Gardena Convalescent Center

In the surveyor’s words

From the most serious findings on record at Gardena Convalescent Center, in the surveyor’s own words.

• Actual harm, isolatedF600May 31, 2023

  Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was protected from abuse as indicated on the facility's policy and procedure, Abuse Prohibition and Prevention Program. Certified Nurse Assistant (CNA) 1 showered Resident 1 with very hot water and grabbed Resident 1's right hand and bent the resident's fingers backwards. This deficient practice caused Resident 1 to sustain an acute fracture (broken bone) to the right 5th (pinky finger). […]

• No harm, potential for more than minimal, widespreadF755Mar 13, 2026

  Based 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).Findings:During a concurrent interview and record review, on 3/11/2026 at 10:32 a.m., with the DON, the DON stated there were 34 individual residents-controlled drug record that she did not sign on 1/30/2026 during drug destruction with RPH. The DON stated all discontinued narcotics were kept in a locked drawer inside of her office. […]

• No harm, potential for more than minimal, widespreadF756Jan 24, 2025

  Based 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. Findings: A. During a review of Resident 15's Admission Record, the Admission Record indicated the facility admitted the resident on 12/20/2011 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and end stage renal disease (irreversible kidney failure). […]

• No harm, potential for more than minimal, patternF761Mar 13, 2026

  Based 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.Findings:During a review of Resident 16's admission Record, the admission Record indicated, Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE]. […]

• No harm, potential for more than minimal, patternF812Mar 13, 2026

  Based 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. […]