Health inspection·July 15, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings: During an observation on 7/11/2025, at 2:19 p.m., of the facility's dry food storage area in their kitchen, in the presence of the Dietary Services Supervisor (DSS), a medium sized dark brown cockroach was seen running out of a box of white powdered thickener that was inside an open plastic bag. During an observation on 7/11/2025, at 2:26 p.m., of the facility's dry food storage area in their kitchen, in the presence of the Dietary Services Supervisor (DSS), a medium sized dark brown cockroach was seen running out of a box of individually packaged crackers. During a review of the facility pest control invoice dated 5/12/2025, the invoice indicated the facility treated Resident 1's room for roaches. During a review of facility pest control invoice dated 5/20/2025, the invoice indicated the facility treated Resident 1's room for American roaches (water bugs). During a review of facility pest control invoice dated 5/28/2025, the invoice indicated the facility treated Resident 1's room for American roaches. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of heart failure ([CHF] a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's History and Physical (H&P), dated 6/4/2025, the H&P indicated Resident 1 had capacity to understand and make decisions. During an interview on 7/11/2025 at 2:38 p.m., the Dietary Supervisor (DS) stated the thicker plastic bag should have been closed as part of their infection control practices and so bugs do not get inside. During an interview on 7/11/2025 at 2:40 p.m., the Dietary Aide (DA) 1 stated approximately one month ago, she noticed a few small roaches on a few different occasions in the dry storage area and informed the DS to tell pest control. DA 1 stated pest control came twice in the past month to treat the area. During an interview on 7/11/2025 at 2:44 p.m., the DS stated she had not been informed by anyone that cockroaches were seen in the kitchen, and she had not seen any herself. During an interview on 7/15/2025 at 10:02 a.m., Resident 1 stated approximately one month ago he saw two big roaches in his room but stated he has not seen any since then. During an interview on 7/11/2025 at 12 p.m., the Director of Nursing (DON) stated she had worked at the facility for three years and was not aware there were roaches in the building. The DON stated she found out today (7/11/2025) there were roaches found in the kitchen when the environmental health department came to the facility at approximately 12 p.m. and pointed them out to the DSS. The DON stated the environmental health department staff used a flash light, tapped firmly on a wood shelf in the kitchen and two roaches measuring about one and a half inches came out During review Residents Affected - Some (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555410 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Gardena Post Acute 16530 S Broadway Street Gardena, CA 90248 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)