West Gardena Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure the prescribers of psychotropic medications (drugs that affect mood, behavior, or mental processes and are used to treat certain mental health conditions) personally provided information and obtained informed consent from the residents and/or their responsible parties for two of five sampled residents (Residents 17 and 45). This failure had the potential to result in miscommunication or misunderstanding between the prescribers and the residents or their representatives regarding the purpose, risks, and benefits of the prescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 10 and 32) received their scheduled 9:00 a.m. medications within the required one-hour administration window. This failure had the potential to result in delays in treatment, which may affect the residents' health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for three of six sampled residents (Residents 7, 9, and 39) with ROM concerns by failing to: 1. Objectively measure Resident 7's limited ROM in both hips and both knees during the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 11/24/2024. 2. Objectively measure Resident 39's limited finger ROM of the right hand during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 5/14/2025. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an organized medication storage system in the medication room. Medications were found stored in buckets labeled for different medications, and the overall storage lacked a systematic organization (example: alphabetical or by drug class). This deficient practice had the potential to result in medication errors and/or delays in administration if licensed staff were unable to locate the correct medication promptly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and served in a sanitary manner by failing to:Ensure the freezer's temperature was not greater than zero degrees Fahrenheit (F-unit of measurement) while frozen items were stored. Ensure an open bag of popsicles was dated and labeled with open date and use by date. Ensure an open bag of frozen burritos was dated with open date and stored in a sealed bag. Ensure the cook performed hand hygiene after the removal of used gloves and before removing the baked burritos from the oven. These failures had the potential to put residents at risk for food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aides (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) accurately documented RNA services provided for two of six sampled residents (Residents 7 and 9) in 5/2025, 6/2025, and 7/2025. This failure had the potential to negatively impact the provision of necessary care and services due to the inaccurate reflection of services provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control measures for two of six sampled residents (Residents 6 and 7) by failing to:1. Ensure Certified Nursing Assistant (CNA) 4 wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assisting with range of motion (ROM, full movement potential of a joint) exercises to Resident 6's both knees and both ankles which required direct contact with Resident 6 who was on Enhanced Barrier Precautions (EBP- infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms [microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents]). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the reach in freezer for frozen vegetables and frozen meat products in the kitchen were maintained and kept in a safe and operating condition by failing to:1. Follow their policy and procedure titled Freezer Storage which indicated to maintain a temperature of zero-degree Fahrenheit (F- unit of measurement) or lower. This failure had the potential to put residents at risk for food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites).

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a change of condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) to the physician for one of six sampled residents (Resident 39) when a decline in range of motion (ROM, full movement potential of a joint) of Resident 39's both hands were identified on the Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 3/20/2025. This failure resulted in Resident 39 not receiving the appropriate services and interventions to address and improve ROM, prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), and improve overall mobility and physical functioning.

Inspectors wroteBased on interview and record review, the facility failed to ensure a preadmission screening and annual review of a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was accurately documented for two of four residents (Residents 17 and 45). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident's 17 and 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for the assessment and application of splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) for one of six sampled residents (Resident 27). The facility failed to: 1. Ensure the Director of Rehab (DOR) who was a Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) performed an assessment to determine the appropriateness, fit, and splint wear time tolerance (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits) of Resident 27's right knee splint. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 7) who was assessed as being at risk for pressure ulcer ( localized damage to the skin and/or underlying tissue usually over a bony prominence) development was provided a pressure relieving barrier to be placed between Resident 7's overlapping, contracted (loss of motion of a joint associated with stiffness and joint deformity) toes of the right foot per facility's policy and procedure titled Prevention of Pressure Injuries. This failure had the potential for Resident 7 to develop pressure ulcers on the right foot.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 31) humidifier bottle (a medical device used with oxygen therapy to add moisture to dry oxygen) was dated with the last change date. This failure had the potential for Resident 31 to receive oxygen through equipment that may not have been maintained according to infection control standards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 5 diluted potassium chloride oral solution (a medication used to treat and prevent low potassium levels) prior to administration per physician order for one of three sampled residents (Resident 22). This failure had the potential to cause adverse effects, which may impact the resident's health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dental services for one of two sample residents (Resident 62) in a timely manner by failing to:1. Refer Resident 62 to the dentist for recurrent toothache.2. follow up Resident 62 dental x-rays (a special camera that takes pictures of the inside of the mouth, teeth and jaw) result. These failures had the potential to put Resident 62 for unnecessary pain and increased risk of gum disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lunch meal for one of six sampled residents (Resident 3) was fortified (foods have protein, carbohydrates, and/or fats added to increase the total nutritional value of the food) as ordered by the physician. This failure had the potential to result in inadequate caloric and nutritional intake which could lead to unplanned weight loss, decreased strength, and a decline in overall health status.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of two sampled residents (Resident 64). This deficient practice had the potential for Resident 64 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the therapy mat (a padded surface used for therapeutic treatment) in the Rehabilitation Gym (Rehab Gym) was maintained in a clean and unobstructed condition. The mat was observed to be cluttered with various miscellaneous items, including multiple cardboard boxes, a cushion pad, inflatable balls, a large paper towel roll, bags, splints (rigid devices used to support and immobilize a broken bone or impaired joint), a wooden device with plastic rings, folded linen, and personal belongings of staff. This failure had the potential to limit the availability and use of therapeutic equipment, reduce usable treatment space for residents during rehab therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 24 residents' rooms met 80 square feet (sq. ft- a unit of area measurement) per residents in multibed resident rooms. Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9,10,11,12,14,15,16,17,18,19, 20, 21, 22, 23, 25, and 26 were occupied with at least two residents. rooms [ROOM NUMBERS] were occupied with three residents per room. This deficient practice had the potential to result in inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained when cockroaches were observed in the kitchen. This deficient practice resulted in the facility's kitchen being closed for use to the residents and had the potential to spread bacteria and viruses that cause illness, affecting the population of residents in the facility (44) who resided in there and who received food from the facility's kitchen by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 4 and 19) was provided their activities of choice (preference). This failure had the potential for Resident 4 and 19 to have no mental and emotional interaction that could negatively impact their quality of life.

Inspectors wroteDuring an interview and record review the facility failed to ensure one of 12 sampled resident (Resident 25) advance directive (a legal document that specifies what actions should be taken for your health if you are no longer able to make decisions for yourself) had a signature of a witness when it was signed by Resident 25. This failure had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate safety precautions to residents at risk for fall and seizures (involuntary muscle movement) for two of three sampled residents (Resident 246, 4). Facility failed to ensure: a. Resident 246, who was on fall risk precaution with one floor mat placed on the left corner of the bed had no foot metal bedside table on top of the floor mat. b. Resident 4, who was placed on fall precautions and seizure precaution with a floor mat by the left corner of the bed had no big sized wheelchair placed on top of the floor mat. This deficient practice had the potential for injury when Residents 246 and 4 would fall out of bed and hit their head on the metal equipment placed on top of the floor mat.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess for pain before wound care treatment on one of three sampled residents (Resident 246) who had a skin tear on right upper knee. This failure had the potential for Resident 246 to experience unrelieved pain during wound care treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 21 of 25 residents rooms met of 80 square feet ([sq. ft] a unit of area measurement) per residents in multi-bed resident rooms. Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, 17, 18, 20, 21, 22, 23, 25, and 26 were occupied with two residents and room [ROOM NUMBER] was occupied with three residents per room, and room [ROOM NUMBER] was occupied with four residents per room. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's physician was notified when the resident had a change of condition (COC) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 promptly notified Resident 1's physician when Resident 1 had loose/watery stools for five days as indicated in the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status. 2. Ensure nursing staff implemented Resident 1's Care Plan titled, Resident at Risk for Constipation, by monitoring the amount, consistency, and frequency of Resident 1's bowel movements. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two facility exit doors, the lobby door (Door 1) and front door (Door 2), were secured to prevent the elopement (an unauthorized departure of a resident without the facility's knowledge and supervision) of one of four sampled residents (Resident 1), a resident who had a history of elopement and assessed as high risk for elopement. As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including olanzapine (medication to treat schizophrenia) 15 milligrams twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024 and subsequently transferred to a general acute care facility (GACH) for further evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement one of four sampled resident ' s (Resident 1) care plan to ensure Resident 1 was wearing his Wander guard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time), and that Resident 1 was not going to leave the premises unassisted. As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including olanzapine (medication to treat schizophrenia) 15 milligrams twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024 and subsequently transferred to a general acute care facility (GACH) for further evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement one of four sampled resident ' s (Resident 1) care plan to ensure Resident 1 was wearing his Wander guard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time), and that Resident 1 was not going to leave the premises unassisted. As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including olanzapine (medication to treat schizophrenia) 15 milligrams twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024 and subsequently transferred to a general acute care facility (GACH) for further evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a plan of care was developed and implemented for one of five sampled residents (Resident 1) addressing Resident 1's laceration (a wound that occur when skin or muscle is torn or cut open) on the forehead. This deficient practice had the potential to result in an infected laceration that could pose as a threat to Resident 1's overall health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 1) laceration (a wound that occur when soft tissue such as skin or muscle is torn or cut open) on the forehead had documented monitoring for signs and symptoms of infection and complications after the resident sustained a fall on 2/29/2024. This deficient practice had the potential to result in an infected laceration that could pose as a threat to Resident 1's overall health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure a certified nursing assistant (CNA 1) did not turn and reposition a resident (Resident 1), who required a two-person physical assist with bed mobility, by himself, without the assistance of another staff for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling from bed and sustaining a left parietal (near the back and top of head) scalp hematoma (an injury that causes blood to collect and pool under the skin resulting in a spongy, rubbery, lumpy feel) and laceration (a deep cut or tear in the skin or flesh) with a potential for Resident 1 to sustain more serious consequences such has a brain injury, fractures (a partial or complete break in the bone) and death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served food in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to: 1. Ensure dishes were washed and rinsed at the correct temperature of 120-140 degrees Fahrenheit ([ °F] a scale of temperature) on a low temperature dishwasher. 2. Ensure frozen health shakes have been thawed by immersing under running water 3. Ensure cream pies and pastries were properly sealed, stored in the freezer and labeled with an open date. [...]

Inspectors wroteBased on interview and record review the facility failed obtain recommended Level II preadmission screening and resident review evaluation ([PASARR]-a mental health evaluation done to determine if an individual can benefit from specialized mental health services) for two of 12 sampled residents (Resident 4 and Resident 38) This deficient practice placed Resident 4 and Resident 38 at risk of inappropriate placement, not receiving necessary care, and unidentified specialized services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 24) received proper assistive devices to maintain hearing abilities by not assisting in arranging for audiologist (diagnose, manage, and treat patients who have hearing, balance, or related problems) referral consults to replace missing hearing aids. This deficient practice resulted in delay of services and Resident 24 not able to hear adequately during a conversation, and provision of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 5) who was admitted to the facility with an indwelling suprapubic urinary catheter (tube inserted into the bladder through the stomach to drain urine) received appropriate care, services and followed physician orders to send a urine specimen for urinalysis (UA -urine test) and urine culture and sensitivity (urine C/S- used to diagnose a urinary tract infection [UTI] an infection in any part of the urinary system, the kidneys, bladder, or urethra) when Resident 5 complained of burning sensation on urination. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to: 1. Check residents' identification band (wrist band) prior to medication administration for four of five sampled residents (Resident 17, 21, 23 and 37). This deficient practice had the potential for medication error including administering medication to the wrong resident. 2. Ensure Licensed Vocation Nurse (LVN) 3 signed narcotics reconciliation record ( a record of narcotic or controlled substance inventory) after taking the controlled (a medication with a high abuse potential) medication for one of one sampled residents (Resident 99) according to facility's policy and procedure. This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 21 of 25 residents rooms met of 80 square feet ([sq. ft] a unit of area measurement) per residents in multi-bed resident rooms. Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, 17, 18, 20, 21, 22, 23, 25, and 26 were occupied with two residents and room [ROOM NUMBER] was occupied with three residents per room, and room [ROOM NUMBER] was occupied with four residents per room. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.