West Hills Health and Rehabilitation Center admitted Resident 2 on August 15, 2025, and readmitted them on September 19 with diagnoses including cerebral palsy, Arnold-Chiari Syndrome, and difficulty swallowing. But the facility's original screening form indicated the resident had no primary diagnosis of cerebral palsy.
The error went uncorrected for weeks.
Resident 2 has severe cognitive impairment and cannot make decisions, according to physician notes from August 19. The resident depends entirely on staff for toileting, bathing, dressing, personal hygiene, and movement.
Cerebral palsy affects movement, muscle tone, and coordination due to brain damage before or during birth. The resident also has Arnold-Chiari Syndrome, a structural skull abnormality that causes part of the brain to move into the spinal canal.
The Level 1 PASARR screening dated August 13 failed to list cerebral palsy as a primary diagnosis, despite admission records clearly identifying it as the principal admitting diagnosis. PASARR screenings help ensure people with mental disorders or intellectual disabilities aren't inappropriately placed in nursing homes for long-term care.
Director of Nursing acknowledged the mistake during an interview with inspectors on September 30.
"Resident 2's Level 1 PASARR dated 8/13/2025 indicated Resident 2 had no primary diagnosis of cerebral palsy and was an error," she told inspectors. "The facility should have submitted a new corrected Level 1 PASARR for Resident 2 reflecting the primary diagnosis of cerebral palsy."
The Director of Nursing said she was responsible for overseeing PASARR screenings. She explained that the evaluation determines appropriate placement and whether specialized services are needed.
But the facility never submitted the corrected screening.
The facility's own policy requires submitting a new Level 1 PASARR "if there is any error/discrepancy in the previous PASARR screening." The policy, last reviewed in January 2025, states the screening ensures residents with serious mental illness or intellectual and developmental disabilities receive appropriate settings and any needed specialized or rehabilitative services.
Federal inspectors found the deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 2.
The screening error persisted from the original August 13 assessment through the resident's readmission on September 19. Even after readmission with cerebral palsy clearly documented as the principal diagnosis, staff failed to correct the screening form.
Resident 2's complex medical needs include the Arnold-Chiari Syndrome without spina bifida or hydrocephalus. Spina bifida occurs when the spine and spinal cord don't form properly, while hydrocephalus involves fluid accumulation in the brain that can cause enlargement and damage.
The resident's dysphagia, or difficulty swallowing, adds another layer of care complexity requiring specialized attention.
PASARR screenings serve as a critical safeguard against inappropriate nursing home placements. The assessments help identify when individuals might be better served in different settings or need additional specialized services within the facility.
The Director of Nursing's admission that the facility "should have submitted" a corrected screening highlights awareness of the requirement. Yet no corrected form was filed despite clear documentation of the error and the resident's actual diagnoses.
Inspectors reviewed admission records, physician progress notes, the Minimum Data Set assessment, and the original PASARR screening to document the discrepancy. The evidence showed a clear pattern: cerebral palsy was consistently identified in medical records but omitted from the screening that determines placement appropriateness.
The facility's failure to correct the screening potentially affected not just Resident 2's placement determination but also identification of specialized services they might need. With severe cognitive impairment and complete dependence on staff for basic activities, proper screening becomes even more critical for ensuring appropriate care.
Federal regulations require nursing homes to conduct accurate PASARR screenings to prevent inappropriate placements and ensure residents receive necessary specialized services. The West Hills facility acknowledged its error but took no action to fix it, leaving Resident 2 with an inaccurate assessment that could affect their long-term care planning.
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 2025-10-01 including all violations, facility responses, and corrective action plans.
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