Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Gardena Post Acute during CMS and state inspections, most recent first.
A facility failed to ensure the prescribing physician personally provided information and obtained informed consent for psychotropic medications for two residents. One resident with dementia and psychosis was receiving trazodone, mirtazapine, and quetiapine, and another resident with bipolar disorder and delusional behavior was receiving risperidone. In both cases, the DON confirmed that a psychiatric NP handled the consent process even though the attending physician was the actual prescriber, which was inconsistent with the facility policy requiring the physician to personally examine the resident and obtain informed written consent.
Delayed Morning Medication Administration: Two residents did not receive their scheduled 9:00 a.m. medications within the required one-hour window. An LPN was observed still completing the morning med pass after 10:00 a.m., with one resident still waiting while the nurse obtained a BP reading for the other. The DON confirmed the medications were given outside the acceptable timeframe, and the facility policy stated meds are to be administered within one hour of the prescribed time.
Failure to maintain ROM for three residents involved incomplete therapy assessments and missed RNA exercises. One resident with contractures and impaired ROM had PT findings that were not objectively measured with a goniometer, another resident with impaired hand and finger ROM had an OT evaluation that also lacked objective measurement, and a third resident with quadriplegia and hemiplegia did not receive ordered AAROM to the right wrist and hand during an RNA session. Staff observations showed significant stiffness, limited movement, and curled fingers in the affected joints.
Medication storage in the med room was not organized in an orderly system. Buckets on shelving contained mixed OTC meds and supplements with labels that did not match the contents, including calcium, vitamin D, thiamin, diphenhydramine, loratadine, and loperamide. The LVN stated the buckets were not arranged alphabetically or by class and that finding a specific medication could be time-consuming; the DON acknowledged the storage system was not organized and that staff could have difficulty locating meds promptly.
Unsafe food storage and hand hygiene practices were observed in the kitchen. The freezer was repeatedly found above the proper temperature while frozen foods were stored inside, with some items beginning to thaw. Open popsicles and burritos were found without required dates, and the burritos were stored in an unsealed bag. During tray line, a cook changed gloves without hand hygiene before continuing food preparation, and the DON stated this could lead to cross contamination.
Inaccurate RNA Documentation for Two Residents: The facility failed to accurately document restorative services for two residents on RNA programs. One resident with diabetes, contractures, and a chronic foot ulcer had blank RNA charting for PROM and splinting on multiple days, while another resident with quadriplegia and hemiparesis had blank charting for PROM and walking exercises on numerous days. RNA staff and the DSD stated the blank entries could mean the treatments were not documented or not provided, and the DON stated accurate documentation was needed to reflect the type and frequency of services provided.
Failure to Use Gowns During EBP Care: Two CNAs provided direct hands-on care to two residents on EBP without wearing isolation gowns. One resident had a G-tube and osteoarthritis and needed ROM to both legs, and the other had diabetes, contractures, chronic foot ulcers, Parkinson’s disease, and required repositioning and ROM to both hands and legs. Both CNAs wore gloves but no gowns, and both later confirmed the omission. The IPN and facility policy stated gowns and gloves were required for high-contact care for residents on EBP.
Freezer Not Maintained at Safe Temperature: The reach-in freezer used for frozen meats and vegetables was observed at 39 degrees F, then 12 degrees F, and later 20 degrees F, while the DM stated it should be kept at -10 to 0 degrees F. During observation, frozen pizza was starting to defrost and ice cream was melting. The ADM stated she was notified the freezer was not functioning properly and called for repair, and facility policy required the freezer to be maintained at 0 degrees F.
Failure to report a significant change in condition to the physician: a resident with COPD and peripheral autonomic neuropathy had a JMA showing full ROM in both hands, but a later JMA showed moderate ROM loss in the right hand and severe ROM loss in the left hand with finger contractures. Survey observation found the resident unable to straighten multiple fingers without assistance, and the DOR, OT, and DON confirmed the decline was significant and should have been reported to the MD but was not.
PASARR screening documentation was not accurately completed for two residents with diagnoses including bipolar disorder, major depressive disorder, anxiety, and psychosis. One resident had a positive level one screen with a required level two eval that was not completed, while the other had a negative level one screen despite serious mental illness that also required a level two eval. The DON stated the PASARR documentation was incorrect for both residents.
Failure to Assess and Establish Splint Wear Tolerance: A resident with right hemiplegia, hemiparesis, osteoporosis, aphasia, severe cognitive impairment, and ROM limitations had orders for RNA-applied splints to the right knee, right hand, and right elbow. The DOR and OT confirmed there was no documented evidence that PT/OT completed the required splint assessments, determined the correct splints, or established wear tolerance and wear schedules. The DON stated Rehab was responsible for these assessments, and the facility P&P required therapist evaluation, fitting, trial wear, and documentation.
Failure to separate overlapping contracted toes with a pressure-relieving barrier. A resident with DM, severe cognitive impairment, immobility, and contractures was assessed as very high risk for pressure injury. During observation, the resident’s right middle, fourth, and small toes were hyperextended and overlapping, and staff confirmed they were creating pressure points. The DON stated the resident needed a barrier or device between the toes to offload pressure, but none was in place.
Undated Oxygen Humidifier Bottle: A resident with hypoxia and dependence on supplemental O2 had a pre-filled humidifier attached to the O2 setup that was not dated during multiple observations. The resident’s order required the humidifier to be changed weekly and PRN, and both an LVN and the DON confirmed the humidifier was undated; the facility policy addressed weekly labeling of O2 tubing but did not include a procedure for labeling pre-filled humidifiers.
An LVN administered potassium chloride oral solution to a resident without diluting it as ordered. The resident had difficulty taking the medication directly from the cup and showed an unpleasant facial expression while sipping it. The med label and PO both directed that the dose be diluted with 4 oz of water before administration, and the LVN acknowledged she did not dilute it. The DON stated staff should follow PO directions and that undiluted potassium chloride could cause stomach irritation.
A resident with intact cognition, broken natural teeth, and a care plan for oral pain/discomfort was not timely referred for recurrent toothache and did not have follow-up on dental x-ray results. The resident had severe left upper mouth pain, low oral hygiene, high plaque and tartar, and the dental note recommended extractions and x-rays for treatment recommendations; pain meds and an antibiotic were ordered, and Ibuprofen was later given for severe pain.
Failure to Provide Ordered Fortified Meal: A resident with encephalopathy, muscle weakness, dysphagia, type 2 DM, and protein-calorie malnutrition was ordered a fortified pureed diet with mildly thick liquids and an inner lip plate. During observation, the lunch tray had no sauce, gravy, or margarine. A dietary aide said she did not read the meal card out loud to the cook, and the DM and DON stated fortified diets are intended to add calories and support weight gain.
A resident with dementia and DM was started on Nitrofurantoin for a presumed UTI despite no documented urinary symptoms and no documentation of a urine infection or urine culture before the antibiotic was ordered. The IPN stated she missed the case, and the DON said a time-out should have been done because the antibiotic was unnecessary and could contribute to resistance.
Cluttered Therapy Mat in Rehab Gym: The therapy mat in the Rehab Gym was observed covered with cardboard boxes, a cushion pad, inflatable balls, a paper towel roll, splints, a wooden device with plastic rings, folded linen, and staff personal items. The DOR confirmed the mat was used for resident transfers, sitting balance, and exercises, and stated the clutter limited usable space for therapy sessions. The DON stated the mat should be clear and free of clutter so residents could access therapy equipment.
Resident rooms 1 through 12, 14 through 23, 25, and 26 did not meet the required 80 sq. ft. per resident in multibed rooms, and some rooms housed three residents. Surveyors observed residents moving freely and nurses providing care, while the ADM stated there were no resident concerns about room size and that the facility could accommodate resident needs and daily cleaning. The facility policy stated double rooms must provide at least 80 sq. ft. per resident and single rooms at least 100 sq. ft.
Surveyors observed cockroaches in the kitchen's dry food storage area, including inside an open bag of thickener and a box of crackers. Staff interviews revealed that a dietary aide had previously reported seeing roaches, prompting pest control visits, but the Dietary Supervisor and DON were unaware of the ongoing issue. Pest control invoices confirmed recent treatments in a resident's room, and the resident recalled seeing large roaches about a month earlier.
Two residents with cognitive impairments were not provided with their preferred activities, as observed during multiple instances where they were found sleeping in bed. Despite care plans outlining activities like watching TV and socializing, there was no documentation of these activities being offered. Interviews with staff confirmed the lack of activity provision, which could impact the residents' psychosocial well-being.
A resident's advance directive was found to be invalid due to missing witness signatures, despite the resident's capacity to make medical decisions. This oversight could lead to conflicts in honoring the resident's healthcare wishes, as confirmed by the Social Services Director and Director of Nursing.
The facility failed to ensure safety precautions for two residents at risk for falls and seizures. A resident had a metal bedside table on a floor mat meant to cushion falls, risking injury if they fell. Another resident had a wheelchair on their floor mat, posing a similar risk. Staff confirmed these items should not have been placed on the mats.
A resident with severe cognitive impairment and a skin tear on the knee experienced unrelieved pain during wound care due to the facility's failure to assess pain and lack of a pain medication order. The LVN did not assess the resident's pain level before treatment, contrary to the facility's policy requiring pain assessment before, during, and after treatment.
A facility failed to clarify a physician's order for Combivent, a COPD medication, for a resident, as the order lacked frequency details. The LVN admitted this could lead to incorrect dosing, and the DON confirmed the order was incomplete. Additionally, the facility did not ensure the medication was available, with no record of administration found. The resident did not recall receiving the medication and relied on a CPAP machine for breathing assistance.
The facility did not meet the required 80 square feet per resident in 21 out of 25 rooms, with some rooms occupied by multiple residents. Despite submitting a room waiver, observations showed that residents had enough space to move freely, and room size did not affect care or privacy.
A resident experienced loose stools for five days without physician notification, despite facility policy requiring such action. The resident, with a history of multiple health issues, was on antibiotics for a UTI. The care plan to monitor bowel movements was not followed, leading to a delay in care. The resident was later hospitalized with septic shock and underwent emergency surgery for C. Diff colitis. Staff interviews revealed communication failures in reporting the resident's condition.
A resident with a history of elopement and severe cognitive impairment managed to leave an LTC facility undetected due to unsecured exit doors. The facility's alarms were deactivated or easily disarmed, allowing the resident to exit without triggering alerts. The resident was found after ten days without medication, requiring hospitalization for acute psychosis and severe anemia.
A resident with paranoid schizophrenia and high elopement risk eloped from the facility due to inadequate monitoring and unsecured doors. The resident's wander guard was found damaged, and they were without medication for ten days until found and hospitalized with acute psychosis and severe anemia.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to the failure to implement the care plan, which included wearing a Wander guard. The resident was without necessary medications for ten days and was found wandering the streets, leading to hospitalization for acute psychosis and severe anemia. The facility's unsecured exit doors and inadequate monitoring contributed to the incident.
Informed Consent for Psychotropic Medications Not Obtained by Prescribing Physician
Penalty
Summary
The facility failed to ensure that prescribers of psychotropic medications personally provided information and obtained informed consent from residents and/or their responsible parties for two sampled residents. Resident 45 had diagnoses including dementia and psychosis and was receiving multiple psychotropic medications, including trazodone, mirtazapine, and quetiapine for depression, poor oral intake, and hallucinations. During interview and record review, the DON stated that a psychiatric NP had conducted the evaluations, ordered the medications, provided drug information, and obtained informed consent, but the medication orders showed the NP was not the prescriber and that the attending physician had prescribed the medications. Resident 17 was prescribed risperidone for bipolar disorder and delusional behavior, with documentation noting paranoia and statements that staff were conspiring against the resident. During interview and record review, the DON confirmed that the risperidone order was prescribed by the attending physician, but the informed consent for the medication had been obtained and signed by the psychiatric NP rather than the prescribing physician. The facility policy titled Verification of Informed Consent for Psychotherapeutic Medications stated that before prescribing a psychotherapeutic drug, the physician must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative.
Delayed Morning Medication Administration
Penalty
Summary
The facility failed to ensure that two sampled residents, Residents 10 and 32, received their scheduled 9:00 a.m. medications within the required one-hour administration window. During a concurrent observation and interview on 9/30/2025 at 10:16 a.m., LVN 1 was observed in the hallway of Station 1 with a medication cart and stated that two residents were still waiting to receive their morning medications, pointing to the room shared by Residents 10 and 32. At 10:21 a.m., LVN 1 stated she would begin preparing medications for Resident 10. During further observation on 9/30/2025 at 10:34 a.m., LVN 1 was observed obtaining a blood pressure reading for Resident 32, and at 10:35 a.m. stated that Resident 32 would be the last resident to receive medications during the morning medication pass. At 10:41 a.m., LVN 1 completed the medication administration process and stated the morning medication pass ran late because she was trying to be extra careful. During an interview at 2:51 p.m., the DON stated scheduled medications are expected to be administered within one hour before and one hour after the scheduled time, and that medications for Residents 10 and 32 were given after 10:00 a.m., outside the acceptable timeframe. The facility policy titled Administering Medications stated medications are administered within one hour of their prescribed time.
Failure to Maintain ROM Through Incomplete Assessments and Missed Ordered Exercises
Penalty
Summary
The facility failed to provide appropriate care to maintain and/or improve range of motion for three residents with documented ROM concerns. Resident 7 had diagnoses including type 2 diabetes mellitus, contractures of both knees, both elbows, and both hands, and a chronic diabetic ulcer of the left foot. The resident’s PT evaluation documented impaired ROM in both legs, including the right hip, right ankle, left hip, and left ankle, but the evaluation did not use a goniometer to objectively measure the limited ROM in both hips and both knees. During observation, Resident 7 was seen in bed with splints to both elbows, the right wrist, and right hand, a rolled towel in the left hand, and soft boots on both feet. RNA and CNA staff removed the knee splints and boots and performed PROM to both knees, both ankles, and the toes, but were unable to straighten both hips and both knees, and noted stiffness in both ankles. Resident 39 had diagnoses including COPD and peripheral autonomic neuropathy. The OT evaluation documented impaired ROM in both hands and described multiple finger limitations, including tightness, increased risk of deformity, contracture, and loss of motion in the left hand. The evaluation also identified impaired ROM of the ring finger on the right hand, but the OT did not use a goniometer to objectively measure the limited finger ROM. During observation, Resident 39 was lying in bed with all fingers on the left hand bent into the palm, and the middle finger on the left hand and the ring finger on the right hand bent to about 90 degrees at the middle joints. Resident 39 stated he could not straighten all the fingers on the left hand and the ring finger on the right hand without assistance. Resident 9 had diagnoses including quadriplegia, hemiplegia, and hemiparesis. The physician’s order directed RNA to provide AAROM to the right arm five times a week as tolerated. During an RNA session, the resident was observed lying in bed while the RNA verbally cued AROM to the right shoulder, right elbow, right wrist, and right hand. The resident moved the shoulder and elbow independently with effort, minimally bent and straightened the right wrist, and could not extend all the fingers of the right hand, which were curled toward the palm. The RNA did not assist with ROM exercises to the right wrist and hand as ordered, and later confirmed that assistance should have been provided to the entire right arm, including the wrist and hand, but was not.
Medication Room Storage Was Not Organized
Penalty
Summary
The facility failed to maintain an organized medication storage system in the medication room. During observation with the LVN, the room between the two nursing stations was found to contain two walls of shelving with gallon-sized buckets used to store medications. A posted sign instructed charge nurses to maintain organization and cleanliness, and the LVN stated that the buckets contained over-the-counter medications and that inventory was maintained by central supply personnel. Several buckets were observed to contain medications with multiple labels that did not match the contents inside. One bucket labeled for calcium and vitamin D products contained bottles of calcium 500 mg and vitamin D3 50 mg, and another bucket labeled with several vitamin and supplement names contained bottles of vitamin D 25 mcg. A separate bucket labeled for diphenhydramine and loratadine contained three boxes of loperamide HCl, while a bucket labeled for loperamide was located on the top shelf. The LVN stated the storage system was not organized in any order, including alphabetically or by class, and that it would be time-consuming to search for a particular medication. The DON stated the medication storage system was not organized and acknowledged that if staff could not find a medication, there could be a delay in medication administration. The DON also stated it would be difficult to rotate stock and prevent expired medications from remaining in circulation.
Unsafe Food Storage and Hand Hygiene Practices
Penalty
Summary
Food was not stored and handled in a sanitary manner in the kitchen. During observation, the reach-in freezer was found at 39 degrees F during an initial tour, then later at 12 degrees F, and later at 20 degrees F while frozen items remained inside. At the higher temperatures, frozen foods were observed beginning to thaw, including a deep pizza that was starting to defrost and an ice cream container with beads of water on the surface. The Dietary Manager stated the freezer should be maintained at -10 degrees to 0 degrees F, and the Registered Dietician stated frozen meats could be thawed in the refrigerator and used for two days, while other food would be discarded. Open frozen food items were also observed without proper labeling and storage. An open box of popsicles was found without an open date or use-by date, and a Dietary Aide stated it should have been labeled and dated. In another observation, an open bag of bean and beef burritos was stored in an unsealed bag in the freezer and was not labeled with an open date. The Dietary Manager stated the burritos should have been stored in a sealed container or bag and that labeling and dating open food items in the freezer and refrigerator are important so staff know when to discard expired food and to ensure food safety. During tray line preparation, a cook removed bean cheese burritos from the oven while wearing gloves used for plating food, then removed the used gloves and put on a new pair without performing hand hygiene before continuing to plate food. The cook stated hand hygiene should be practiced before and after preparing food and before putting on a new pair of gloves to avoid cross contamination. The DON stated not practicing hand hygiene in the kitchen during tray line and between tasks can put residents at risk for foodborne illness caused by cross contamination.
Inaccurate RNA Documentation for Two Residents
Penalty
Summary
The facility failed to ensure Restorative Nursing Aides (RNA) accurately documented restorative services provided for two residents on the RNA program. The deficiency involved blank entries on RNA flowsheets for multiple dates in 5/2025, 6/2025, and 7/2025, even though the facility stated RNA coverage was available Monday through Friday and the residents were expected to receive services as ordered. One resident had diagnoses including type 2 diabetes mellitus, contractures of both knees, both elbows, and both hands, and a chronic diabetic ulcer of the left foot. The resident’s RNA orders included passive range of motion (PROM) to both arms and both legs five times a week and application of splints to the right hand, both elbows, both knees, and a towel roll to the left hand for four hours five times a week. The RNA flowsheets for 5/2025, 6/2025, and 7/2025 contained blank squares on several dates for these orders. The resident’s MDS indicated severe cognitive impairment, dependence in multiple activities of daily living, and functional limitations in ROM in both arms and both legs. During observation, the resident was lying in bed with splints on both elbows, a rolled towel in the left hand, and both legs appearing bent and rotated to the left side. The second resident had diagnoses including quadriplegia, hemiplegia, and hemiparesis. The resident’s RNA orders included PROM to the left arm three times a week and walking exercises using a front wheeled walker for approximately 30 feet with one person assistance five times a week. The RNA flowsheets for 5/2025, 6/2025, and 7/2025 contained multiple blank squares for both orders on numerous dates. The resident’s MDS indicated cognitive intactness, required varying levels of assistance with care, and had functional limitations in ROM in both arms. During observation and interview, the resident was in bed, had limited movement of the left arm and fingers, could partially move the right arm and fingers, and stated staff assisted with exercises almost every day. RNA staff and the DSD stated the blank squares likely meant the treatments were either not documented or not provided, and both confirmed that blank entries could be mistaken for missed RNA treatments.
Failure to Use Gowns During EBP Care
Penalty
Summary
The facility failed to maintain infection control measures for two residents who were on Enhanced Barrier Precautions (EBP). Resident 6 had diagnoses including dysphagia and osteoarthritis and was ordered to be on EBP because of a gastrostomy tube. During an observation, CNA 4 entered the resident’s room, put on gloves, and did not put on an isolation gown before removing blankets and providing direct hands-on assistance with range of motion to both knees, hips, and ankles. The resident stated she could not straighten her legs on her own and needed assistance. CNA 4 later confirmed he did not wear an isolation gown while providing this care and stated he should have done so because the resident was on EBP. Resident 7 had diagnoses including type 2 diabetes mellitus, contractures of both knees, elbows, and hands, a chronic diabetic ulcer of the left foot, and Parkinson’s disease. The resident was also ordered to be on EBP because of a G-tube and diabetic ulcers on both feet. During an observation, CNA 2 entered the room, put on gloves, and did not put on an isolation gown before removing blankets and providing direct contact care. CNA 2 repositioned both legs, removed a towel roll from the left hand, and attempted to straighten the fingers of both hands while the resident remained in bed with splints and boots in place. CNA 2 later confirmed she did not wear an isolation gown while providing this direct care and stated she should have worn one because the resident was on EBP. The Infection Preventionist Nurse stated EBP was intended to reduce transmission of infection for residents with non-healing wounds and indwelling devices, and that staff providing direct patient care, including repositioning and assisting with ROM for residents on EBP, must wear appropriate PPE including an isolation gown and gloves. The facility’s policy on Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions stated gowns and gloves are used for high-contact care activities for residents with indwelling devices such as G-tubes and chronic open non-healing wounds. The DON also stated it was important for staff to follow proper infection control protocols to prevent the spread of infection.
Freezer Not Maintained at Safe Temperature
Penalty
Summary
The facility failed to ensure the reach-in freezer used for frozen vegetables and frozen meat products was maintained in safe operating condition and at the temperature required by its policy. During a kitchen observation and interview, the freezer temperature was found at 39 degrees F, then later at 12 degrees F, and later at 20 degrees F. The Dietary Manager stated the freezer should be maintained at -10 degrees to 0 degrees F to keep frozen meats and vegetables out of the danger zone, and the Administrator stated she was notified the freezer was not functioning properly and called for repair. During the later observation, frozen food items were visibly affected by the temperature issue, including a deep pizza that had started to defrost and an ice cream container with beads of water on the surface and appearing to melt. The Dietary Manager stated the facility would discard frozen food items that were defrosting and that defrosted food could not be refrozen because it had the potential to promote bacterial growth. Review of the facility’s policy titled Freezer Storage indicated the freezer should be maintained at 0 degrees F, and the Food Receiving and Storage policy stated frozen foods are to be maintained frozen solid with wrappers intact until thawing.
Failure to Report Significant ROM Decline to Physician
Penalty
Summary
The facility failed to report a significant change of condition to the physician for one resident after a Joint Mobility Assessment identified a decline in range of motion of both hands. The resident was admitted with diagnoses including COPD and peripheral autonomic neuropathy, and an earlier JMA showed full ROM in both hands. A later JMA showed moderate ROM loss in the right hand and severe ROM loss in the left hand, with specific losses noted in multiple finger joints, but the assessment recommended no skilled OT evaluation and continued the RNA program as indicated. At the time of the survey observation, the resident was lying in bed and had visible stiffness and contractures of the fingers, including all fingers on the left hand bent into the palm and other fingers bent at about 90 degrees at the middle joints. The resident stated he could not straighten all the fingers on the left hand and the ring finger of the right hand without assistance. During an RNA session, the resident again stated he could not straighten the knuckle and middle joints of all fingers of the left hand and the ring finger of the right hand and needed assistance. The DOR and OT reviewed the JMAs and confirmed the decline from full ROM to moderate and severe loss was significant and should have been reported to the doctor when identified, but was not. The DON also confirmed the decline was a significant change in condition that should have been reported to the physician. The facility policy stated the facility shall notify the resident, attending physician, and representative of changes in medical, mental, or status condition, and that the nurse would notify the physician when there was a significant change in the resident's physical, emotional, or mental condition.
PASARR Screening Documentation Not Accurately Completed for Two Residents
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately documented for two residents. One resident was admitted and readmitted with diagnoses including bipolar disorder and major depressive disorder. The resident’s MDS dated 9/5/2025 indicated cognitive intactness, and the MAR showed orders for Risperidone for bipolar disorder with paranoia and delusions and Trazadone for depression and sleep difficulty. The care plan identified a behavior problem related to bipolar disorder with goals to reduce paranoia and delusions. During interview and record review, the DON reviewed the PASARR dated 9/5/2025 and stated the level one screening was positive and a level two evaluation was required due to serious mental illness, but it was not completed because the level two evaluation letter stated the resident did not have a serious mental illness. The DON stated the level two evaluation was documented incorrectly and that she was responsible for reviewing and completing the PASARR. A second resident was admitted and readmitted with diagnoses including major depressive disorder, anxiety, and psychosis. The resident’s MDS indicated severely impaired cognition, and the MAR showed medications ordered for depression, psychosis, and sleep, including Mirtazapine, Quetiapine, Trazadone, and Seroquel. The care plan addressed behavior problems related to psychosis and included interventions to protect the rights and safety of others. During interview and record review, the DON reviewed the PASARR dated 7/24/2025 and stated the level one screening was negative, but a level two evaluation should have been done due to serious mental illness. The DON stated the level one evaluation letter was incorrect and that she would resubmit the PASARR so the resident could receive specialized individualized resources for mental illness.
Failure to Assess and Establish Splint Wear Tolerance
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for the assessment and application of splints for Resident 27. Resident 27 was admitted with diagnoses including right hemiplegia, hemiparesis, osteoporosis, and aphasia, and the MDS dated 10/7/2025 indicated severe cognitive impairment, dependence in eating, hygiene, bathing, dressing, and mobility, and functional ROM limitations in both arms and one leg. The resident had physician orders for RNA to apply a right knee splint, right-hand splint, and right elbow splint for 3 to 5 hours daily, 5 times a week. During observation on 11/19/2025, Resident 27 was lying in bed wearing splints to the right elbow, right hand, and right knee, and both knees were bent and rotated to the left side of the body. In a concurrent interview and record review, the DOR and OT 1 stated that licensed PTs and OTs must assess residents for splints, determine the correct type of splint, establish wear tolerance and schedule, and document the findings in the clinical record. They reviewed the record and confirmed there was no documented evidence that splint assessments for the right elbow, right wrist/hand, and right knee were completed or that wear time was evaluated and established by a therapist. The DON stated the Rehab Department was responsible for splint assessments, determining the correct type of splint, and establishing wear time for residents. The facility policy titled Splinting stated the therapist would contact the physician for an evaluation order, apply the splint, make fitting adjustments, place the resident on a two-hour trial wearing period to check for pressure points, assess tolerance, increase wear time throughout treatment, and document instructions and recommendations in the plan of care. The DOR and OT 1 also stated that if a resident was not properly assessed for the correct splints and wear time tolerance, the resident could potentially have skin breakdown, pain, discomfort, and ROM decline.
Failure to Separate Overlapping Contracted Toes
Penalty
Summary
The facility failed to ensure that a pressure relieving barrier was placed between a resident’s overlapping, contracted toes on the right foot, despite the resident being assessed as at very high risk for pressure ulcer development. The resident had diagnoses including type 2 diabetes mellitus, contractures of both knees, both elbows, and both hands, and a chronic diabetic ulcer of the left foot. The resident’s MDS indicated severe cognitive impairment, dependence in multiple activities of daily living, functional limitations in range of motion in both arms and both legs, and risk for pressure ulcer development. The Braden Scale dated 10/7/2025 identified very high risk due to very limited sensory perception, occasionally moist skin, complete immobility, and very poor food intake. During observation, the resident was in bed with splints to both elbows, the right wrist, and the right hand, a rolled towel in the left hand, and soft boots on both feet. When the boots were removed, the middle toe, fourth toe, and small toe of the right foot were observed to be hyperextended and overlapping, with the small toe overlapping the fourth toe and the fourth toe overlapping the middle toe. The RNA and CNA stated the toes were overlapping and needed to be physically separated because they were creating points of pressure. The LVN confirmed the contractures of the right foot toes and stated the soft boots helped prevent skin breakdown of the heels and feet but caused the overlapping toes to press against each other when fastened. The DON also confirmed the contractures of the right foot toes and stated the resident required a barrier or device to separate the overlapping toes to offload pressure and prevent pressure ulcers, but did not have one. The DON stated the resident was at high risk for skin breakdown and pressure ulcers because of total care needs for mobility and repositioning, multiple contracted toes, and constant pressure between the overlapping toes with no barrier in between. The facility policy titled Prevention of Pressure Injuries stated staff were to inspect skin daily, reposition residents, provide support devices as needed, and use facility-approved protective dressings for at-risk individuals.
Undated Oxygen Humidifier Bottle
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 31. The resident’s admission record showed diagnoses including encephalopathy, muscle weakness, difficulty walking, acute respiratory failure with hypoxia, and dependence on supplemental oxygen. The quarterly MDS dated 9/5/2025 indicated the resident needed oxygen therapy, and the order summary dated 10/3/2025 directed staff to change the pre-filled humidifier every seven days and as needed when oxygen was in use, with the weekly change starting on 6/20/2025. During observations on 9/30/2025 and 10/1/2025, Resident 31 was seen in bed with oxygen at 3 liters per minute via nasal cannula, and the pre-filled humidifier attached to the oxygen setup was not dated. During a concurrent observation and interview, an LVN stated the humidifier was not dated and should be changed weekly, and that undated humidifiers and oxygen tubing could create a potential risk for infection. The DON also observed that the humidifier was not dated and stated the oxygen tubing and humidifier should be changed weekly by the treatment nurse and as needed if soiled or damaged. The facility policy titled Oxygen Administration stated oxygen tubing should be changed and labeled weekly and as indicated, but it did not include a procedure for labeling pre-filled humidifiers.
Failure to Dilute Potassium Chloride Oral Solution Before Administration
Penalty
Summary
The facility failed to ensure an LVN diluted potassium chloride oral solution before administering it to one resident as ordered. During observation, the LVN prepared 30 mL of potassium chloride 20 mEq/15 mL for Resident 22 and poured it into a medication cup without diluting it. When the medication was later observed being taken, the resident had difficulty taking the solution directly from the cup and displayed an unpleasant facial expression while sipping the medication. The resident's medication label and physician order both directed that 40 mEq of potassium chloride oral solution be given by mouth once daily and diluted with 4 oz (120 mL) of water before administration. During interview, the LVN stated she did not dilute the potassium chloride before giving it and acknowledged that it should be diluted because of the taste. The DON stated nurses should follow physician order directions and later stated that taking potassium chloride oral solution without diluting it first could cause stomach irritation. The facility policy stated medications are to be administered in a safe and timely manner, and as prescribed.
Failure to Provide Timely Dental Referral and Follow Up on Dental X-Rays
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for one resident with intact cognition and the capacity to understand and make decisions. The resident was admitted with diagnoses including MI, angina pectoris, HF, and hyperlipidemia, and the MDS indicated set-up or clean-up assistance with oral hygiene and eating, along with obvious or likely cavity or broken natural teeth. The resident’s order summary included a dental consult and follow treatment as needed, and the care plan identified broken natural teeth and risk for oral pain/discomfort, with a goal that the resident would not exhibit mouth pain and interventions for dental consultation and evaluation as needed. The resident’s record showed a history of toothache to the left upper side, and an onsite mobile dental note documented broken teeth in the upper and lower mouth, mostly broken teeth, low oral hygiene, high plaque, and tartar, with recommendations for extractions and dental x-rays for treatment recommendations. The dental note also documented orders for Amoxiclavunate and Ibuprofen, and the physician order summary later listed Amoxicillin-Pot Clavunate and Ibuprofen for tooth infection and pain. On observation, the resident grimaced and pointed to the left upper side of the face and stated having a toothache rated 9 out of 10. The MAR showed Ibuprofen was given for severe pain on 11/18/2025 and again on 11/19/2025.
Failure to Provide Ordered Fortified Meal
Penalty
Summary
The facility failed to ensure that Resident 3’s lunch meal was prepared in the fortified form ordered by the physician. Resident 3 was admitted and later readmitted with diagnoses including encephalopathy, muscle weakness, dysphagia, type 2 DM, and unspecified protein-calorie malnutrition. The quarterly MDS dated 11/15/2025 indicated moderate cognitive impairment, need for supervision or touching assistance with eating, dependence on staff for toileting, showering, dressing, and footwear, and partial to moderate assistance with oral and personal hygiene. Resident 3’s care plan, revised on 11/13/2025, identified a nutritional problem and dehydration risk related to advancing age, mechanically altered diet, and therapeutic diet, with interventions including a fortified 4-pureed texture, mildly thick consistency diet and use of a plate guard. The order summary dated 11/19/2025 showed an order for a fortified diet, 4-pureed texture, mildly thick consistency, with an inner lip plate. During observation on 11/19/2025 at 12:30 p.m., the lunch tray in Resident 3’s room had no sauce, gravy, or margarine. A dietary aide stated she was responsible for announcing the fortified diet to the cook but did not read the diet out loud, and said she should have read the meal card carefully and told the cook the diet was fortified. The dietary manager stated fortified diets were ordered for residents who were losing weight to help them gain weight, and the DON stated fortification adds calories to the diet.
Failure to Follow Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol for one sampled resident, who was admitted with dementia and diabetes mellitus and had moderately impaired cognition and dependence with activities of daily living. On 11/6/2025, a progress note documented that the resident did not have sediment, hematuria, pain, or foul-smelling urine. Later that day, an order was entered for Nitrofurantoin, 100 mg twice daily for 10 days. During interview and record review, the Infection Prevention Nurse stated there was no documentation showing whether the resident had a urine infection or a urine culture before the antibiotic was started. The IPN stated she missed this case and that screening residents before starting antibiotic therapy is important to prevent antibiotic resistance and killing good bacteria. The DON stated the IPN should have done a time-out when the antibiotic was prescribed and that the resident did not have symptoms of a UTI, making the antibiotic unnecessary.
Cluttered Therapy Mat in Rehab Gym
Penalty
Summary
The facility failed to ensure that the therapy mat in the Rehabilitation Gym was maintained in a clean and unobstructed condition. During an observation on 9/30/2025 at 4:10 p.m., the therapy mat was seen cluttered with four cardboard boxes, a blue cushion pad, two inflatable balls, a large paper towel roll, a large bag containing splints, two leg splints, a wooden device with plastic rings, folded linen, a personal carrying bag, a cell phone, eyeglasses, and an eyeglass case. During a concurrent observation and interview on 9/30/2025 at 4:30 p.m., the DOR confirmed the items were on the therapy mat and stated the mat was used for residents to work on transfers, sitting balance, and various exercises. The DOR stated the miscellaneous items limited the amount of usable space for residents during therapy sessions and said the items should be stored in their designated areas and not on the therapy mat for resident safety and to ensure the equipment was clear and accessible for resident use. The DON later stated all therapy equipment should be accessible for resident use and that the therapy mat should always be clear and free of clutter to prevent accidents and to ensure residents could access the equipment during therapy. The facility policy titled, Rehab Space Requirements, stated rehabilitation services would be provided in a safe and suitable environment that encouraged resident participation and enabled the treating clinician to address the modalities listed on the plan of care.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that 24 resident rooms met the required 80 square feet per resident in multibed rooms. During an initial tour, 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 observed and found not to meet the square footage requirement. The report also states that some of these rooms were occupied by three residents per room. During later observation, residents were seen in their rooms and able to move freely, and nurses were able to perform patient care, with the room size not affecting resident privacy according to the observation. The Administrator stated that a letter was sent out every year to ensure the California Department of Public Health was aware of the room sizes, and stated there were no resident concerns about room size and that the facility could accommodate residents' needs, provide care, and perform environmental cleaning daily. The facility's policy titled Bedrooms stated that double rooms must measure at least 80 square feet per resident and single rooms at least 100 square feet.
Cockroach Infestation Observed in Kitchen Dry Storage Area
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by the observation of cockroaches in the dry food storage area. During an inspection, surveyors observed medium-sized dark brown cockroaches running out of a box of white powdered thickener and a box of individually packaged crackers, both located in the kitchen's dry storage area. The thickener was found inside an open plastic bag, which the Dietary Supervisor acknowledged should have been closed to prevent pest entry. Staff interviews revealed that a dietary aide had noticed small roaches in the dry storage area about a month prior and reported this to the supervisor, resulting in pest control treatments. However, the Dietary Supervisor stated she had not been informed of any cockroach sightings in the kitchen and had not seen any herself. Review of pest control invoices indicated that pest control treatments had been conducted in a resident's room for roaches on multiple occasions in the preceding months. The resident confirmed seeing large roaches in his room about a month earlier but had not seen any since. The Director of Nursing reported being unaware of any roach issues in the building until the environmental health department identified the problem during their visit. The facility's policy indicated an ongoing pest control program was in place to keep the building free from insects and rodents.
Failure to Provide Activities of Choice for Residents
Penalty
Summary
The facility failed to provide activities of choice for two residents, which could negatively impact their quality of life. Resident 4, who has severe cognitive impairment and requires assistance for all activities of daily living, was observed sleeping in bed during multiple observations. Despite having a care plan that included independent activities such as watching television, listening to music, and socializing, there was no documentation of these activities being provided. Similarly, Resident 19, with moderate cognitive impairment and a preference for independent activities like listening to television in the lobby, was also observed sleeping in bed during several observations. Resident 19 expressed a desire to socialize in the activity room, but this was not offered in recent days. Interviews with facility staff, including an LVN and the Activity Director, confirmed that there was no documentation of activities provided to Residents 4 and 19 from 9/25/2024 through 9/30/2024. The Activity Director acknowledged that the lack of activities according to the care plan could affect the residents' psychosocial well-being, including their mental health. The facility's policy on activity programs, revised in 2018, emphasizes the importance of activities in supporting residents' physical, mental, and psychosocial well-being, yet this was not adhered to in the cases of Residents 4 and 19.
Failure to Validate Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's advance directive was properly witnessed, which is a legal requirement for its validity. Resident 25, who had chronic kidney disease, COPD, and type 2 diabetes, had an advance directive dated 2/5/2023 that lacked the necessary witness signatures. This oversight was discovered during a review of the resident's records, which indicated that the advance directive was not valid without the signatures of two witnesses. The Social Services Director confirmed that the absence of a witness signature rendered the advance directive invalid, meaning the resident's healthcare wishes might not be honored. The resident's Minimum Data Set (MDS) and History and Physical (H&P) assessments indicated that the resident had the capacity to make medical decisions and could communicate effectively. Despite this, the facility's failure to ensure the advance directive was properly completed could lead to conflicts in honoring the resident's healthcare decisions. The Director of Nursing acknowledged that without a valid advance directive, the resident's healthcare decisions might not be respected. The facility's policy on advance directives, revised in 2016, states that such directives will be respected in accordance with state law and facility policy, highlighting the importance of proper documentation.
Inadequate Safety Precautions for Residents at Risk of Falls
Penalty
Summary
The facility failed to provide appropriate safety precautions for two residents at risk for falls and seizures. Resident 246, who was on fall risk precaution, had a metal bedside table placed on top of the floor mat intended to cushion falls. This placement posed a risk of injury if the resident were to fall out of bed and hit their head on the metal table. The resident had severe cognitive impairment and was admitted with conditions including muscle weakness and a pelvic fracture. Similarly, Resident 4, who was on fall and seizure precautions, had a wheelchair placed on top of the floor mat by the bed. This arrangement also posed a risk of injury if the resident were to fall and hit their head on the wheelchair. Resident 4 had severe cognitive impairment and required assistance for all activities of daily living, with diagnoses including cardiomyopathy, depression, atrial fibrillation, and epilepsy. Observations and interviews with staff confirmed that these items should not have been placed on the floor mats, as they were intended to prevent injuries from falls.
Failure to Assess and Manage Pain During Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 246, during wound care treatment. Resident 246, who was admitted with diagnoses including muscle weakness, lack of coordination, and a pelvic fracture, also had severe cognitive impairment. The resident had a physician order to monitor for pain before, during, and after treatment of a self-inflicted skin tear on the right knee. However, during an observation, it was noted that the resident complained of pain during the wound care treatment, and the Licensed Vocational Nurse (LVN) attending to the resident was unaware of the need for a pain assessment or the absence of a pain medication order. The LVN admitted to not assessing the resident's pain level prior to the treatment and acknowledged the lack of a physician order for pain medication. The facility's policy, titled Treatment Nurse Competency, required pain to be assessed before, during, and after treatment, but this was not adhered to in the case of Resident 246. This oversight had the potential to cause unrelieved pain for the resident during the wound care procedure.
Failure to Clarify Medication Order and Ensure Availability
Penalty
Summary
The facility failed to clarify a physician's order for Combivent, a medication used to treat COPD, for one resident. The order did not specify the frequency of administration, which is crucial for ensuring the medication is used safely and effectively. The Licensed Vocational Nurse (LVN) acknowledged the absence of frequency in the order and admitted that this could lead to either overdosing or underdosing the medication. The Director of Nurses (DON) confirmed that the order was incomplete and should have been clarified with the physician. Additionally, the facility did not ensure the availability of Combivent as ordered by the prescriber. The LVN could not confirm if the medication was in stock, and the Medication Administration Record (MAR) showed no documentation of Combivent being administered. The resident involved did not recall receiving the medication and relied on a CPAP machine for breathing assistance. The DON stated that the resident had not been pharmacologically treated for COPD due to the lack of medication administration. The facility's policy and procedure for medication orders require specifying the type, route, dosage, frequency, strength, and reason for administration, which was not followed in this case. The failure to clarify the medication order and ensure its availability could have led to adverse effects for the resident, although the report does not specify any such outcomes.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that 21 out of 25 resident rooms met the required 80 square feet per resident in multi-bed rooms. During an initial tour, it was observed that rooms were occupied by two, three, or four residents, with total square footage ranging from 139.43 to 148.19 square feet, which is below the required space per resident. The Director of Nursing acknowledged the small size of the rooms and mentioned that the facility submits a room waiver every year during the recertification survey. The Room Waiver letter, dated 9/16/2024, indicated that the rooms had enough space to provide for each resident's care, dignity, and privacy, and that the lack of space did not adversely affect residents' health, safety, or well-being. Observations from 9/30/24 through 10/3/24 showed that residents had enough space to move freely, with adequate room for wheelchairs, walkers, or canes, and that room size did not affect the nursing care or privacy provided to the residents.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician of a change in condition, specifically loose and watery stools, for five consecutive days. This oversight involved Licensed Vocational Nurses (LVN) 1 and 2, who did not inform the physician as required by the facility's policy and procedure on changes in a resident's condition. The resident, who had a history of hypernatremia, hypertensive heart disease, chronic kidney disease, heart failure, hemiplegia, and hemiparesis, was receiving Cefuroxime Axetil for a urinary tract infection. The medication administration record confirmed the resident received this antibiotic from June 14 to June 20, 2024. The resident's care plan, which aimed to monitor bowel movements due to a risk of constipation, was not implemented effectively. The bowel and elimination form documented multiple episodes of large loose stools from July 1 to July 5, 2024, but there was no record of the nursing staff monitoring the stool or notifying the physician. This lack of communication and monitoring led to a delay in addressing the resident's deteriorating condition, which eventually required emergency medical intervention. On July 6, 2024, the resident was found lethargic, with abnormal vital signs, and was transferred to a General Acute Care Hospital. The resident was diagnosed with septic shock and underwent several emergency surgical procedures due to fulminant Clostridioides difficile colitis. Interviews with staff revealed that the certified nursing assistant had reported the loose stools to a charge nurse, but the information was not relayed to the LVNs or the physician. The Director of Nursing acknowledged the failure in communication and the potential consequences of not addressing the resident's symptoms promptly.
Failure to Secure Exit Doors Leads to Resident Elopement
Penalty
Summary
The facility failed to secure two exit doors, leading to the elopement of a resident with a history of elopement and high risk for such behavior. The resident, who had been admitted with diagnoses including paranoid schizophrenia, type 2 diabetes, and hypertension, was found to have severe cognitive impairment and required assistance with daily activities. Despite being assessed as high risk for elopement, the resident managed to leave the facility undetected, as the wander guard was found stretched and damaged on the floor. Observations and interviews revealed that the facility's exit doors were not properly secured. Door 1's alarm was deactivated, and Door 2 had unsecure latches that could be opened without a key or code. Additionally, the alarm codes were visibly labeled, allowing anyone to disarm them. These security lapses allowed the resident to exit the facility without triggering any alarms, leading to the resident being without necessary medications for ten days. The resident was eventually found wandering the streets and was taken to a general acute care hospital, where they were diagnosed with acute psychosis and severe anemia, requiring a blood transfusion. The facility's policies indicated that safety strategies should be implemented to protect residents, but these were not effectively executed, resulting in the resident's elopement and subsequent medical complications.
Resident Elopement Due to Inadequate Monitoring and Security
Penalty
Summary
The facility failed to implement a care plan for a resident, leading to the resident's elopement. The resident, who was admitted with diagnoses including paranoid schizophrenia, type 2 diabetes, and hypertension, was identified as high risk for elopement due to cognitive impairment and a history of wandering. Despite having a care plan in place that included the use of a wander guard and regular monitoring, the facility did not ensure these measures were effectively implemented. On the night of the incident, the resident was last seen in their room watching television. However, shortly after, the resident was discovered missing, and their wander guard was found stretched and damaged on the floor. The facility's doors were unsecured, allowing the resident to exit undetected. The resident was without their medication, including olanzapine for schizophrenia, for ten days until they were found wandering the streets and brought to a general acute care hospital. The resident was admitted to the hospital with acute psychosis, severe anemia, and required a blood transfusion. The facility's failure to secure the doors and adequately monitor the resident, despite their known high risk for elopement, directly contributed to the resident's elopement and subsequent medical complications.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to implement the care plan for a resident, who was at high risk for elopement due to severe cognitive impairment and a history of wandering. The resident was supposed to wear a Wander guard, a device designed to alert staff if the resident attempted to leave the facility unassisted. However, the Wander guard was found stretched and damaged on the floor, indicating it was not properly secured or monitored. This lapse in supervision allowed the resident to elope from the facility undetected. The resident, who had diagnoses including paranoid schizophrenia, type 2 diabetes, and hypertension, was without his necessary medications, including olanzapine for schizophrenia, for ten days. During this period, the resident was found wandering the streets and was subsequently admitted to a general acute care hospital with acute psychosis, severe anemia, and required a blood transfusion. The psychiatric evaluation at the hospital noted the resident was agitated and aggressive, necessitating continuous supervision and a 72-hour involuntary hold for stabilization. Interviews and record reviews revealed that the facility's doors were not secure, and there was inadequate monitoring of residents at high risk for elopement. The resident's room was located near an unsecured exit door that did not alarm when opened, allowing the resident to leave unnoticed. Staff interviews confirmed that the resident's Wander guard was not checked as required, and the facility's policy for monitoring high-risk residents was not followed, contributing to the resident's elopement and subsequent medical complications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gardena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kei-ai South Bay Healthcare Center | 1.1 mi | ★★★★★ | 16 | 0 |
| Gardena Convalescent Center | 1.2 mi | ★★★★★ | 16 | 0 |
| Clear View Convalescent Center | 1.2 mi | ★★★★★ | 4 | 0 |
| Clear View Sanitarium | 1.2 mi | ★★★★★ | 10 | 0 |
| Memorial Hospital Of Gardena D/p Snf | 1.4 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.