Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Del Amo Gardens Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility's QAA and QAPI committees did not implement corrective actions for systemic issues in monitoring weight loss, reporting falls with major injury, and implementing pressure injury preventive measures. The DON acknowledged the need for improvement in these areas.
The facility failed to ensure RNAs were competent in performing PROM exercises, leading to potential harm for two residents with hypertonicity. RNA 1 performed exercises too quickly, causing pain and resistance. The DSD admitted RNA competencies were not assessed, and performance evaluations for nursing staff were not conducted, compromising resident safety.
The facility failed to document the administration of controlled substances for three residents, leading to discrepancies between the CDR and MAR. A resident with anxiety did not have lorazepam administration recorded, while two other residents with pain management needs had tramadol administration unrecorded. Staff interviews confirmed the importance of matching documentation to ensure proper medication administration.
A facility exceeded the acceptable medication error rate, reaching 14.81% due to failures in following physician orders for three residents. A resident received amlodipine without a required blood pressure check, another was given undissolved MiraLAX and amlodipine without a blood pressure check, and a third received metformin without food. The errors were acknowledged by staff, and the DON confirmed the importance of adhering to orders and guidelines.
The facility failed to follow dietary guidelines for residents on mechanical soft and ground diets, serving improperly sized Chicken Alfredo and broccoli. Five residents on a chopped diet received large food pieces, while 17 residents on a ground diet were served chopped instead of ground food, contrary to the production guides. This was due to a misunderstanding by the cook, as confirmed by the dietary supervisor and registered dietitian.
The facility failed to ensure safe food storage and preparation practices, risking foodborne illnesses. Nutritional supplements and chicken were stored without thaw dates, and expired thickened water was not discarded. These actions violated facility policy and FDA guidelines.
A resident's privacy was compromised during a wound care dressing change due to inadequate privacy curtains that did not fully cover the care area. Staff interviews confirmed awareness of the issue, and the facility's policy emphasized the importance of respecting residents' private space.
Two residents with severe cognitive impairments were found to be living in a room with peeling paint and exposed walls, which did not provide a homelike environment. Staff interviews confirmed the issue, and the facility's policy emphasized the need for a homelike setting.
A resident with severe cognitive impairment and legal blindness experienced an unwitnessed fall resulting in a right hip fracture, requiring surgery and hospitalization. The incident was not reported to the CDPH, delaying an investigation. Despite the facility's policies requiring reporting of such events, the DON did not report the fall, citing unreliable information from the resident's cognitively impaired roommate.
A resident with multiple health issues, including diabetes and chronic kidney disease, experienced a significant change in condition with the progression of a pressure injury from Stage I to Stage II. Despite this, the facility failed to complete a significant change in status assessment (SCSA) as required. The MDSC acknowledged the oversight, and the DON emphasized the importance of SCSA in addressing specific resident problems.
The facility failed to ensure accurate MDS documentation for two residents, leading to potential negative effects on their care plans. One resident's MDS inaccurately documented a Stage III pressure ulcer, while the resident only had a resolved Stage II ulcer. Another resident's MDS incorrectly recorded an unplanned discharge to a hospital, instead of a discharge to a private home with home health services. These discrepancies were confirmed by staff interviews and record reviews.
The facility failed to update care plans for two residents, one after discontinuation of OT services and another following hypoglycemic events. This oversight could lead to confusion and inadequate care, as the care plans did not reflect the residents' current needs and conditions.
A resident with diabetes experienced two hypoglycemic events, and the facility failed to conduct IDT meetings to address these incidents. During the second event, the emergency response system was not activated despite the resident being unresponsive after interventions. The facility did not clarify insulin orders with the physician, leading to a deficiency in maintaining the resident's highest level of practicable functioning.
A resident at moderate risk for pressure injuries developed a Stage II ulcer due to the facility's failure to implement timely care interventions, including repositioning and using a low air loss mattress. The use of bath towels instead of incontinence pads contributed to skin shearing, and poor communication among staff regarding the resident's nutritional needs and pressure injury progression further exacerbated the situation.
A resident with right-sided hemiplegia and hemiparesis was not provided with the recommended resting hand splint and hand roll splint, as advised by OT. Instead, rolled-up towels were used in the resident's hands, and PROM exercises were performed at a fast speed, causing discomfort. The Director of Rehabilitation confirmed the splints were not issued due to time constraints, and the Director of Nursing acknowledged the Rehabilitation Department's responsibility for splint assessment and issuance.
A resident experienced significant unplanned weight loss due to the facility's failure to monitor and report decreased oral intake and implement effective interventions. Despite having a care plan, the staff did not notify the physician of the resident's condition, leading to continued weight loss. The resident, with multiple health issues and severe cognitive impairment, was dependent on staff for daily activities and had poor food intake, which was not adequately addressed by the facility.
A resident with severe cognitive impairment and dysphagia was given a peanut butter and jelly sandwich instead of a pureed diet, contrary to physician and speech therapist recommendations. The dietary manager admitted the oversight, acknowledging the risk of aspiration and choking due to the inappropriate meal. The facility's policy required adherence to prescribed diets, which was not followed in this case.
A facility failed to accurately document a resident's occupational therapy (OT) discharge recommendations and range of motion (ROM) status. The resident, with right-sided hemiplegia and hemiparesis, was evaluated by OT for a decline in ROM. The OT evaluation recommended splints for the resident's hands, but the discharge summary inaccurately documented the resident's tolerance for wearing them. The Director of Rehabilitation admitted to the documentation errors, which could cause confusion and harm. The Director of Nursing stressed the importance of accurate documentation to ensure necessary care and services.
A resident at high risk for pressure ulcers developed a deep tissue injury on the right heel due to the facility's failure to ensure regular turning, repositioning, and offloading. Despite being non-ambulatory and bedfast, the resident was not consistently repositioned every two hours, leading to the progression of a Stage 1 pressure ulcer to a DTI. The facility's care plan lacked specific interventions for repositioning and offloading, contributing to the preventable injury.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Corrective Actions for Systemic Issues
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to implement corrective actions for systemic issues identified in the monitoring of weight loss, reporting of falls with major injury, and implementation of pressure injury preventive measures. During an interview, the Director of Nursing (DON) acknowledged that the QAA committee discusses monthly falls, pressure injuries, and weight loss, but recognized a need for improvement in these areas. A review of the facility's policy and procedures indicated that the purpose of QAPI/QAA activities is to identify and correct quality deficiencies and improve the quality of care, quality of life, and resident safety.
Inadequate Competency and Performance Evaluations in LTC Facility
Penalty
Summary
The facility failed to ensure that Restorative Nursing Aides (RNA) were competent in performing passive range of motion (PROM) exercises for residents, which led to potential harm and pain for the residents involved. Specifically, RNA 1 was observed performing PROM exercises at a very fast speed on two residents, both of whom had conditions that required careful handling. Resident 2, who had right-sided hemiplegia and hypertonicity in both arms, experienced pain and resistance during the exercises. Similarly, Resident 18, who had right-sided hemiplegia and hypertonicity in the right arm, also experienced pain and requested the exercises to stop. The Director of Rehabilitation confirmed that PROM exercises should be performed slowly for residents with hypertonicity to avoid causing pain and further muscle contraction. However, RNA 1 continued to perform the exercises quickly, leading to discomfort and potential harm to the residents. The Director of Staff Development (DSD) admitted that competencies for RNAs were not being conducted, and there was no clear responsibility for ensuring RNA competencies were assessed. This lack of oversight and training contributed to the improper execution of PROM exercises. Additionally, the facility failed to conduct performance evaluations for nursing staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, as per the facility's policy. The Director of Nursing acknowledged the importance of annual performance evaluations to ensure staff competency and safe delivery of care. The absence of these evaluations further highlighted the facility's failure to assess and maintain the necessary skills and competencies of its staff, potentially compromising resident safety.
Failure to Document Controlled Substance Administration
Penalty
Summary
The facility failed to accurately account for the administration of controlled substances for three residents, leading to discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). For Resident 31, the facility did not document the administration of lorazepam 0.5 mg on two occasions, despite the medication being removed from the CDR. This resident, who was dependent on staff for all activities of daily living and had a diagnosis of anxiety disorder, did not have the administration of the medication recorded on the MAR, as confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). Similarly, for Resident 46, who had diagnoses including diabetes mellitus and osteomyelitis, the administration of tramadol 50 mg was not documented on the MAR, although it was removed from the CDR. The resident's care plan required the administration of analgesics as ordered, but the lack of documentation on the MAR meant that the administration could not be confirmed. An LVN acknowledged that the discrepancy could lead to confusion about whether the medication was given. For Resident 12, who had severe cognitive impairment and a diagnosis of a wedge compression fracture, the administration of tramadol 50 mg was also not documented on the MAR, despite being removed from the CDR. This discrepancy was noted by an LVN, who expressed concern that it could result in the medication being administered again or not at all, potentially leading to increased pain for the resident. Interviews with nursing staff highlighted the importance of matching documentation on the CDR and MAR to ensure proper medication administration and prevent issues such as drug diversion or duplicate therapy.
Medication Administration Errors Exceeding Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below the 5% threshold, resulting in a 14.81% error rate during medication administration for three residents. Resident 29 was administered amlodipine without the required blood pressure check, which was a physician-ordered parameter to determine whether the medication should be held or administered. The Licensed Vocational Nurse (LVN) acknowledged the oversight, recognizing the potential for blood pressure changes that could lead to falls or injuries. Resident 48 also received amlodipine without a prior blood pressure check, contrary to the physician's orders. Additionally, the LVN failed to properly dissolve MiraLAX powder before administration, allowing the resident to consume it in an undissolved state. The Director of Nursing (DON) confirmed the necessity of adhering to physician orders and manufacturer specifications to prevent adverse effects such as dizziness or falls. Resident 42 was given metformin without food, despite the physician's order to administer it with meals to mitigate side effects like nausea and upset stomach. The Registered Nurse (RN) admitted to not following the order, and the DON reiterated the importance of administering medications as prescribed to avoid potential side effects. The facility's policies on medication administration were not followed, contributing to the medication errors observed.
Failure to Follow Dietary Guidelines for Mechanical Soft and Ground Diets
Penalty
Summary
The facility failed to adhere to the standardized recipes for the lunch menu on 11/19/2024, specifically for residents on mechanical soft chopped and ground diets. Five residents on a mechanical soft chopped diet received Chicken Alfredo with broccoli that was not chopped appropriately, with chicken pieces measuring 1.5 inches and broccoli florets at 2 inches, contrary to the required half-inch size. Additionally, 17 residents on a mechanical soft ground diet were served chopped Chicken Alfredo instead of the required ground consistency, as per the food production guides. Observations and interviews revealed that the cook misunderstood the dietary requirements, preparing the same chopped Chicken Alfredo for both chopped and ground diets. The dietary supervisor confirmed the inconsistency in food sizes and acknowledged the risk of choking due to large food pieces. The registered dietitian and speech therapist emphasized the importance of proper food texture for residents with limited chewing ability, highlighting the facility's failure to follow its policy and procedure for mechanical soft and ground diets.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, which could potentially lead to foodborne illnesses among residents. During an observation, it was found that nutritional supplements labeled to be stored frozen and used within 14 days of thawing were not monitored for their thaw dates. Specifically, a box of 30 single-serve cartons of vanilla-flavored high-protein nutrition supplements and another box of sugar-free chocolate high-calorie nutrition supplements were stored in the walk-in refrigerator without any thaw date. The Dietary Supervisor acknowledged that there should be a date on the supplements to monitor when they were thawed and when they should be discarded. Additionally, a large tray of boneless chicken thighs was observed thawing on the bottom rack of the walk-in refrigerator without a thaw date. The Dietary Supervisor and a cook confirmed that the chicken was removed from the freezer but failed to mark the thaw date, which is necessary to ensure safe storage and cooking. Furthermore, a bottle of thickened water stored in the reach-in refrigerator was found to have exceeded its storage period, as indicated by the manufacturer's use-by date. The Dietary Supervisor and a dietary aide confirmed that the thickened water was expired and should have been discarded. These lapses in food storage and preparation practices were contrary to the facility's policy and the 2022 U.S. Food and Drug Administration Food Code, which require proper labeling, dating, and monitoring of refrigerated food.
Privacy Violation During Wound Care
Penalty
Summary
The facility failed to maintain the right to privacy for a resident during a wound care dressing change. The privacy curtains in the resident's room were not long enough to cover the entire room, only providing a barrier between the resident and their roommate. This deficiency was observed during a wound dressing change for a resident with multiple medical conditions, including diabetes mellitus, chronic kidney disease, and severe cognitive impairment. The resident was dependent on staff for various activities of daily living and was at risk of developing pressure injuries. Interviews with facility staff, including a Certified Nursing Assistant and a Treatment Nurse, revealed that the issue with the short privacy curtains had been ongoing, with staff acknowledging the need for curtains to fully cover the resident's care area to ensure privacy and dignity. The Director of Nursing also confirmed the necessity for privacy curtains to cover the entire care area during personal care provision. The facility's policy on dignity and respect emphasized the importance of respecting residents' private space and property at all times.
Failure to Maintain Homelike Environment Due to Peeling Paint and Exposed Walls
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents, as evidenced by peeling paint and exposed walls in their shared room. Resident 1, who was initially admitted with dementia, hemiplegia, and hemiparesis, and Resident 49, admitted with metabolic encephalopathy and dementia, both had severe cognitive impairments and were dependent on staff for activities of daily living. During observations, the room was noted to have peeling yellow paint and cracked walls above the baseboards, which did not reflect a homelike environment. Interviews with facility staff, including a CNA and the Maintenance Supervisor, confirmed the condition of the room and acknowledged that it did not meet the standards of a homelike environment. The Director of Nursing also stated that the room should not have chipped paint or dirty walls, as this could potentially affect the residents' dignity and mood, violating their rights to a homelike environment. The facility's policy on maintaining a homelike environment emphasized the responsibility of all staff to address such issues promptly.
Failure to Report Unwitnessed Fall Resulting in Injury
Penalty
Summary
The facility failed to report an unwitnessed fall of a resident, which resulted in a right hip fracture requiring surgical repair and hospitalization, to the California Department of Public Health (CDPH). The resident, who had severe cognitive impairment and was legally blind, was found on the floor by a CNA. The fall was unwitnessed, and the resident was transferred to a General Acute Care Hospital for treatment. Despite the severity of the injury, the incident was not reported to the state agency, delaying an investigation by CDPH. The resident had a history of falls and was dependent on staff for most activities of daily living due to severe cognitive impairment and legal blindness. On the morning of the fall, the resident was found sitting on the floor between the beds, complaining of hip pain. An x-ray confirmed a right hip fracture, and the resident underwent surgery. Interviews with staff revealed that the fall was unwitnessed, and the resident's roommate, who was also cognitively impaired, could not provide reliable information about the incident. The facility's policies on fall management and reporting unusual occurrences were reviewed, indicating that unusual events, such as unwitnessed falls resulting in injury, should be reported. However, the Director of Nursing did not report the fall, citing the roommate's unreliable account. This oversight resulted in a failure to comply with state reporting requirements, as the fall was not reported to CDPH, preventing timely investigation and intervention.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to ensure that a significant change in status assessment (SCSA) was completed for a resident who experienced a significant change in condition. The resident, who had multiple diagnoses including diabetes mellitus, chronic kidney disease, and pulmonary hypertension, was admitted with a diagnosis of moderate protein-calorie malnutrition. The resident's Minimum Data Set (MDS) dated 11/2/2024 indicated severe cognitive impairment and dependency on staff for various activities of daily living. Additionally, the resident was at risk for pressure injuries and had developed a Stage 1 pressure injury. Despite these conditions, the Minimum Data Set Coordinator (MDSC) did not complete an SCSA when the resident's pressure injury progressed to Stage II, as noted in the Pressure Sore Management Record dated 11/11/2024. The MDSC acknowledged that the SCSA should have been triggered by the presence of two major changes, such as weight loss and pressure injury. The Director of Nursing (DON) confirmed the importance of completing an SCSA to address specific problems. The facility's policy indicated that an SCSA is appropriate when there are two or more areas of decline or improvement, or if the Interdisciplinary Team (IDT) determines it would benefit the resident. This oversight had the potential to impact the resident's care and treatment.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the Minimum Data Set (MDS) assessments for two residents, leading to potential negative effects on their care plans. For one resident, the MDS inaccurately documented a Stage III pressure ulcer, while the resident only had a Stage II pressure ulcer that had resolved. This discrepancy was identified during interviews with the Treatment Nurse and the MDS Coordinator, who confirmed the miscoding. The resident had been readmitted to the facility after surgery with a Stage II pressure ulcer, which was resolved, and no further wound care was being provided. For another resident, the MDS inaccurately recorded an unplanned discharge to a Short-Term General Hospital, whereas the resident was actually discharged to a private home with home health services. This error was identified during a review of the resident's discharge summary and confirmed by the MDS Coordinator. The Director of Nursing Services emphasized the importance of accurate MDS documentation to ensure appropriate care and services for residents. The facility's policy on the accuracy of assessments requires that the MDS reflect the resident's status during the observation period, capturing only occurrences within that timeframe.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for two residents, leading to potential negative impacts on their care. For Resident 2, the Occupational Therapy (OT) services were discontinued as per a physician's order, but the care plan was not updated to reflect this change. The Director of Rehabilitation confirmed that the care plan still indicated ongoing OT services, which was inaccurate. This oversight could lead to confusion and inappropriate care for Resident 2, who had severe cognitive impairments and functional limitations. Resident 46 experienced a significant change in condition due to hypoglycemic events, yet the care plan was not revised accordingly. Despite a physician's order to decrease the insulin dosage following a hypoglycemic episode, the care plan was not updated to reflect this change. The Minimum Data Set Coordinator acknowledged that the care plan should have been revised to prevent further hypoglycemic events. The failure to update the care plan after the resident's condition changed could have serious implications for the resident's health. The facility's policy and procedure require that comprehensive care plans be developed, reviewed, and revised by the interdisciplinary team, especially after any assessment or change in condition. However, in both cases, the care plans were not updated as required, indicating a lapse in following the facility's established procedures. This deficiency in care planning could lead to inadequate care and potential harm to the residents involved.
Failure to Conduct IDT Meetings and Activate Emergency Response
Penalty
Summary
The facility failed to conduct an Interdisciplinary Team (IDT) meeting after a resident experienced two hypoglycemic events. The resident, who had a history of diabetes mellitus and osteomyelitis, experienced confusion and cold, clammy skin, with blood glucose levels dropping to 42 mg/dL and 34 mg/dL on separate occasions. Despite these events, the IDT meetings were not held to discuss potential causes and revise care plans to prevent recurrence. Additionally, the facility did not activate the emergency response system when the resident remained unresponsive after interventions during the second hypoglycemic event. The resident's blood glucose was 34 mg/dL, and after administering glucagon, it only rose to 49 mg/dL. The resident was still not verbally responsive, and the emergency response system was not activated, which could have led to a delay in care. The facility's policy indicated that care and services should maintain the resident's highest level of practicable functioning. However, the failure to clarify insulin orders with the physician and the lack of IDT meetings after the hypoglycemic events demonstrated a deficiency in adhering to this policy. The Director of Nursing Services acknowledged that the emergency response system should have been initiated and that IDT meetings should have been conducted to address the hypoglycemic events.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident who was assessed at moderate risk for developing pressure injuries. The resident, who had intact skin upon admission, developed a Stage I pressure injury on the coccyx area, which progressed to a Stage II injury. The facility did not implement the resident's care plan in a timely manner, specifically delaying the use of a low air loss mattress and failing to reposition the resident to offload pressure from the coccyx area. The resident's care plan included interventions such as turning and repositioning every two hours, using a low air loss mattress, and providing nutritional support. However, these interventions were not initiated promptly, and the resident's pressure injury worsened. Additionally, the facility used bath towels instead of incontinence pads, which contributed to skin shearing and further compromised the resident's skin integrity. The resident's severe cognitive impairment and dependency on staff for mobility and hygiene further complicated the situation. Interviews with staff revealed that the resident's poor food intake and refusal of a mechanical soft diet were not adequately addressed, and there was a lack of communication regarding the progression of the pressure injury. The use of bath towels instead of appropriate incontinence products was identified as a practice that could lead to skin breakdown. The facility's failure to properly reposition the resident and use appropriate incontinence care measures contributed to the development and progression of the pressure injury.
Failure to Provide Recommended Splints for Resident
Penalty
Summary
The facility failed to provide a resting hand splint for the left arm and a hand roll splint for the right hand to a resident, as recommended by Occupational Therapy (OT). The resident, who was admitted with right-sided hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage, was at high risk for contracture development due to increased muscle tone and a tendency to hold both hands in fists. Despite the OT's recommendation for splinting to maintain joint integrity and manage muscle tone, the splints were never issued to the resident. Observations revealed that the resident was lying in bed with rolled-up towels in both hands instead of the recommended splints. The Restorative Nursing Aide (RNA) was unaware of any orders for splints and used towel rolls to prevent the resident's nails from digging into her palms. The RNA provided passive range of motion (PROM) exercises at a fast speed, causing the resident to moan and grimace in pain. The Director of Rehabilitation confirmed that the splints were not issued due to a lack of time to assess the resident for appropriate splint wear time before discharge from OT services. The Director of Nursing stated that the Rehabilitation Department was responsible for assessing and issuing splints. The facility's policies indicated that treatment and services should be provided to maintain or improve each resident's range of motion and prevent further decline unless clinically unavoidable. The failure to issue the recommended splints potentially contributed to the resident's risk of range of motion decline and contracture development.
Failure to Prevent Unplanned Weight Loss in a Resident
Penalty
Summary
The facility failed to prevent significant unplanned weight loss in a resident, identified as Resident 25, who experienced a 9.2% weight loss over three months and a 10.5% loss over six months. The staff did not adequately monitor the resident's oral intake or notify the physician of the significant weight loss in a timely manner. Despite having a care plan in place to address altered nutrition and hydration status, the facility did not effectively implement interventions to prevent further weight loss. Resident 25 was admitted with multiple diagnoses, including diabetes mellitus, chronic kidney disease, and moderate protein-calorie malnutrition. The resident was dependent on staff for daily activities and had severe cognitive impairment. Despite being on a prescribed diet and receiving nutritional supplements, the resident's food intake was consistently low, ranging from 0% to 50% of meals consumed. The care plan required monitoring of weight and food intake, but the staff failed to document and report significant changes to the physician as required. Interviews with staff revealed a lack of communication and follow-up regarding the resident's declining condition. The CNA responsible for feeding the resident did not notify the charge nurse of low food intake, and the LVN and RN acknowledged the resident's poor eating habits but did not take appropriate action. The RD was not aware of the continued weight loss despite interventions and had not personally assessed the resident. The facility's policies on nutrition and notification of change were not followed, contributing to the resident's ongoing weight loss and risk of malnutrition.
Failure to Provide Appropriate Pureed Diet
Penalty
Summary
The facility failed to ensure that a resident on a pureed diet received food consistent with their diet order and according to the pureed menu recipe. The resident, who had severe cognitive impairment and was dependent on staff for various activities, was observed consuming a peanut butter and jelly sandwich, which is not part of a pureed diet. This was contrary to the physician's order and the speech therapist's recommendation for a pureed diet due to the resident's dysphagia and diabetes mellitus. The resident's care plan indicated a need to monitor and report signs of dysphagia, yet the dietary manager admitted that the resident was not receiving the correct diet. The dietary manager acknowledged that the peanut butter and jelly sandwich was not appropriate for the resident's pureed diet and that the facility should have requested another speech therapy evaluation to ensure the resident's safety. The speech language pathologist confirmed that the resident's diet should be pureed and that a peanut butter and jelly sandwich could pose a risk of aspiration. The facility's policy and procedure on therapeutic diets stated that residents should receive foods in the appropriate form as prescribed by the physician. However, the dietary manager did not verify the resident's diet, leading to the resident receiving an inappropriate meal. This oversight had the potential to put the resident at high risk for aspiration and choking, as the facility did not adhere to the prescribed diet and recommendations.
Inaccurate Documentation of OT Recommendations and ROM Status
Penalty
Summary
The facility failed to ensure accurate documentation of clinical records for a resident, specifically regarding occupational therapy (OT) discharge recommendations and range of motion (ROM) status. The resident, who was admitted with diagnoses including right-sided hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage, was evaluated by OT due to a decline in ROM in both hands. The OT evaluation recommended the use of a resting hand splint on the left hand and a hand roll on the right hand for 4 hours on and 4 hours off to maintain joint integrity and manage muscle tone. However, the OT discharge summary inaccurately documented that the resident could tolerate wearing both splints for 4 hours, despite only tolerating 30 minutes at the time of discharge. The Director of Rehabilitation (DOR), who conducted the OT evaluation, confirmed that the documentation of contractures in both hands was inaccurate, as the resident did not have contractures. The DOR admitted to mistakenly documenting the recommendation for the splints' wear time due to a lack of attention while writing the discharge summary. This inaccurate documentation could potentially cause confusion and harm, as it did not accurately reflect the resident's current level of function and needs. The Director of Nursing (DON) emphasized the importance of accurate documentation in a resident's clinical record, as it reflects the resident's status and ensures the provision of necessary care and services. The facility's policy and procedure on documentation, as well as the OT job description, highlight the responsibility of accurately charting patient care services and evaluating patient progress. The failure to accurately document the resident's condition and OT recommendations had the potential to negatively impact the provision of necessary care and services for the resident.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident who was at high risk for developing pressure ulcers. The resident, who was non-ambulatory and bedfast, was admitted with multiple diagnoses including hemiplegia, hemiparesis, and malnutrition. Despite being assessed as high risk for pressure ulcers, the resident developed a deep tissue injury (DTI) on the right heel, which evolved from a Stage 1 pressure ulcer. The facility did not ensure the resident was turned and repositioned every two hours, nor did they maintain offloading of the right heel to prevent constant pressure. Interviews and record reviews revealed that the resident's care plan included interventions such as repositioning and the use of a pressure-reducing device, but these were not consistently implemented. Documentation showed numerous instances where the resident was not turned or repositioned as required. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) acknowledged that the resident's pressure ulcer was avoidable and attributed its development to poor nutrition, immobility, and constant pressure on the heel. The facility's failure to reassess the resident's condition and update the care plan with necessary interventions contributed to the progression of the pressure ulcer. The Director of Nursing (DON) confirmed that the resident was not consistently turned and repositioned, as indicated by the documentation survey reports. The facility's policy emphasized the importance of repositioning and relieving constant pressure for residents at risk of pressure ulcers. However, the resident's care plan did not include specific interventions for repositioning and offloading the right heel after the DTI was identified. This lack of adherence to standard nursing practices and the facility's policy resulted in the resident developing a preventable pressure ulcer.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Torrance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Torrance Care Center West, Inc | 0.9 mi | — | 7 | 0 |
| Providence Little Co Of Mary Transitional Care Ctr | 1 mi | — | 3 | 0 |
| The Earlwood | 1.1 mi | — | 30 | 0 |
| Driftwood Healthcare Center | 1.1 mi | — | 2 | 0 |
| Beachside Post Acute | 1.2 mi | — | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.