Palos Verdes Health Care Center

In the surveyor’s words

From the most serious findings on record at Palos Verdes Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880May 17, 2024

  Based on observation, interview, and record review the facility failed to implement infection control practices to prevent the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility for 11 out of 11 sampled residents by failing to: 1.Ensure personal protective equipment (PPE-equipment used to prevent or minimize exposure to hazards) was accessible and readily available to staff while providing direct care to residents at high risk of acquiring MDRO. 2. […]

• Immediate jeopardy, widespreadF727Jun 6, 2023

  Based on observation, interview, and record review, the facility failed to ensure they had a Registered Nurse (RN) at least eight consecutive hours a day, seven days a week from 5/8/2023 to 6/5/2023 (28 days) to provide residents with required care and services to 41 residents residing at the facility and to one of two sampled resident (Resident 1), who had a pressure ulcers (a localized injury to the skin and underlying tissue resulting from prolonged pressure) to the left heel infected with Methicillin-resistant Staphylococcus aureus [(MRSA)-a type of bacteria that is resistant to most antibiotics {medication used to treat infections caused by bacteria}] and was not receiving ordered intravenous [(IV) administered into the veins] antibiotics (medication to treat infection), Vancomycin… […]

• Immediate jeopardy, isolatedF760Jun 6, 2023

  Based on observation, interview, and record review, the facility failed to ensure the resident, who had an order for an intravenous [(IV) administered through the vein) administration of Vancomycin [(antibiotic)- medication to treat infections] 750 milligrams [(mg)- unit of measurement] every 48 hours for infected pressure ulcers [(PU)-induced injury that breaks down the skin and underlying area due to prolonged pressure], received medication every 48 hours without omission (a failure to do something) for one of one sampled resident (Resident 1). The facility failed to: 1. […]

• Immediate jeopardy, isolatedF600Jun 21, 2021

  Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) were free from repeated verbal and physical abuse and exploitation (the action or fact of treating someone unfairly to benefit from it) (Resident 1). Certified Nursing Assistant 1 (CNA 1) threw water in Resident 1's face and took pictures of Resident 1 without his permission, knowing the resident did not want his picture taken. The Director of Staff Development (DSD) threaten Resident 1 with her tone of voice and was rude (offensively impolite or ill-mannered) to him, while they both continued to taunt (unkind remarks made to intentionally annoy and upset someone) the resident, which resulted in Resident 1 being sad and depressed with crying spells. […]

• Actual harm, isolatedF689Nov 22, 2024

  Based on observation, interview, and record review, the facility failed to ensure the resident, who was transported to a shower room, did not get hit by a shower room door and sustain an injury to a left great toe for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA 1) requested assistance to hold the door to Shower room [ROOM NUMBER] while he was pulling Resident 1 on a shower chair into the Shower room [ROOM NUMBER]. 2. Ensure CNA 1 and Licensed Vocational Nurse (LVN 1) reported Shower room [ROOM NUMBER]'s door malfunctioning by documenting about it in the Maintenance Logbook. 3. […]