West Gardena Post Acute

In the surveyor’s words

From the most serious findings on record at West Gardena Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jan 22, 2022

  Based on observation, interview, and record review the facility failed to implement acceptable infection control practices to prevent the spread and transmission of coronavirus (COVID-19, a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) for seven of 13 sampled residents (Residents 1, 6, 9, 17, 20, 31, 48). The facility failed to: A. Ensure a Certified Nurse Assistant (CNA 1) wore gown and gloves while in Residents 1's and Resident 17's room, who were residing in the yellow zone (zone for residents who are mixed quarantine or symptomatic) to prevent transmission of COVID-19 infection. B. […]

• Actual harm, isolatedF580Jul 29, 2024

  Based 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. […]

• Actual harm, isolatedF689Oct 26, 2023

  Based 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. […]

• Actual harm, isolatedF773Apr 15, 2022

  Based on observation, interview, and record review, the facility failed to promptly notify the physician of the abnormal urinalysis (a test of your urine) results for one of three residents (Resident 4). The facility did not notify the physician until five days after the abnormal urinalysis results had been reported. As a result of this deficient practice there was a delay in diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 4 was transferred to the acute hospital and was diagnosed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of the Admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF552Nov 20, 2025

  Based 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.Findings: During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was originally admitted to the facility on [DATE] and readmitted on [DATE], with… […]