West Hills Health And Rehabilitation Center
Inspection Findings
F-Tag F0645
F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to submit a new corrected and accurate Level 1 Preadmission Screening and Resident Review (PASARR- an assessment to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of four sampled residents (Resident 2).This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident
on 8/15/2025 and readmitted the resident on 9/19/2025 with diagnoses that included cerebral palsy (a group of disorders that affect movement, muscle tone, and coordination caused by the damage to the developing brain before or during birth), [NAME] -Chiari Syndrome (structural abnormality in the skull that causes part of the brain to move into the spinal canal) without spina bifida (condition that occurs when the spine and spinal cord don't form properly) or hydrocephalus (condition in which fluid accumulates in the brain, enlarging the head and sometimes causing brain damage), and dysphagia (difficulty swallowing).During a review of Resident 2's Physician Progress Notes dated 8/19/2025, the Physician Progress Notes indicated Resident 2 does not have the capacity to understand and make decisions.During
a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 8/20/2025, the MDS indicated that Resident 2 had severe impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was dependent on staff with toileting hygiene, shower or bathing, dressing, personal hygiene, and mobility (movement).During a
review of Resident 2's Level 1 PASARR for 8/13/2025, the Level 1 PASARR indicated Resident 2 had no primary diagnosis of cerebral palsy.During a review of Resident 2's admission Record diagnosis information, the diagnosis information indicated Resident 2 had a principal admitting diagnosis of cerebral palsy.During a concurrent interview and record review on 9/30/2025 at 2:00 p.m., with the Director of Nursing, reviewed Resident 2's Level 1 PASARR dated 8/13/2025 and Resident 2's admission Record diagnosis information. The DON stated that she (DON) was responsible for overseeing the PASARR. The DON stated that Resident 2's Level 1 PASARR dated 8/13/2025 indicated Resident 2 had no primary diagnosis of cerebral palsy and was an error. The DON stated the facility should have submitted a new corrected Level 1 PASARR for Resident 2 reflecting the primary diagnosis of cerebral palsy. The DON stated the Level 1 PASARR evaluation was to determine appropriate placement and /or the need for specialized services.During a review of the facility`s policy and procedure (P&P) titled, Preadmission Screening and Resident Review (PASARR), last reviewed on 1/8/2025, the policy indicated to ensure each resident with serious mental illness (SMI) and/or intellectual/developmental disability/related conditions (ID/DD/RC) will have appropriate setting, as well as if any specialized services and/or rehabilitative services would be needed. The facility will submit a new Level 1 PASARR if there is any error/discrepancy in the previous PASARR screening.
Residents Affected - Few
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:
WEST HILLS HEALTH AND REHABILITATION CENTER in CANOGA PARK, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CANOGA PARK, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WEST HILLS HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.