West Hills Health And Rehabilitation Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on observation, interview, and record review the facility failed to ensure staff were not standing over

a resident while assisting with feeding for one of three sampled residents (Resident 3).This deficient practice had the potential to affect the resident's self-esteem, self-worth, and sense of independence.

During a review of Resident 3's admission Record, the admission Record indicated the facility readmitted

the resident on 7/25/2024 with diagnoses including anoxic brain damage (when the brain is deprived of oxygen entirely, leading to the death of brain cells and potential permanent damage after just a few minutes), epileptic seizure (a sudden, abnormal surge of electrical activity in the brain that can cause temporary changes in movement, behavior, sensations, or awareness), and dysphagia, oral phase (difficulty swallowing that originates in the mouth).During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 5/27/2025, the MDS indicated Resident 3's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 3 was dependent on staff with eating, oral hygiene, toileting hygiene, shower/bath self, and personal hygiene.During a meal observation on 8/14/2025 at 1:45 p.m., in Resident 3's room, observed Certified Nursing Assistant 1 (CNA 1) assisting Resident 3 with feeding and standing over and hovering over Resident 3.During an interview on 8/14/2025 at 1:49 p.m., with CNA 1, CNA 1 stated that she (CNA 1) was standing while assisting Resident 3 with lunch because she could not find a chair to sit on. CNA 1 continued to state that she knows she is supposed to sit down on a chair while assisting residents with feeding, however she was unable to find a chair to sit on.During an interview on 8/14/2025 at 3:05 p.m., with the Director of Staff Development (DSD), the DSD stated that staff should be sitting at eye level while assisting with feeding. The DSD stated staff should be sitting at eye level for residents' dignity and respect. The DSD continued to state that staff should be sitting down so that residents will not feel intimidated while being assisted with feeding.During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, review date 1/8/2025, the P&P indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals.During a review of the facility's P&P titled, Dignity, review date 1/8/2025, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Hills Health and Rehabilitation Center

7940 Topanga Canyon Blvd.

Canoga Park, CA 91304

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to state that if medications are not administered, residents' physicians should be made aware of the missed medication dose so that licensed nurses can receive new orders for a missed medication dose if needed.

The MDSN stated that Resident 1's doxycycline monohydrate, mirtazapine, atorvastatin were not administered on 8/2/2025 and omeprazole was not administered on 8/3/2025. During an interview on 8/14/2025 at 3:32 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that LVN 1 did not administer Resident 1's doxycycline monohydrate, mirtazapine, and atorvastatin because Resident 1 was a new admit on 8/2/2025 at around 3:00 p.m. and the facility had not received Resident 1's medications. LVN 1 stated that he (LVN 1) went through the emergency kit (e-kit a pre-packaged, set of medications kept onsite for immediate use) to look for the medications, however, none of Resident 1's medications were in

the e-kit. LVN 1 stated the facility does not have an in-house pharmacy, and the facility has to wait for an outside pharmacy to deliver all medications. LVN 1 continued to state medication deliveries can take a whole shift (eight hours). LVN 1 further stated that he (LVN 1) should have called Resident 1's physician to inform the physician that the medications were not administered and documented that LVN 1 called Resident 1's physician. LVN 1 stated LVN 1 did not call Resident 1's physician to inform of Resident 1's missed medications because it was a very busy shift. During a concurrent interview and record review on 8/14/2025 at 4:49 p.m., with the Registered Nurse Supervisor (RNS), reviewed the facility's pharmacy contract titled, Pharmaceutical Services Agreement, dated 4/2013. The RNS stated that the facility does not have an in-house pharmacy and licensed nurses have to wait for the pharmacy to deliver residents' medication which can take six hours or more. The RNS stated the pharmacy only has two deliveries between the evening (3pm-11pm) and night shift 11pm-7am), at 12:00 a.m. and at 5:00 a.m. The RNS stated that medications should be delivered promptly and stated that the facility should receive residents' medications in less than six hours of the pharmacy receiving residents' medication orders. During a concurrent interview and record review on 8/14/2025 at 5:10 p.m., with the Director of Nursing (DON), reviewed Resident 1's delivery manifest and Resident 1's MAR dated 8/2025. The DON stated that all ordered medications from the pharmacy should be delivered within 6-24 hours of the pharmacy receiving residents' medication orders. The DON stated that it is impossible for the facility to administer medications right away unless the medications ordered are in the e-kit. The DON continued to state that newly admitted residents should be given their evening doses of medication before being transferred from the hospital to

the facility. The DON stated that it is not the facility's fault that residents are not given their medications as a new admit resident to the facility. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, review date 1/8/2025, the policy indicated medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who administer without unnecessary interruptions. Medications are administered in accordance with the prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. During a review of the facility pharmacy contract titled, Pharmaceutical Services Agreement, dated 4/2023, the facility pharmacy contract indicated in the event the Pharmacy cannot deliver an ordered medication on a prompt and timely basis, the Pharmacy shall make agreements with another pharmacy in the local community to provide such service(s) to the facility.

Event ID:

Facility ID:

If continuation sheet