Gardena Convalescent Center

Inspectors wroteBased on interview and record review, the facility failed to develop a pain care plan for one out of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 not receiving specific care interventions related to Resident 1's pain.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure 36 out of 36 narcotic destruction log sheets were signed by the Director of Nursing (DON) and the facility's pharmacist consultant. This deficient practice had the potential to result in narcotic diversion (the illegal transfer of prescription drugs, specifically controlled substances like opioids, from their intended, legal purpose to an unauthorized person or for illegal use).

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label with an opened date and remove expired ipratropium with albuterol (a combination medication used to treat and prevent shortness of breath) inhalation solution for three of three sampled residents (Resident 16, Resident 20, and Resident 72) in Medication cart 1. This deficient practice had the potential to result in prolonged use and loss of strength of the expired inhalation solution and can lead to ineffective treatment of respiratory symptoms for Resident 16, 20 and 72.

Inspectors wroteBased on observation, interview, and record review the facility failed to:1. Ensure food items stored in the kitchen walk in refrigerator were maintained in a safe and sanitary manner by allowing expired hot dog buns and corn tortillas to remain stored and available for use. This deficient practice had the potential to result in residents being served expired food products. During a concurrent observation and interview on 3/10/2026 at 8:40 a.m. with the [NAME] in the kitchen walk in refrigerator observed was an opened bag of [NAME] brand corn tortillas 80 count with an expiration date of 12/21/2025 and 5 bags of [NAME] Deli 16 count hot dog buns with 3 with expiration dates of 1/31/2026 and 2 with expiration dates 2/2/2026. The [NAME] stated the hot dog buns and tortillas should not be in the refrigerated stored with other food they should be thrown out. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure the call light (a device used by a resident to signal his or her need for assistance from a staff) was within reach for one of 17 sampled residents (Resident 39). This failure had the potential for increased risk of falls, delayed response to emergencies, and unmet basic needs for Resident 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure personal information of residents was protected by not throwing the protected information (PHI - any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) in the trash can without shredding. This failure had the potential to violate residents rights and privacy. During an observation on 3/12/2026 at 1:45 p.m. observed meal tickets in the trash by the dishwashing machine area. The meal tickets contained resident names, room numbers and diet types, texture level, liquid consistency level and likes and dislikes. During an interview on 3/12/2026 at 1:50 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the quarterly (every 3 months) Minimum Data Set Assessment ([MDS] - a resident assessment tool) for one of one sampled resident (Resident 2) was completed within the required timeframe. This deficient practice could potentially affect the care services of Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 17 sampled residents (Resident 2). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice for one of one sampled resident (Resident 3) by failing to: 1. Obtain a medical order clearance for tooth extraction (removal of a tooth) for Resident 3 as recommended by the dentist. This deficient practice had the potential to put Resident 3 at risk for oral infection, pain, and weight loss.

Inspectors wroteBased on observation interview and record review the facility failed to: 1. Ensure one of two sampled residents (Resident 36), assessed as being at risk for elopement (leaving the facility without permission) wore a ROAM Alert device (an electronic safety device worn by a resident that triggers an alarm if the resident attempts to exit the building) ordered by the physician to notify staff of potential elopement. This failure had the potential to allow a resident to leave the facility unsupervised and without staff awareness, placing the resident at risk of harm or injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 39) who has a Peripherally Inserted Central Catheter ([PICC] - a thin flexible tube that is inserted into a vein in the upper arm above the right side of the heart, used to give intravenous fluids, blood transfusions, and medications) was placed on Enhanced Barrier Precaution ([EBP] - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four residents (Resident 1), was provided with a safe and hazard-free environment while providing care. This deficient practice had the potential to cause severe injuries to Resident 1 including hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA 1) had the specific competencies, and skill sets necessary to care for one of four residents (Resident 1), by failing to report Resident 1's alleged fall incident. This deficient practice resulted in a delay in Resident 1's treatment/evaluation.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident 1) glucose (the process of measuring the amount of sugar in a patient ' s blood) was checked after returning to the facility after being out on pass. This deficient practice of not checking the blood sugar after returning to the facility had the potential for Resident 1 exacerbate (a worsening of a medical condition that increases symptoms and may require hospitalization) his diabetes (a chronic condition characterized by high blood sugar levels).

Inspectors wroteDuring an interview and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident 1) had a care plan for non-compliance (when a patient don't follow the rules, regulations, or advice that ' s been set in place) when out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning). This deficient practice of not developing a care plan (a document that summarizes a person ' s health needs, current treatments, and desired outcomes) for Resident 1 ' s non-compliance had the potential to place the resident at risk for injury and not be continuously monitored for diabetes mellitus([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident1) had a plan in place after being identified as a high risk for falls (a patient has a significantly increased likelihood of experiencing a fall due to various factors like poor balance, muscle weakness, which could potentially cause physical harm if they do fall) for continuous supervision and monitoring while out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning). This deficient practice of not having a plan in place for continuous supervision and monitoring had the potential risk for Resident 1 to fall while out on pass.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure four of six sampled residents' (Residents 15, 30, 37, and 38) Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) was completed monthly. This deficient practice placed Residents 15, 30, 37, and 38 at risk of not having medication irregularities identified.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized person-centered care plan (a document that summarizes a person's health condition, care needs, and current treatments) with measurable objectives, timeframe, and interventions to meet the residents needs for two of two sampled residents (Residents 58 and 167) by failing to: 1. Ensure a care plan for out on pass was develop for Resident 58. 2. Ensure a care plan with interventions for Peripherally Inserted Central Catheter ([PICC] - a thin flexible tube that is inserted into a vein in the upper arm above the right side of the heart, used to give intravenous fluids, blood transfusions, and medications) line was develop for Resident 167. These deficient practices had the potential to negatively affect the delivery of care and services for Residents 58 and 167.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure resident was involved in decision making and notified in change of physician for one of one sampled resident (Resident 52). This failure had violated Resident 52's resident rights to choose her own physician.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement the facility's policy and procedures on reporting an unusual occurrence when Resident 58 left the facility and did not return. This deficient practice had the potential to result in serious harm, injuries and death.

Inspectors wroteBased on interview and record review, the facility staff failed to: 1. Report to California Department of Public Health (CDPH) of resident leaving and not returning to the facility on [DATE] for one of two sampled residents (Resident 58). This deficient practice resulted in the delay of investigation by the CDPH.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure a smoking safety assessment was completed for one of 6 sampled residents (Resident 48). 2. Ensure an assessment was completed before going out on pass for one of 2 sampled residents (Resident 58). This deficient practice had the potential to result in a safety hazard for Resident 48 and serious harm for Resident 58.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 17 sampled residents (Resident 36). This deficient practice had the potential to negatively affect the plan of care and delivery of care and services for Resident 36.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Submit a Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) for one of three sampled residents (Resident 21) which included an existing psychiatric diagnosis. This deficient practice resulted in a delay of Resident 21 receiving a PASSR II evaluation for mental health needs.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a Level 2 Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) evaluation was obtained for one of six sampled residents (Resident 48). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 48.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure physician orders were carried out for one of 6 sampled residents (Resident 31). 2. Provide services which meet professional standards of quality regarding smoking safety for one of 6 sampled residents (Resident 48). This deficient practice had the potential to result in skin breakdown for Resident 31 and a smoking accident for Resident 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to: 1. Assess and monitor one of 6 sampled residents smoking safety (Resident 48). This deficient practice had the potential to result in serious harm due to smoking without supervision. 2. Ensure one out of six sampled residents (Resident 49) had their pain management referral processed timely. This deficient practice resulted in a delay in assessing, monitoring (Resident 48) and care to manage the pain of Resident 49.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the low air loss mattress ([LALM] - a mattress designed to prevent and treat pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) was set and maintained at the correct setting for one of two sampled residents (Resident 36). This deficient practice placed Resident 36 at risk for worsening of pressure ulcer/injury and further skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one out of six sampled residents (Resident 37) received Restorative Nurse Assistant ([RNA]- a healthcare worker who helps residents improve and maintain function in physical abilities) services timely and five days a week as ordered. This deficient practice had the potential to result in Resident 37 having a decline in function or development of contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion).

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure whether supervision was required during smoke breaks and ensure the environment was free from a fire hazard for one of 6 sampled residents (Resident 48). This deficient practice had the potential to result in an accidental fire in the facility and lead to residents' injuries.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure dental services were provided for one of 6 sampled residents (Resident 110). This deficient practice had the potential to result in tooth decay, gum disease, bad breath and cavities.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure a resident who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice for one of two sampled residents (Resident 166) by failing to: 2. Ensure Resident 166's dialysis emergency kit (E-KIT - supplies to help meet the needs of a dialysis resident in the event of an emergency) was readily available at the bedside, in case of excessive bleeding from the dialysis site. This deficient practice had the potential to result in staff inability to manage and control the bleeding from Resident 166's dialysis site in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure it was free of a medication error rate of five percent (5%) or greater, as evidenced by the identification of two out of 28 medication opportunities (observations during medication administration) for error, to yield a cumulative error rate of 7.14% for one of two sampled residents (Resident 167) observed during the medication administration facility task by failing to: 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Label with an opened date one vial (a small container, usually made of glass or plastic used to store liquids) 5 millimeter ([ml] - unit of measurement) of influenza vaccine (a vaccine that protects against the influenza virus) found from the facility's medication storage room [ROOM NUMBER] refrigerator. This deficient practice had the potential for harm to residents due to potential loss of strength of the influenza vaccine. 2. Remove two vials of unopened expired insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) from the facility's medication storage room [ROOM NUMBER] refrigerator for two of two sampled residents (Residents 14 and 15). [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure dental services were provided for one of 6 sampled residents (Resident 6). This deficient practice had the potential to result in tooth decay, gum disease, bad breath and cavities.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Provide one out of six sampled residents (Resident 37) with a therapeutic diet at lunch time as ordered. This deficient practice put Resident 37 at risk for further weight loss.

Inspectors wroteBased on interview and record review, the facility failed to assess, and managed pain in a timely manner, for one of three sampled residents (Resident 3). This deficient practice had the potential to affect the quality of life of the affected resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure, activities of daily living, for three of four residents (Residents 1, 3 and 4), were attended to, promptly. This deficient practice had the potential to result in residents developing skin breakdown and other needs not met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Infection policy and procedure (P&P) by failing to report a Coronavirus disease ([Covid-19] a highly contagious illness caused by a virus that could easily spread from person to person) outbreak to the California Department of Public Health District Office (CDPH DO). This failure had the potential to result in the spread of Covid-19 cases in the facility and placed residents, staff and the community at risk for contracting the Covid 19 virus. Findings During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, and diabetes mellitus (high blood sugar). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a dignity bag (a bag used for privacy to cover and hold the urine collection bag so that it is not visible) was used to cover the urine collection bag for one of two residents (Resident 9). This deficient practice had the potential to cause embarrassment and affect Resident 9's self-worth and dignity.

Inspectors wroteBased on interview and observation, the facility failed to ensure residents' call lighs devices were placed within the resident's reach for three out of four sampled residents (Residents 13, 51, 122). This deficient practice had the potential to result in a delay or an inability for the residents to obtain necessary care and services as needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Follow menu as written for nine residents on renal and regular diets. 2. Follow menu one of nine residents (Resident 54) by putting crunchy fish instead of baked fish plate. This deficiency had the potential for resident to receive the wrong carb and caloric intake when not following the menu, resulting meal dissatisfaction, decreased nutritional intake and weight loss and potentially alter the nutritional value of meals for residents.

Inspectors wroteBased on observations, interviews, and facility policy review the facility failed to ensure food preparation operations were conducted under sanitary conditions in the facility's kitchen for 54 of 62 residents by. 1. Failing to ensure proper hand hygiene was performed during the preparation of meals. 2. Failing to ensure hairnets, gloves, and masks were worn while in the kitchen and during the preparation of meals. 3. Failing to ensure the kitchen was free of standing water on the kitchen equipment and the floor. 4. Failing to ensure there were no unopened foods or foods stored on the floor in the dry storage area. 5. Failing to ensure clean utensils were used to serve and prepare food. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for two of two sampled residents (Resident 41, Resident 51) by failing to: 1. Ensure Resident 51's indwelling catheter (a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag was not touching the floor. 2. Ensure hand hygiene was performed after touching soiled items while performing wound care on Resident 41. These deficient practices resulted in contamination of the resident's care equipment and placed the residents at risk for infection and had the potential to spread infection that could delay the healing process and cause further complications for Resident 41.

Inspectors wroteBased on interview and record review the facility failed to honor resident's right to visit family members outside of the facility for one of one sampled resident (Resident 6). This deficient practice caused Resident 6 to miss time with his family during the Christmas holiday and had the potential to negatively impact his psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) were provided for two of two sampled residents (Resident 122 & 222). This deficient practice had the potential to cause inadequate oxygen therapy and respiratory distress for all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served was palatable and attractive as voiced by one out of one sampled resident (Resident 46). This deficient practice had the potential to impact the residents' nutritional status and not meet the residents' desires to be served food they felt was palatable and attractive.

Inspectors wroteBased on interview and record review the facility failed to document the resident's approved out on pass (OOP) order to visit family for the Christmas holiday for one of one sampled resident (Resident 6). This deficient practice caused Resident 6 to miss spending time with his family during the Christmas holiday and had the potential to negatively impact Resident 6's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement abuse prohibition and prevention program policy and procedure by not reporting an allegation of physical abuse for one of three sampled resident (Resident 1) to the California Department of Public Health (CDPH), after Resident 2 slapped Resident 1 on the face on 12/10/2023. This deficient practice had the potential for the underreporting of abuse incidents, and delay in investigation a physical abuse allegation, placing Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prohibition and prevention program policy by failing to submit the results of the investigation of an allegation of physical abuse to the state agency (California Department of Public Health [CDPH]) within 5 working days of the incident for one of three sampled residents (Resident 1). This deficient practice delayed the CDPH investigation of the allegation of physical abuse, potentially placing Resident 1 at risk for further abuse and violation of resident rights.