GARDENA, CA - Federal health inspectors documented multiple compliance failures at Kei-ai South Bay Healthcare Center during a January 2025 inspection, including improper medication storage, delayed dental services, and infection control protocol breaches that placed residents at risk.
Medication Storage Failures Raise Safety Concerns
During the January 13, 2025 inspection, surveyors discovered 52 acetaminophen suppositories stored in an unmarked plastic bag inside the facility's medication refrigerator at Station 1. The bag contained no labeling indicating the medication type, opening date, expiration date, or intended recipient.
When Licensed Vocational Nurse 3 (LVN 3) was shown the unlabeled medication, the nurse acknowledged the violation and explained the potential consequences. According to the inspection report, LVN 3 stated: "We don't know if the medication is expired, if it belongs to a resident or what the medication is."
Acetaminophen suppositories are rectal medications used to reduce fever and relieve mild to moderate pain. These medications require proper storage conditions and careful tracking to ensure they remain effective and are administered safely. Suppository formulations are particularly sensitive to temperature variations, which is why they must be refrigerated. However, refrigeration alone is insufficient without proper identification and dating protocols.
The facility's Administrator acknowledged during the inspection that all medications in storage areas must be labeled with both opening and expiration dates. The Administrator explained the risks of this violation: "We wouldn't know if the medication belongs to a resident or if it's a house medication. We also wouldn't know if the medication is expired. It could result in bad consequences if given to the wrong resident."
Medication errors represent one of the most preventable categories of patient harm in healthcare settings. Proper labeling serves as a critical safety barrier that prevents wrong-patient errors, expired medication administration, and confusion between house stock and individual resident medications. When medications are stored without identification, multiple error pathways open simultaneously. A nurse might administer expired medication that has lost potency, give a resident's personal supply to another patient, or use medication that should have been discarded.
The facility's own policy, titled "Storage of Medications," clearly states that medications requiring refrigeration must be stored separately from food and must be labeled accordingly. This policy exists because proper medication management requires multiple checkpoints, with labeling serving as the foundation of the entire system.
Resident Left Waiting Year for Denture Repair
Inspectors identified a significant delay in providing dental services to Resident 35, who experienced problems with ill-fitting upper dentures for approximately one year without resolution. The resident's son reported during the January 7, 2025 interview that the facility's contracted dental service, Golden Age Dental Care, was scheduled to visit monthly, yet his mother's dentures requiring realignment were never properly addressed.
Resident 35, a woman with severe cognitive impairment who was completely dependent on staff for daily activities including toileting, bathing, and dressing, also had diagnoses of dementia, dysphagia, atrial fibrillation, and pneumonia. The combination of swallowing difficulties and poorly fitting dentures created compounding risks for this vulnerable resident.
The Social Services Director (SSD) confirmed that Golden Age Dental Care visited residents monthly and that Resident 35's last dental appointment occurred on November 1, 2024. The SSD acknowledged that Social Services was responsible for following up with dental providers and admitted that no follow-up had occurred for Resident 35. According to the inspection report, the SSD stated: "The risk of not following up on dental services could result in a resident not being able to eat, pain and discomfort."
Properly fitting dentures are essential for adequate nutrition, particularly for residents with existing swallowing difficulties. When dentures fit poorly, residents experience pain during eating, difficulty chewing food thoroughly, and reduced food intake. For a resident with dysphagia—a condition requiring careful management to prevent aspiration—poorly fitting dentures compound the risks significantly. Inadequately chewed food increases choking hazards and aspiration risk, potentially leading to pneumonia.
The connection between dental health and overall health becomes particularly critical in the nursing home population. Residents who cannot chew effectively often avoid nutritious foods that require more chewing effort, leading to inadequate protein and nutrient intake. Weight loss frequently follows, which can trigger a cascade of health complications including decreased immunity, poor wound healing, and increased fall risk due to weakness.
Only after surveyors identified this issue did the Social Services Director contact Golden Age Dental Care on January 10, 2025, at 11:25 a.m., receiving approval to repair Resident 35's dentures. This meant the resident had waited approximately 14 months since the problem was first identified before action was taken.
The facility Administrator confirmed that Social Services held responsibility for scheduling appointments, arranging follow-ups, coordinating transportation, and managing reimbursements for dental services. The Administrator acknowledged that Resident 35's denture issues should have received timely follow-up and recognized that failure to provide appropriate dental services could result in weight loss, inadequate food intake, and resident discomfort.
The facility's own policy on Dental Services, revised in December 2016, explicitly states that social services representatives will assist residents with appointments, transportation arrangements, and reimbursement coordination for dental services.
Infection Control Breach with Oxygen Equipment
Surveyors documented an infection control violation involving Resident 66, whose oxygen tubing had not been changed according to facility protocol. During a December 26, 2023 observation at 9:43 a.m., inspectors found oxygen tubing dated December 18, 2023—meaning it had been in use for eight days rather than the required maximum of seven days.
Resident 66, admitted with chronic obstructive pulmonary disease, heart failure, and chronic kidney disease, required continuous supplemental oxygen at 2 liters per minute through a humidifier system. The resident lacked capacity to make decisions and required assistance with most daily activities.
Oxygen delivery systems using humidifiers create an environment where moisture accumulates inside the tubing. This moisture provides an ideal breeding ground for bacterial growth. When oxygen tubing remains in use beyond recommended timeframes, biofilm can develop on interior surfaces, and contaminated water droplets can be delivered directly into a resident's respiratory system with each breath.
For residents with chronic lung disease like Resident 66, respiratory infections pose serious health threats. COPD already compromises lung function and weakens the body's ability to clear secretions. Introducing bacteria through contaminated oxygen equipment can trigger pneumonia, acute exacerbations of COPD requiring hospitalization, or respiratory failure.
Licensed Vocational Nurse 1 (LVN 1) confirmed during a December 28, 2023 interview that oxygen tubing should be changed weekly. The nurse explained that humidity buildup in the tubing could enter the resident's lungs if tubing was not changed every seven days, stating it was "important to change the oxygen tubing once a week to prevent infection."
Both the Assistant Director of Nursing and the Infection Preventionist Nurse confirmed that seven-day tubing changes represented facility policy and that failure to follow this protocol placed Resident 66 at risk for infection.
The facility maintained written policies supporting these practices. Its "Infection Prevention and Control Program" policy, dated June 2021, established that the facility would maintain an infection control program reflecting current standards of practice and requiring assessment of staff compliance with policies. The "Respiratory Therapy-Prevention of Infection" policy, dated November 2023, specifically directed staff to "change the oxygen cannula and tubing every seven days."
Infection prevention in skilled nursing facilities requires consistent adherence to evidence-based protocols. While a one-day delay might seem minor, systematic failures to follow established timelines indicate broader problems with protocol compliance and monitoring. Infection control measures protect residents individually and collectively—preventing one resident's respiratory infection reduces transmission risks throughout the facility.
Additional Issues Identified
Beyond these three major violations, the inspection documented the facility's need to strengthen its systems for medication management, care coordination, and infection prevention monitoring. Each identified violation represented a breakdown in processes designed to protect resident safety and wellbeing.
The medication storage violation indicated gaps in nursing staff training or supervision regarding pharmaceutical management protocols. The dental care delay revealed weaknesses in the facility's system for tracking and following up on ordered services. The oxygen tubing violation suggested insufficient monitoring of infection control compliance at the bedside.
Federal regulations require nursing homes to maintain systems ensuring that residents receive necessary services, that medications are handled safely, and that infection risks are minimized through adherence to established protocols. These requirements exist because nursing home residents represent a vulnerable population with limited ability to identify problems or advocate for corrective action independently.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kei-ai South Bay Healthcare Center from 2025-01-13 including all violations, facility responses, and corrective action plans.
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