West Hills Health: Missed Medications for New Admits - CA
Resident 1 missed doses of doxycycline monohydrate, mirtazapine, and atorvastatin on August 2nd and omeprazole on August 3rd at West Hills Health and Rehabilitation Center. The resident had been admitted around 3:00 p.m. on August 2nd.
Licensed Vocational Nurse 1 told inspectors he searched through the facility's emergency medication kit but none of the resident's prescribed drugs were available. The nurse acknowledged he should have called the resident's physician to report the missed medications but said he didn't because "it was a very busy shift."
West Hills relies entirely on an outside pharmacy for medication deliveries. The facility has no in-house pharmacy, forcing nursing staff to wait for deliveries that Licensed Vocational Nurse 1 said "can take a whole shift" of eight hours.
The Registered Nurse Supervisor explained the pharmacy makes only two deliveries during evening and night shifts, at midnight and 5:00 a.m. She said medications should arrive within six hours of the pharmacy receiving orders, but acknowledged deliveries "can take six hours or more."
Director of Nursing took a different stance during her interview with inspectors. She said medication orders should be delivered within 6 to 24 hours and claimed "it is impossible for the facility to administer medications right away unless the medications ordered are in the e-kit."
The Director of Nursing shifted responsibility elsewhere. She told inspectors newly admitted residents "should be given their evening doses of medication before being transferred from the hospital to the facility" and stated "it is not the facility's fault that residents are not given their medications as a new admit resident."
Federal inspectors found this violated the facility's own medication policy. West Hills' written procedures require medications be administered "in a safe and timely manner, and as prescribed" within one hour of their scheduled time "unless otherwise specified."
The facility's pharmacy contract, dated April 2023, specifically addresses delivery delays. The agreement states that when the pharmacy "cannot deliver an ordered medication on a prompt and timely basis," it must arrange with another local pharmacy to provide the service.
But none of these backup systems functioned when Resident 1 arrived needing multiple daily medications.
The missed medications included doxycycline monohydrate, an antibiotic used to treat bacterial infections that can become serious without consistent dosing. Mirtazapine is an antidepressant that requires steady levels in the bloodstream to remain effective. Atorvastatin manages cholesterol levels, and omeprazole reduces stomach acid production.
Licensed Vocational Nurse 1 admitted during his interview that facility policy requires notifying physicians about missed medication doses so nurses can receive new orders if needed. The Medical Director of Staff Nursing confirmed this requirement but noted the nurse failed to make the required physician notification.
The inspection revealed a systemic problem beyond one busy shift. With pharmacy deliveries limited to twice per night and no in-house alternatives, newly admitted residents routinely face medication gaps lasting hours or even days.
West Hills' emergency medication kit apparently contains only common medications, not the specific prescriptions individual residents require. When residents arrive with unique medication regimens, nursing staff have no immediate options.
The facility's leadership appeared to view the situation as unavoidable. The Director of Nursing's comment that hospitals should provide evening medications before transfer suggests West Hills expects other facilities to compensate for its delivery limitations.
Federal regulations require nursing homes to ensure residents receive medications as prescribed by their physicians. The inspection found West Hills failed this basic requirement during Resident 1's first days of care, when establishing medication routines is most critical.
The violation received a "minimal harm" classification affecting "few" residents, but inspectors documented a clear breakdown in the facility's medication management system. Licensed Vocational Nurse 1's admission that he should have called the physician but didn't due to workload pressures suggests the problem extends beyond pharmacy logistics to staffing and prioritization issues.
Resident 1's experience illustrates how administrative convenience can override patient care. While West Hills blamed external pharmacy schedules and hospital discharge practices, the resident went without prescribed medications because no one at the facility took responsibility for ensuring continuity of care during the admission process.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Hills Health and Rehabilitation Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WEST HILLS HEALTH AND REHABILITATION CENTER in CANOGA PARK, CA was cited for violations during a health inspection on August 14, 2025.
The resident had been admitted around 3:00 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.