West Hills Health and Rehabilitation Center received an immediate jeopardy citation after federal inspectors discovered the facility had secretly arranged the August 8 discharge without involving the resident in any planning process.
The resident told inspectors on August 26 that no one asked him where he wanted to go after his stay at the facility. He said he was unaware he had any choice or input in the matter and that he trusted the facility to make decisions on his behalf.
"I was not involved in any discharge planning," the resident stated during the interview.
The facility's discharge summary shows the resident was discharged to the board and care facility at 2:20 p.m. on August 8. Eleven days later, he was transferred to a hospital with hyperkalemia — elevated potassium levels that can cause dangerous heart rhythm problems.
Laboratory results from August 19 at 7:13 p.m. showed his potassium level had reached 5.8 mEq/L, well above the normal range. Hospital notes indicated the resident appeared weak and required transfer to a skilled nursing facility for continued care.
The resident does not clearly remember being discharged to the board and care facility but recalls being taken to the hospital. He said hospital staff informed him he could not return to the unlicensed facility where he had been placed.
Hospital discharge planning notes from August 19 confirmed that the resident was transferred from an unlicensed board and care facility and noted that he "cannot return to the board and care facility due to its unlicensed status."
When inspectors interviewed the facility's social services assistant on August 26, she revealed a complete breakdown in discharge planning protocols. She stated there were no discharge planning notes found in the resident's medical record from July 11 through August 8.
The social services assistant said she found no documented evidence indicating who arranged the resident's transfer to the unlicensed facility. She stated there should have been documentation reflecting coordination between West Hills Health and the board and care facility.
More troubling, the social services assistant was not aware of the resident's discharge until after he had already been transferred. She only learned about it on August 12 when she was asked to make a follow-up call.
She attempted several follow-up calls to the resident on August 12 but kept getting a busy signal and was unable to speak with him. The social services assistant stated she was not informed of the discharge plan and was not involved in the resident's discharge process at any point.
"I don't know who coordinated the discharge," she told inspectors.
The inspection report cuts off mid-sentence while the social services assistant was explaining her lack of involvement in the discharge process, suggesting additional violations may have been documented.
Federal regulations require nursing homes to involve residents in discharge planning and ensure they are transferred to appropriate, licensed facilities. The immediate jeopardy citation indicates inspectors determined the facility's actions posed an immediate threat to resident health and safety.
The case illustrates how discharge planning failures can cascade into serious medical consequences. The resident's elevated potassium levels required immediate medical intervention, and his placement at an unlicensed facility left him without appropriate care options.
Following his hospital stay, the resident was transferred back to West Hills Health, completing a dangerous circle that began with the facility's undocumented discharge decision.
The facility's inability to explain who arranged the discharge or why the resident was not involved in planning suggests systemic problems with discharge procedures that could affect other residents.
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 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
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