West Valley Post Acute

F 0600 Level of Harm - Actual harm

individuals. 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents. 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Valley Post Acute

7057 Shoup Ave West Hills, CA 91307

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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Resident 2 to stop touching his TV. Resident 1 stated Resident 2 turned around and hit (Resident 1) with a closed fist on his chest and in turn he (Resident 1) punched Resident 2 with a closed fist in the face.

Resident 1 stated that after he punched Resident 2, Resident 2 left the room. Resident 1 stated when Resident 2 returned, he (Resident 2) wheeled himself to his (Resident 1‘s) side of the room, stood up, walked over to him and swung the footrest at him, hitting him in the face, resulting in bleeding to the nose and thumb. During an interview on 11/14/2025 at 11:48 a.m. with Licensed Vocational Nurse 1 (LVN ) 1, LVN 1 stated that a resident-to-resident altercation between Resident 1 and Resident 2 occurred on 10/30/2025 after dinner (does not recall exact time) during the 3 p.m.-11 p.m. shift (a work schedule from 3 p.m. to 11 p.m.) LVN 1 stated that prior to the incident Resident 2 approached LVN 1 and stated that his roommate's (Resident 1) TV was on and he wanted it off. LVN 1 stated that she explained to Resident 2 that Resident 1 has the right to have his TV on. LVN 1 stated that next thing she knew, she (LVN 1) heard Certified Nursing Assistant 2 (CNA) 2 running towards her (LVN 1) reporting that Resident 1 and Resident 2 were yelling at one another. LVN 1 stated when she arrived in Resident 1 and Resident 2's room, she witnessed Resident 2 holding his wheelchair footrest and hitting Resident 1 with the wheelchair footrest.

LVN 1 stated that Resident 2 was swinging the wheelchair footrest and Resident 1 was holding on to the footrest trying to protect himself. LVN 1 stated both Resident 1 and Resident 2 were going back and forth pushing and pulling the wheelchair footrest towards one another. LVN 1 stated that she and CNA 2 separated Resident 1 and Resident 2 when it was safe to do so. LVN 1 stated that she observed blood all over Resident 1's face. LVN 1 stated that when she asked Resident 2 why he hit Resident 1 with the footrest, Resident 2 stated it was because of the TV. During an interview on 11/17/2025 at 10:40 a.m. with

the Director of Nursing (DON), the DON stated that the facility was aware that Resident 2 has behavioral triggers. The DON stated that Resident 2's anger is triggered when his roommates' TVs are on or when Resident 2 hears other residents screaming. The DON stated that the roommates' TVs being on and the loud noises triggers behaviors that cause the resident to become angry. During a concurrent interview and

record review on 11/17/2025 at 11:00 a.m., with the Director of Nursing (DON), reviewed Resident 2's Care Plans. The DON stated that Resident 2 does not have a care plan specific to Resident 2's behavioral triggers. The DON stated that a care plan should have been developed to address Resident 2's triggers so that specific interventions could have been in place to avoid behavioral outbursts.During an interview on 11/14/2025 at 3:35 with the Administrator (ADM), the ADM stated the resident altercation between Resident 1 and Resident 2 was avoidable based on Resident 2's history of not liking noises and roommate incompatibility and that interventions should have been put in place to prevent the incident from occurring.

During a review of the facility's policy and procedure (P&P) titled Care plans, Comprehensive Person-Centered, reviewed 1/10/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT) in conjunction with

the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Event ID:

Facility ID:

If continuation sheet