West Gardena Post Acute
16530 S Broadway Street, Gardena, CA 90248 · Los Angeles County · 50 certified beds · avg 45 residents/day · certified since Oct 1, 1989
Part of chain: ABRAHAM BAK & MENACHEM GASTWIRTH (18 facilities, chain avg rating 2.5★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 29, 2024 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 28, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 26, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 17, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (39)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Nov 20, 2025 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide routine dental care and 24-hour emergency dental care for residents. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide enough space and equipment to meet each resident's needs. |
| Nov 20, 2025 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Jul 15, 2025 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Oct 3, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 3, 2024 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Jul 29, 2024 | ▲ G · Actual harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jul 5, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jul 5, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Jul 5, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 22, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Mar 22, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 26, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 1, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 1, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Oct 1, 2023 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Oct 1, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Oct 1, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 1, 2023 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 19).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 1 | G ▲ |
| 2024 | 12 | 1 | G ▲ |
| 2025 | 20 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $43,004.
| Date | Type | Amount / length |
|---|---|---|
| Jul 5, 2024 | Fine | $34,660 |
| Oct 1, 2023 | Fine | $8,344 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.14 | 4.31 | 3.95 | top 49% in California; top 34% in the U.S. |
| Registered Nurse hours | 0.31 | 0.61 | 0.69 | bottom 13% in California; bottom 10% in the U.S. |
| Weekend total nurse staffing | 3.61 | 3.90 | 3.50 | bottom 40% in California; top 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.27 | 0.51 | 0.48 | bottom 27% in California; bottom 26% in the U.S. |
| Total nursing staff turnover (%) | 43.5 | 36.7 | 45.8 | bottom 29% in California; top 46% in the U.S. |
| RN turnover (%) | 0.0 | 38.1 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.60, RN 0.34, weekend 4.01. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Lehmann, Kenneth | Individual | 5% or Greater Direct Ownership Interest | 32% | 11/01/2019 |
| 16530 South Broadway Street,llc | Organization | ADP of the SNF | NOT APPLICABLE | 09/06/2019 |
| Abak Consulting LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/27/2021 |
| Abe and Rachel Bak Family Trust | Organization | ADP of the SNF | NOT APPLICABLE | 11/10/2021 |
| Bagz Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/10/2021 |
| Bak, Abraham | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/06/2019 |
| Bak, Abraham | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/07/2019 |
| Bak, Abraham | Individual | Trustee of the SNF | NOT APPLICABLE | 01/13/2016 |
| Bak, Abraham | Individual | ADP of the SNF | NOT APPLICABLE | 09/06/2019 |
| Bak, Juda | Individual | ADP of the SNF | NOT APPLICABLE | 09/06/2019 |
| Bak, Rachel | Individual | Trustee of the SNF | NOT APPLICABLE | 01/13/2016 |
| Bak, Rachel | Individual | ADP of the SNF | NOT APPLICABLE | 09/06/2019 |
| Gastwirth, Henry | Individual | ADP of the SNF | NOT APPLICABLE | 09/06/2019 |
| Gastwirth, Menachem | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/19/2020 |
| Gastwirth, Menachem | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/07/2019 |
| Gastwirth, Menachem | Individual | ADP of the SNF | NOT APPLICABLE | 09/06/2019 |
| Gewirtz, Chonoch | Individual | ADP of the SNF | NOT APPLICABLE | 10/07/2019 |
| Lehmann, Kenneth | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/07/2019 |
| Lehmann, Kenneth | Individual | ADP of the SNF | NOT APPLICABLE | 09/06/2019 |
| Mgaz Consulting LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/27/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you explain health changes and treatment options to residents and their families?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Kei-Ai South Bay Healthcare Center | 1.1 mi | Gardena, CA | ★★★☆☆ | 3/5 | |
| Gardena Convalescent Center | 1.2 mi | Gardena, CA | ★★★☆☆ | 3/5 | |
| Clear View Convalescent Center | 1.2 mi | Gardena, CA | ★★★★★ | 5/5 | |
| Clear View Sanitarium | 1.2 mi | Gardena, CA | ★★★★★ | 5/5 | |
| Memorial Hospital of Gardena D/P SNF | 1.4 mi | Gardena, CA | ★★★★☆ | 4/5 | |
| Rosecrans Care Center | 1.5 mi | Gardena, CA | ★★☆☆☆ | 2/5 | |
| View Heights Conv Hosp | 2.6 mi | Los Angeles, CA | ★★☆☆☆ | 1/5 | |
| Las Flores Convalescent Hospital | 2.7 mi | Gardena, CA | ★☆☆☆☆ | 1/5 | |
| Avalon Villa Care Center | 2.9 mi | Los Angeles, CA | ★☆☆☆☆ | 1/5 | SFF |
| Camino Healthcare | 3.3 mi | Hawthorne, CA | ★★☆☆☆ | 2/5 | |
| Heritage Rehabilitation Center | 3.3 mi | Torrance, CA | ★★☆☆☆ | 1/5 | |
| Harbor Post Acute Care Center | 3.4 mi | Torrance, CA | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 555410.