Memorial Hospital of Gardena D/P SNF

Inspectors wroteBased on observation and interview, the facility failed to:Ensure food items in walk-in refrigerator 1 were labeled and unexpired. Ensure the walk-in freezer 2 had an internal thermometer (used to check the refrigerator's inside temperature). Ensure the walk-in refrigerator 3 had an internal temperature that was within range (acceptable is 41 degrees F or lower) .This deficient practice had the potential to result in residents developing a foodborne illness (food poisoning).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 17 sampled residents (Resident 22). 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 22.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level 1 screening (a federally required preliminary screening for individuals seeking admission to a Medicaid-certified nursing facility) was conducted and resubmitted for one of two sampled residents (Resident 5), who had diagnoses of mental illness (abnormal behavior or disturbing feelings, thoughts, or actions that interfere with every day functioning) and was receiving psychotropic medications (any drug that affects brain activities associated with mental process and behavior). This deficient practice had the potential to result in Resident 5 not appropriately evaluated and not provided the necessary specialized services for mental illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattresses (special mattress for skin management) settings for one of eight sampled residents (Resident 7), were correct basing on the resident's weight. This deficient practice resulted in inaccurate settings and placed the resident at risk for further skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the normal saline ([NS] - sterile solution of sodium chloride) intravenous (IV - into or connected to vein), 500 cubic centimeter ([cc] metric unit of volume) solutions, used to keep-vein-open (a continuous, very slow-rate IV infusions to prevent blood clots, drug precipitates, or obstructions from forming within an IV catheter), were not used longer than 24 hours, for two of two sampled residents (Residents 3 and 37) as indicated in its policy and procedure (P&P) titled, IV Therapy Administration. This deficient practice had the potential to placed Resident Residents 3 and 37 at risk for infection and IV therapy complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 9) was free of unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) by failing to monitor resident's behavior and implement non-pharmacological interventions (intervention that does not primarily use medicine) prior to initiation of psychotropic medication. This failure had the potential to place Resident 9 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication) related to psychotropic medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove Resident 25's one vial of expired Lispro (type of fast acting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) insulin from medication cart 5. This deficient practice placed Resident 25 at increase risk to receive expired insulin that could be ineffective in treating the resident's high blood sugar levels.

Inspectors wroteBased on interview and record review, the facility failed to ensure a contingency plan (a pre-defined set of actions to be taken if an original plan fails or an unexpected event occurs) for staffing was developed and included in the Facility Assessment (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential for the facility to ineffectively respond during unexpected circumstances and negatively impact resident care.

Inspectors wroteBased on observation and interview, the facility failed to:Ensure the Certified Nurse Assistant 1 (CNA 1) had a disposable gown on when performing direct- resident care to Resident 64, as indicated in its policy and procedures (P&P), titled Enhanced Barrier Precautions (EBP- infection control steps used in nursing homes to prevent the spread of germ-resistant bacteria) for Subacute Unit, which indicated to don (put on) gown and gloves prior to high contact care activity (hands-on tasks performed by healthcare staff involving direct contact with residents and/or immediate environment, often resulting in the transfer of multidrug-resistant organisms (MDROs) to staff clothing and hands). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 27 sampled residents (Resident 5 and Resident 32) received care in accordance with the facility's policies and procedures (P&P) by failing to: 1. Implement turning interventions for Resident 5. 2. Provide wound care as ordered by the physician for Resident 32. These deficient practice had the potential for the resident to acquire new pressure ulcers and/or worsen current pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure food items were labeled with received and used dates in the dry storage area and two refrigerators. 2. Ensure expired foods were not stored in the kitchen and accessible to be used in food preparation in accordance with food service safety. These failures had the potential to place the residents at risk for developing a foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for four out of 27 sampled residents by failing to: 1. Sanitizing their hands between changing gloves, washing hands after cleaning the wound, and applying a clean dressing for Resident 32. 2. Sanitize hands and change gloves after cleaning the colostomy stoma (an opening in the abdomen that allows stool to pass through instead of the anus) and before putting on the new colostomy bag for Resident 38 and after cleaning the wound and before applying the treatment and dressing for Resident 38 and Resident 46. 3. Keep the urinary catheter bag off the floor for Resident 64. These failures had the potential to spread infections and illnesses amongst residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure one of 27 sampled residents (Resident 4), was properly assessed for dry and crusty (rough or thickened texture) skin on his left palm. This deficient practice resulted in lack of or delay in care for Resident 4 and potential risk for skin breakdown.

Inspectors wroteBased on observation, and interview, the facility failed to: 1. Implement turning interventions in accordance with the facility's policies and procedures (P/P) for one of 27 sampled residents (Resident 5.) This deficient practice resulted in delayed turning for Resident 3 which resulted in a blister on left trochanter (hip joint) and two blisters on left thigh.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure that the facility staffed sufficient Certified Nurse Assistant (CNAs) to administer and provide nursing services in a timely manner for one out of 27 sampled residents (Resident 5) The deficient practice resulted in delayed care for Resident 5.

Inspectors wroteBased on observations and interviews, the facility failed to: 1. Provide one of 27 sampled residents (Resident 38) a special call light system to use. This failure caused Resident 38 to feel frustrated and helpless. Findings During a review of Resident 38's admission Record, dated 1/3/2025, the admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure with hypoxia (a condition when there is not enough oxygen in the tissues in the body). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents who were admitted to the facility with intact skin did not develop a pressure ulcer ([PU], injury to skin and underlying tissue resulting from prolonged pressure on the skin or bony prominences) for three of three sampled residents (Residents 163, 40, and 38). The facility failed to: 1. Ensure Resident 163's did not develop a Stage III PU (Full thickness tissue loss) to the right buttocks after the admission to the facility. 2. Ensure the nursing staff monitored Resident 163 skin condition to identify development of a PU to the right buttock at the earlier stage to prevent development of a Stage III PU. 3. Ensure the nursing staff implemented Resident 163's care plan titled Skin Integrity by ensuring the resident will not have a skin breakdown. 4. [...]

Inspectors wroteb. During a review of Resident 36's admission Record (Face Sheet), the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), renal failure (one or both kidneys no longer function well on their own), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 36's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/12/2023, the MDS indicated, Resident 36's cognition (ability to learn reason, remember, understand, and make decisions) skills Resident 36 was oriented to year, month, year, and could recall questions that were previously asked. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to; 1. Ensure the physician was promptly notified when one of one sampled resident (Resident 163), had a change of condition (a change in resident's normal, physical, mental, or behavioral state). Resident developed full-thickness skin loss potentially extending into the subcutaneous tissue layer (stage 3 pressure ulcer) on the right buttock. A physician notification was made on 2/8/2024 (1 day after the initial identification of the pressure ulcer). This deficient practice had the potential for a delay in care and intervention of Resident 163's Stage 3 pressure ulcer

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the comprehensive Minimum Data Set ([MDS] resident assessment and care screening tool) assessment for one of fifteen sampled residents (Resident 51) was completed within the required timeframe. This deficient practice had the potential to result in Resident 51 not receiving proper care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS] resident assessment and care screening tool) assessment for two of fifteen sampled residents (Resident 10 and Resident 36). This deficient practice had the potential to result inaccurate care and services for the residents due to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on interview and record review the facility failed to: 1. Revise tube feeding (a way to give medications or liquid food through a small tube placed into the stomach) care plans for two out of five sampled Residents (Resident 40, and 18). These deficient practices had the potential for repeat occurrences for not revising residents care plans.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to: 1. Provide an ongoing activity program to meet the needs and interests for one of 5 sampled residents (Residents 40) to ensure residents maintained their highest physical, mental, and psychosocial well-being. This failure had the potential of not enhancing Resident 40's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received dialysis (process of removing waste products and excess fluids from the body) received treatment in accordance with standard of practice for one of one sampled resident (Resident 164) by failing to implement the physician's order for fluid restriction accurately. This deficient practice placed Resident 164 at risk for fluid overload, swelling, shortness of breath and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the treatment nurse was competent in wound site identification. This failure had the potential for a resident receiving treatment at the wrong site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure expired medications were removed from the medication cart for 1 out of 5 sampled Residents (Resident 40). This failure resulted in Resident 40 receiving expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure potassium levels were checked prior to administering a potassium supplements. This failure had the potential to result in the resident having a high potassium level, which can be life threatening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure all medication carts were secured after a nurse left the keys on the side of the medication cart. This failure had the potential to result in an unauthorized person obtaining the keys and taking medication from the cart.

Inspectors wroteb. During a review of Resident 36 admission Record (Face Sheet), the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), renal failure (one or both kidneys no longer function well on their own), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 36 Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/12/2023, the MDS indicated, Resident 36's cognition (ability to learn reason, remember, understand, and make decisions) skills Resident 36 was oriented to year, month, year, and could recall questions that were previously asked. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the inside compartment of the ice machine was to be maintained in a sanitary manner for nine out of 59 residents. This deficient practice had the potential to result in an outbreak of foodborne illness that could affect all or most of the residents who reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to: 1. Accurately document fluids (the amount of liquid going into the body) that were infused intravenously ([IV]a method of putting fluids, including drugs, into the bloodstream) into the body for one out of five sampled Residents (Resident 40). This deficient practice had the potential to result in confusion in the care and services rendered to Residents and inaccurate information could be entered into the resident's clinical record.

Inspectors wroteBased on observation, interview, and record review the facility's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to: 1. Identify facility dental services and care issues for one of one sampled residents (Resident 36). [...]