Memorial Hospital of Gardena D/P SNF

In the surveyor’s words

From the most serious findings on record at Memorial Hospital of Gardena D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 9, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF868Mar 10, 2023

  Based on interview and record review, the facility failed to: 1. Ensure the Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) committee meet at least quarterly and as needed to coordinate and evaluate activities under the Quality Assurance Performance Improvement QAPI ([QAPI] a data driven and proactive approach to quality improvement) program. 2. Ensure the Infection preventionist (IP) and the Medical Director participated on the facility's QAA/QAPI meeting. These deficient practices had the potential to result in a lack of oversight for infection prevention practices, overall medical care being provided by the facility, and ensuring that resident care policies were implemented appropriately. […]

• No harm, potential for more than minimal, patternF812Apr 10, 2026

  Based 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). Findings:During a concurrent observation and interview, on 4/7/2026 at 8:48 a.m., with the Dietary Services Supervisor (DSS), an unopened cheese danish was observed unlabeled and undated, and a pack of opened hot dog buns had an expiration date of 4/4/2026 in the walk-in refrigerator 1. […]

• No harm, potential for more than minimal, patternF686Feb 16, 2025

  Based 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. Findings: 1. During a review of Resident 5's Admission Record, the Admission Record, indicated Resident 5's was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF812Feb 16, 2025

  Based 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. Findings: During a concurrent observation and interview on [DATE] at 11:43 a.m. […]