A list of the most recent deficiencies for West Gardena Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-17 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-01 | 2023-10-31 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-01 | 2023-10-31 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-01 | 2023-10-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-01 | 2023-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-01 | 2023-10-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-10-01 | 2023-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-03 | 2023-10-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-06 | 2023-04-14 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-06 | 2023-04-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-14 | 2022-12-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-21 | 2022-11-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-21 | 2022-11-21 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-29 | 2022-08-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-04 | 2022-06-17 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-04-15 | 2022-06-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-22 | 2022-03-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-01-22 | 2022-03-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-22 | 2022-03-04 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-01-22 | 2022-03-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-22 | 2022-03-04 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-01-22 | 2022-03-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-22 | 2022-03-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-22 | 2022-03-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-22 | 2022-03-04 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-01-22 | 2022-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-22 | 2022-03-04 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-01-22 | 2022-03-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-20 | 2022-02-22 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-01-20 | 2022-02-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-20 | 2022-02-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-24 | 2021-10-18 | N |
| Respond appropriately to all alleged violations. | Health | 2021-06-29 | 2021-07-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-29 | 2021-07-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-29 | 2021-07-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-29 | 2021-07-13 | Y |
| Keep all essential equipment working safely. | Health | 2021-06-29 | 2021-07-13 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-10-08 | 2019-11-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-08 | 2019-11-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-08 | 2019-11-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-10-08 | 2019-11-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-08 | 2019-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-08 | 2019-11-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-08 | 2019-11-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-08 | 2019-11-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-10-08 | 2019-11-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-10-08 | 2019-11-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-08 | 2019-11-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-08 | 2019-11-04 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-10-08 | 2019-11-04 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-10-08 | 2019-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-08 | 2019-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-08 | 2019-11-04 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-10-08 | 2019-11-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-03 | 2019-10-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-03 | 2019-10-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-03 | 2019-10-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-03 | 2019-10-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-03 | 2019-10-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-03 | 2019-10-29 | N |
