Del Amo Gardens Care Center

In the surveyor’s words

From the most serious findings on record at Del Amo Gardens Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686May 7, 2024

  Based on interview and record review the facility failed to ensure the resident, who was assessed as a high risk for developing a pressure ulcer (prolonged pressure on the skin that results in injury to the skin and underlying tissue, usually occur over bony prominence because of long-term pressure), did not develop a deep tissue injury ([DTI] (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on the right heel for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was turned and repositioned every two hours and provided with a pressure reducing device in bed. 2. […]

• No harm, potential for more than minimal, widespreadF867Nov 23, 2024

  Based on interview and record review the facility's Quality Assessment and Assurance (QAA committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintain and improve safety and quality in nursing homes) committee failed to implement corrective action to the potential systemic problems identified: 1. Maintain a system to monitor weight loss. 2. Maintain a system to ensure the reporting of falls with major injury. 3. […]

• No harm, potential for more than minimal, widespreadF812Nov 3, 2023

  Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, disease causing bacteria, viruses, or parasites that contaminate food, as well as toxins) for 70 out 73 total residents in the facility by not: 1. ensuring Foods were dated, labeled, properly sealed, and discarded before the used by date (expiration dates). 2. monitoring and documenting the temperature for the facility's freezers. 3. maintaining a clean environment around the dumpsters outside. 4. monitoring and documenting sanitization bucket log. 5. […]

• No harm, potential for more than minimal, widespreadF880Nov 3, 2023

  Based on observation,interview, and record review the facility failed to: A. Follow their own policy and procedures (P/Ps) titled, Glove Use - Personal Protective Equipment, and Hand Washing - Hand Hygiene to ensure licensed nurses wash or sanitized their hands after removing gloves and before putting on a new pair of gloves. This deficient practice had the potential to expose one out of four residents (Resident 270) to contaminants and infection. B. Clean two of two cloth gait belts (assistive device used for lifting, transferring, and walking patients who have limited mobility issues) in accordance with the manufacturer's recommendations for sanitizing wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces) in-between… […]

• No harm, potential for more than minimal, widespreadF812Nov 4, 2022

  Based on observation, interview, and record review, the facility had: 1.Food items had no open dates and were not properly sealed. 2.One of three dietary staff, did not wear gloves during food handling and preparation. 3.One ice machine with black sediments around the machine upon inspection. These deficient practices had the potential for causing food-borne illnesses (caused by consuming contaminated food, beverages, or water) to residents. Findings: 1.During an observation on 11/1/2022, at 8:20 a.m., in the kitchen, 15 food items that were stored in Storage 1, next to the freezers, and seven (7) food items that were stored in Storage 2, dry storage, had no received date and open date. There was yellow cheese stored in the refrigerator without a covering (open to air). 2. […]