F 0678
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to
physician orders and the resident’s advance directives.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure for three (3) of eight (8) licensed nursing staff
(Registered Nurse 1 [RN 1], Licensed Vocational Nurse 1 [LVN 1], and LVN 2) had a valid Cardiopulmonary
resuscitation (CPR - refers to any medical intervention used to restore circulatory and/or respiratory
function that has ceased) certification while providing care to the patients.
This failure resulted in an unsafe provision of care. This failure had the potential to result for the patients in
a medical emergency situation, received CPR from unqualified licensed nursing staff which may cause
harm, injury, or death on the patients.
Findings:
During a record review on [DATE], the following licensed nursing staff CPR certificates and Time Clock
Report, indicated:
a. For Registered Nurse (RN) 1, RN 1's CPR certificate was issued on [DATE] and needed to be renewed in
3/2023. RN 1's CPR certificate was renewed on [DATE] (RN 1's CPR certificate was expired for three
months).
RN 1's Time Clock Report indicated RN 1 worked in the Subacute Nursing Unit from [DATE] through
[DATE], providing patient care with an expired CPR certificate.
b. For Licensed Vocational Nurse (LVN) 1, LVN 1's CPR certificate was issued on [DATE] and needed to be
renewed in 5/2023. LVN 1's CPR certificate was renewed on [DATE] (LVN 1's CPR certificate was expired
for two months.
LVN 1's Time Clock Report indicated LVN 1 worked in the Subacute Nursing Unit from [DATE] through
[DATE], providing patient care with an expired CPR certificate.
c. For LVN 2, LVN 2's CPR certificate was issued on [DATE] and needed to be renewed in 4/2023. LVN 2's
CPR certificate was renewed on [DATE] (LVN 2's CPR certificate was expired for two months.
LVN 2's Time Clock Report indicated LVN 2 worked in the Subacute Nursing Unit from [DATE] through
[DATE], providing patient care with an expired CPR certificate.
During an interview on [DATE] at 9:10 a.m., with the Chief Human Resources Officer (CHRO) and the Chief
Nursing Officer (CNO), the CHRO stated the HR staff would monitor the employee credentials
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555441
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555441
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial Hospital of Gardena D/P Snf
1145 W. Redondo Beach
Gardena, CA 90247
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0678
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
required to work, and the HR staff would email the Nursing Managers for the list of their employees with
expiring license and certification one month prior to expiration date.
The CHRO stated the HR staff who was responsible for monitoring the employee's credentials did not
follow the process of emailing the Nurse Managers for the list of employees with expiring license one month
prior to expiration date and did not provide the Nurse Managers with the information timely.
The CNO stated the Director of Nursing in Subacute (DNSA) was the one responsible in ensuring all
employees providing patient care had a valid and current CPR certificate. The CNO stated all employees
with expired CPR certification shall not be allowed to work until a valid and current CPR certificate was
obtained.
During a review of the document titled, Job Description the following were indicated:
a. For Registered Nurse, a current BLS (Basic Life Support [CPR]) for Healthcare provider card is required.
b. For LVN, a current BLS (CPR) for Healthcare provider card is required.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555441
If continuation sheet
Page 2 of 2
