West Hills Health and Rehab: Missed Medications - CA
Resident 1 arrived at the facility on August 2, 2025, around 3:00 p.m. That evening, the resident did not receive doxycycline monohydrate, mirtazapine, or atorvastatin. The following morning, omeprazole was also skipped.
The nurse who handled the admission, Licensed Vocational Nurse 1, told inspectors she checked the facility's emergency kit, a pre-packaged set of medications kept on-site for immediate use. None of Resident 1's medications were in it. The outside pharmacy hadn't delivered yet. LVN 1 said deliveries can take a full eight-hour shift.
She did not call the prescribing physician to report the missed doses. She said it was a very busy shift.
West Hills does not have an in-house pharmacy. Every medication for every resident depends on an outside vendor making a delivery. The Registered Nurse Supervisor told inspectors the pharmacy runs only two deliveries during the evening and overnight hours combined, one at midnight and one at 5:00 a.m. She said medications should arrive within six hours of the pharmacy receiving an order, but acknowledged the wait can stretch to six hours or more.
The Director of Nursing put the window even wider. She told inspectors that newly admitted residents should expect their medications to arrive somewhere between six and twenty-four hours after the pharmacy gets the order. She said it is impossible to administer medications immediately unless they happen to be stocked in the emergency kit.
Then she said it was not the facility's fault. Newly admitted residents, she told inspectors, should be given their evening doses at the hospital before being transferred.
The facility's own pharmacy contract, signed in April 2023, says otherwise. The contract states that if the pharmacy cannot deliver a medication on a prompt and timely basis, it must arrange for another local pharmacy to fill the gap. That arrangement was not made for Resident 1.
The facility's internal medication policy, reviewed by inspectors and last updated in January 2025, states that medications are to be administered within one hour of their prescribed time unless a prescriber specifies otherwise.
The gap between that policy and what happened to Resident 1 is what the inspection documents. Four medications. More than twenty-four hours. No physician notification. No documented attempt to source the drugs from an alternate pharmacy. A nurse who knew she should have called and didn't.
The Director of Nursing's explanation, that hospitals should send patients out the door already medicated, shifts the burden entirely off the facility and onto a discharge process the facility does not control. It also does not account for the omeprazole missed the following morning, August 3rd, by which point any gap in hospital discharge planning was no longer the issue.
The inspection was triggered by a complaint. Inspectors rated the harm level as minimal or potential for actual harm, and noted that few residents were affected. The citation covers a narrow set of facts about one admission on one afternoon. But the structural problem it reveals is not narrow: a facility that admits residents in the afternoon, runs two overnight pharmacy deliveries, and has no backup plan when the emergency kit comes up empty.
LVN 1 knew what she was supposed to do. She said so herself. She should have called the physician. She should have documented the call. She did neither, and Resident 1's medications went unaddressed through the night and into the following day.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 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.
Resident 1 arrived at the facility on August 2, 2025, 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.