resident’s 151-lb weight. An LVN confirmed the setting was incorrect, and the mattress instructions directed staff to choose the setting closest to the patient’s weight.
IV fluids used beyond 24 hours for keep-vein-open therapy. Two residents with IV midlines, trachs, GTs, and significant cognitive and functional impairment had NS 500 cc keep-open IV solutions in place longer than the facility’s 24-hour standard. RN stated the NS bags could be used for 4 days or until consumed, while the NM and DON stated IV fluids should not hang longer than 24 hours; the facility policy also required small IV solution bags used for keep-open IVs to not hang longer than 24 hours.
A resident with respiratory failure, tracheostomy, schizoaffective disorder, and GT placement was started on olanzapine for mood disorder without documented behavior monitoring or attempted non-pharmacological interventions. The MDS showed severely impaired decision-making, dependence for ADLs, and no psychosis or physical behaviors toward others, while the NM stated the agitation was vague, there was no nursing documentation to justify the psychotropic, and less restrictive measures such as a sitter and redirection were not tried before the medication was initiated.
A resident with DM, respiratory failure, and ESRD had an expired vial of Lispro insulin left in a medication cart. During observation, the LVN confirmed the vial had been dispensed by the pharmacy, opened, and labeled with a beyond-use date, and stated expired medication should not remain in the cart. The resident had an active SQ sliding-scale order for Lispro, while the manufacturer labeling and facility policy both required opened vials to be discarded after 28 days.
Facility Assessment Missing Staffing Contingency Plan: The facility failed to include a staffing contingency plan for emergencies in its Facility Assessment. The DON stated the assessment covered day-to-day operations but did not address emergency staffing, and the facility's Scope of Care policy also did not mention a contingency plan in the Facility Assessment. CMS guidance reviewed by surveyors stated the assessment must address resources needed for care during routine operations, nights and weekends, and emergencies.
Failure to Use Required Gown During Direct Resident Care: A CNA provided hands-on care to a resident with a trach and cool aerosol without wearing a disposable gown while changing the resident and performing oral care. The resident had acute respiratory failure, hypoxia, hypercapnia, severely impaired cognition, and was dependent on staff for ADLs. The CNA acknowledged not wearing the gown, and the IPN stated PPE was required for this type of care under the facility’s EBP policy.
Two residents in an LTC facility did not receive proper pressure ulcer care. One resident was not repositioned every two hours as required, leading to new blisters. Another resident did not receive wound care as ordered, with incorrect materials used initially. Staff admitted to not following physician orders, highlighting a failure to adhere to facility protocols.
The facility failed to label food items with received and used dates in storage areas and refrigerators, and did not remove expired food items from the kitchen. Observations revealed unlabeled condiments and expired dry goods, while the Director of Nutritional Services acknowledged the importance of labeling for food safety.
The facility failed to follow infection control protocols for multiple residents, including improper hand hygiene during wound care and incorrect positioning of a urinary catheter bag. These lapses occurred despite existing policies, putting residents with significant medical conditions at risk of infection.
A facility failed to properly assess and treat a resident's dry and crusty skin on the left palm, leading to a potential risk for skin breakdown. The resident, with a history of stroke and other conditions, required dependent assistance with daily activities. Despite observations of the dry skin, the treatment nurse did not apply lotion due to the absence of a doctor's order. The DON stressed the importance of daily skin assessments and physician communication.
A resident at high risk for skin breakdown was not repositioned every two hours as required, resulting in blisters. Despite the care plan and facility policy mandating regular turning, the resident remained on the same side for over four hours, leading to skin damage.
A resident with high risk for skin breakdown was not repositioned for several hours due to insufficient CNA staffing, resulting in delayed care and the development of blisters. Staff interviews confirmed that the facility was short-staffed, particularly on weekends, impacting the ability to provide timely care. The DON acknowledged the lack of a contract for registry staff and an insufficient pool of CNAs, which could lead to delays in care.
A resident with quadriplegia and a tracheostomy was unable to use the standard call bell due to physical impairments, leading to frustration and helplessness. The facility's call light system had been broken for three years, and no alternative was provided, forcing the resident to yell for assistance. The DON acknowledged the inadequacy of the situation, and the facility's policy for call system failure was not effectively implemented.
Food Storage and Temperature Monitoring Deficiencies
Penalty
Summary
Food items in walk-in refrigerator 1 were found unlabeled, undated, and expired during a concurrent observation and interview with the Dietary Services Supervisor (DSS). An unopened cheese danish was observed without a label or date, and an opened pack of hot dog buns had an expiration date of 4/4/2026. The DSS stated that all food items should have been labeled and dated and that expired items should have been discarded. During the same survey, the walk-in freezer 2 had no internal thermometer while it contained a variety of meats, including chicken, fish, and pork. The DSS stated that a walk-in freezer should have an internal thermometer. In walk-in refrigerator 3, which contained dairy products such as yogurt and milk, the thermometer was observed at 50 degrees Fahrenheit. Facility policy titled Freshness Dating and Labeling stated that short-term storage for fresh, perishable, and potentially hazardous food items should be at 41 degrees F or lower, and the Food Purchasing and Handling policy stated that food should be clearly labeled and dated and that there should be a reliable thermometer in each refrigerator, freezer, and storeroom.
Inaccurate MDS Race Entry
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for one resident. The resident was admitted with diagnoses including respiratory failure with tracheostomy placement, quadriplegia, and sepsis. The MDS dated [DATE] indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, and upper and lower body dressing. A review of the CMS MDS 3.0 NH Final Validation Report for an assessment reference date of 10/20/2025 showed that the information submitted for Section A1010 (Race) did not match the database entry. During interview and record review, the MDS Nurse stated the resident’s MDS was not completed accurately and that there should have been no check mark entered for White because the resident’s race was Mexican, not White. The MDS Nurse stated she completed the assessment and failed to double-check that the information was entered correctly. The facility policy stated the MDS assessment must accurately reflect the resident’s status.
Failure to Resubmit PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a PASARR Level 1 screening was completed and resubmitted for a resident with mental illness diagnoses. Resident 5 was admitted to the facility with diagnoses including bipolar disorder, respiratory failure, and tracheostomy placement. The resident’s MDS indicated the resident was independent with cognitive skills in daily decision making, could make self-understood and understand others, and required dependent assistance with oral hygiene, toileting hygiene, and upper and lower body dressing. The resident’s order summary showed that a physician ordered Klonopin via GT as needed for anxiety and Zoloft via GT daily for depression. During interview and record review, the CM reviewed a PASARR Level 1 screening completed by another facility that had indicated no serious mental illness diagnoses and no psychotropic medications, and the case had been closed without a PASARR Level II evaluation. The CM stated the facility should have completed and resubmitted a new PASARR Level 1 screening under Resident Review because the resident had bipolar disorder, anxiety disorder, and depression and was prescribed Klonopin and Zoloft. The facility’s policy stated the MDS nurse would coordinate assessments with the PASARR program under Medicaid.
Incorrect Low Air Loss Mattress Setting
Penalty
Summary
The facility failed to ensure that the low air loss mattress settings for Resident 7 were correct based on the resident’s weight. Resident 7 was admitted with diagnoses including acute respiratory failure, hypoxia, and hypercapnia. The MDS dated 12/31/2025 indicated the resident’s cognitive skills were severely impaired and that the resident was dependent on staff for ADLs. On 4/8/2026, Resident 7 was observed lying in bed on a low air loss mattress with the weight settings at [PHONE NUMBER] lbs. A record review later showed the resident weighed 151 lbs. During a concurrent observation and interview on 4/9/2026, LVN 4 observed the mattress settings and stated they were incorrect because the resident only weighed 151 lbs. The low air loss mattress instructions indicated the comfort pressure setting should be selected using the number closest to the patient’s weight.
IV fluids used beyond 24 hours for keep-vein-open therapy
Penalty
Summary
The facility failed to ensure that normal saline (NS) 500 cc IV solutions used to keep a vein open were not used longer than 24 hours for two residents. Resident 3 was admitted with diagnoses including respiratory failure with tracheostomy, gastrostomy tube placement, and CVA, and the MDS indicated severely impaired cognitive skills and dependence on staff for oral hygiene, toileting hygiene, and upper and lower body dressing. During observation on 4/7/2026, Resident 3 had an IV midline in the right upper arm, and RN 1 stated the NS 500 cc IV fluid dated 4/5/2026 at 6 p.m. was being used to keep the vein open and could be used for 4 days or until consumed. Resident 37 was admitted with diagnoses including respiratory failure with tracheostomy, gastrostomy tube placement, and osteomyelitis, and the MDS indicated moderately impaired cognitive skills and dependence on staff for oral hygiene, toileting hygiene, and upper and lower body dressing. During observation on 4/7/2026, Resident 37 had an IV midline in the right upper arm, and RN 1 stated the NS 500 cc IV fluid dated 4/3/2026 at 6 a.m. was being used to keep the vein open and could be used for 4 days or until consumed. The NM stated it was standard practice to use the IV solution to keep the vein open for 24 hours for resident safety, and the DON stated IV fluids should hang no longer than 24 hours because bacteria might grow in the solution and put residents at risk for infection. The facility policy titled IV Therapy Administration stated small bags of IV solutions (250 cc or 500 cc) should be used for keep-open IVs so they do not hang longer than 24 hours.
Unnecessary Psychotropic Medication Use Without Behavior Monitoring
Penalty
Summary
The facility failed to ensure one sampled resident was free from unnecessary psychotropic medication use by not monitoring behavior and not attempting non-pharmacological interventions before starting olanzapine. Resident 9 was admitted with respiratory failure with tracheostomy placement, schizoaffective disorder, and gastrostomy tube placement, and the MDS dated 3/25/2026 indicated severely impaired cognitive skills for daily decision making, dependence for oral hygiene, toileting hygiene, and upper and lower body dressing, and no indicators of psychosis or physical behavioral symptoms directed toward others. The order summary showed a telephone order on 10/16/2025 for olanzapine 5 mg daily via GT for mood disorder. During interview and record review, the Nurse Manager stated the resident’s agitation was vague and not specific, there was no nursing documentation to justify the psychotropic medication, no behavior monitoring was done, and less restrictive measures such as a sitter and redirection were not attempted before the medication was used. The Nurse Manager also stated behavior should be monitored and documented for 72 hours to support psychotropic use, and the facility policy required assessment, attempted alternative behavioral management programs, and documented interventions before initiating psychoactive medications.
Expired Insulin Left in Medication Cart
Penalty
Summary
The facility failed to remove one vial of expired Lispro insulin for Resident 25 from medication cart 5. During observation and interview, the vial was found in the cart, and the LVN stated the insulin had been dispensed by the pharmacy, opened, and labeled with a beyond-use date. The LVN also stated expired medication should not remain in the medication cart and should be discarded in the medication waste container. Resident 25 had diagnoses including DM, respiratory failure, and ESRD, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for several activities of daily living. Resident 25’s order summary showed an active order for Lispro insulin to be given SQ every 6 hours per sliding scale based on blood sugar levels. The LVN stated expired insulin would be ineffective in treating the resident’s high blood sugar levels. The DON stated opened insulin is valid for 30 days and said it would not make any difference to give expired insulin medication to residents in 2 days. The manufacturer’s labeling stated opened Lispro vials must be discarded after 28 days, even if insulin remains, and the facility policy stated all insulin or injectable multiple-dose vials will have a 28-day expiration after initial entry and pharmacy-dispensed vials will have an expiration label.
Facility Assessment Missing Staffing Contingency Plan
Penalty
Summary
The facility failed to ensure that its Facility Assessment included a contingency plan for staffing during emergencies. During a concurrent interview and record review with the DON, the Facility Assessment dated 2/2026 was reviewed, and the DON stated the assessment should be revised when there are changes in the general staffing plan, new leadership, or the operation of the facility. The DON also stated the Facility Assessment described the facility's day-to-day operations, but not emergency operations, and that the revised assessment did not indicate a staffing contingency plan during emergencies. A review of the facility's policy and procedure titled, Scope of Care, dated 2/2026, did not mention a contingency plan during emergencies in the Facility Assessment. The DON stated it was important to include the staffing plan during emergencies in the Facility Assessment to safeguard the health and safety of residents. A CMS reference, QSO-24-13-NH dated 6/18/2024, was reviewed and indicated that the facility must conduct and document a facility-wide assessment for day-to-day operations, including nights and weekends, and emergencies, and use that assessment to inform contingency planning for events that may affect resident care.
Failure to Use Required Gown During Direct Resident Care
Penalty
Summary
The facility failed to ensure a CNA wore a disposable gown while providing direct resident care to a resident with a tracheostomy connected to a cool aerosol. The resident’s chart indicated admission to the facility and diagnoses of acute respiratory failure, hypoxia, and hypercapnia. The resident’s MDS dated 2/23/2026 showed severely impaired cognitive skills and dependence on staff for ADLs. During an observation on 4/7/2026 at 10:23 a.m., the CNA was seen rendering care to the resident without a disposable gown while changing the resident’s diaper, linen, and padding and providing oral care, including swabbing the resident’s tongue and brushing the resident’s teeth. In interview, the CNA stated he was not wearing a gown and said he should have worn one while providing resident care. The Infection Preventionist stated staff were required to wear full PPE when providing patient care, including brushing teeth and changing residents, and the facility’s Enhanced Barrier Precautions policy indicated to don gown and gloves prior to high contact care activity.
Failure to Implement Pressure Ulcer Care and Physician Orders
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in their treatment. Resident 5, who was at high risk for skin breakdown due to a cerebrovascular accident and hypertension, was not repositioned every two hours as required by their care plan. Observations showed that Resident 5 remained on their left side for extended periods, which likely contributed to the development of new blisters on the left trochanter and posterior thigh. The lack of repositioning was confirmed by staff interviews, indicating a failure to implement necessary turning interventions. Resident 32, who had a pressure injury on the right lower lateral leg, did not receive wound care as ordered by the physician. During an observation, the treatment nurse failed to apply Silvadene ointment and an ABD pad as prescribed, initially using a dry foam dressing instead. The nurse admitted to not checking the doctor's orders before treatment, which led to the incorrect application of wound care materials. This oversight was acknowledged by the Director of Nursing, who emphasized the importance of following physician orders to prevent wound deterioration. The facility's policies and procedures for wound care and pressure ulcer prevention were not adhered to, as evidenced by the lack of timely repositioning for Resident 5 and the incorrect wound care for Resident 32. These deficiencies highlight a failure to follow established protocols, potentially compromising the residents' health and recovery. The facility's wound care policy emphasizes the need for individualized treatment plans and adherence to physician orders, which were not followed in these cases.
Failure to Label and Remove Expired Food Items
Penalty
Summary
The facility failed to ensure that food items were properly labeled with received and used dates in the dry storage area and two refrigerators. During an observation, it was noted that several plastic containers containing single-serve condiments were not labeled with receiving or used by dates. The Kitchen Supervisor admitted to not knowing the expiration dates of these products and acknowledged the importance of labeling to prevent serving expired food to residents. Additionally, expired food items such as dry chiles, ground cardamom powder, and cream of mushroom soup cans were found on shelves next to the cooking area. Further observations revealed that bags of bread in Refrigerator #1 and frozen chicken patties in Refrigerator #4 were also not labeled with receiving or used by dates. The Director of Nutritional Services confirmed that food items are delivered three times a week and should be labeled with receiving dates before storage. The facility's policy on Freshness Dating and Labeling requires all foods to be dated for freshness and safety, but this was not adhered to, potentially placing residents at risk for foodborne illness.
Infection Control Lapses in Wound and Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control measures for four residents, leading to potential risks of infection. For Resident 32, the Treatment Nurse (TN) did not sanitize hands between glove changes while performing wound care on multiple areas of the resident's body. This oversight occurred despite the facility's policy requiring hand hygiene between glove changes to prevent contamination and infection. The resident, who was dependent on staff for activities of daily living and had multiple pressure injuries, was at risk due to these lapses in infection control. Resident 38 and Resident 46 also experienced similar deficiencies in infection control practices. TN 3 did not change gloves or perform hand hygiene between different steps of wound care and colostomy bag changes. This was contrary to the facility's policy, which mandates hand hygiene and glove changes between each step of wound care and colostomy care to prevent contamination. Both residents had significant medical conditions, including multiple pressure sores and respiratory issues, making them vulnerable to infections. Additionally, the facility failed to maintain proper positioning of a urinary catheter bag for Resident 64. The catheter bag was observed on the floor, which could lead to urinary tract infections. The facility's policy requires catheter bags to be kept below the bladder and off the floor to prevent such infections. The resident, who had a history of pneumonia and hypertension, was dependent on staff for personal hygiene and had an indwelling catheter, further emphasizing the need for strict adherence to infection control protocols.
Failure to Assess and Treat Resident's Dry Skin
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment for dry and crusty skin on the left palm. The resident, who was unable to verbally communicate, was observed with very dry, white, and rough skin on the left hand. The resident's admission record indicated a history of cerebral vascular accident, tracheostomy, and coronary artery disease. The Minimum Data Set (MDS) noted that the resident required dependent assistance with activities of daily living and was rarely understood. However, the Treatment Administration Record (TAR) did not include a treatment order for the left palm. During an observation and interview, a treatment nurse acknowledged the dry skin on the resident's left palm and recognized the risk for skin breakdown. The nurse admitted to not applying lotion to the left palm because a doctor's order had not been obtained. The Director of Nursing emphasized the importance of daily skin assessments and communication with physicians regarding changes in skin condition. The facility's policy and procedure documents highlighted the need for prompt communication of medical changes to physicians and ongoing assessment of patient needs.
Failure to Implement Turning Interventions
Penalty
Summary
The facility failed to implement turning interventions in accordance with its policies and procedures for a resident, resulting in delayed turning and the development of blisters. The resident, who was admitted with diagnoses including cerebrovascular accident and hypertension, was identified as being at high risk for skin breakdown and pressure ulcers. The care plan required repositioning every two hours to promote circulation, but observations revealed that the resident remained on the same side for extended periods without being repositioned. During multiple observations, the resident was found lying on the left side for over four hours without being turned, contrary to the facility's policy that mandates repositioning every two hours for bedbound patients. Interviews with staff confirmed that no repositioning occurred during this time, and the development of blisters was attributed to the prolonged pressure on the same side. The facility's wound care policy aimed to prevent pressure ulcers through regular repositioning, but this was not adhered to, leading to the resident's skin breakdown.
Inadequate CNA Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing of Certified Nurse Assistants (CNAs) to provide timely nursing services, resulting in delayed care for a resident. The resident, who was admitted with diagnoses including cerebrovascular accident and hypertension, required supervision and assistance with various activities of daily living and was at high risk for skin breakdown. The care plan indicated the need for repositioning every two hours to promote circulation and prevent pressure ulcers. However, observations revealed that the resident was not repositioned for several hours, remaining on the same side from 8:16 a.m. to 11:00 a.m., which contributed to the development of blisters. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a CNA, confirmed that the facility was short-staffed, particularly on weekends, leading to inadequate care and increased risk of skin breakdown for residents. The Director of Nursing (DON) acknowledged the lack of a contract for registry staff and an insufficient pool of CNAs, which could result in delays in care and basic resident needs not being met. The facility's policy indicated the requirement for 24-hour nursing care, but staffing levels were not adjusted to meet the needs of residents as census and acuity changed.
Failure to Provide Adequate Call System for Resident with Physical Impairments
Penalty
Summary
The facility failed to provide a special call light system for a resident with significant physical impairments, leading to feelings of frustration and helplessness. The resident, who was admitted with chronic respiratory failure, quadriplegia, and a tracheostomy, was unable to use the standard call bell due to impairments in both upper and lower extremities. Despite being cognitively intact and able to communicate, the resident was dependent on staff for all activities of daily living and had to resort to yelling for assistance, which was difficult and ineffective. Observations and interviews revealed that the call light system had been broken for three years, and the facility relied on bedside call bells, which the resident could not use. The resident's family and staff confirmed the resident's inability to use the call bell and the lack of an alternative system. The Director of Nursing acknowledged the inadequacy of the situation, stating that residents should not have to yell for care. The facility's policy indicated that in the event of a call system failure, temporary measures should be implemented, but these were not effectively in place for this resident.
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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.
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Nursing homes near Gardena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clear View Convalescent Center | 0.3 mi | ★★★★★ | 4 | 0 |
| Clear View Sanitarium | 0.3 mi | ★★★★★ | 10 | 0 |
| Kei-ai South Bay Healthcare Center | 0.6 mi | ★★★★★ | 18 | 0 |
| Gardena Convalescent Center | 0.6 mi | ★★★★★ | 15 | 0 |
| Rosecrans Care Center | 0.9 mi | ★★★★★ | 6 | 0 |
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