West Hills Health & Rehabilitation

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure proper personal hygiene practices and safe food storage handling techniques for 1 of 1 facility kitchen and 2 of 2 facility ice machines reviewed for kitchen sanitation. This placed residents at risk for cross contamination and foodborne illnesses.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#293) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration.

Inspectors wroteBased on interview and record review it was determined the facility failed to obtain information related to advance directives and health care decisions for 3 of 3 sampled residents (#s 45, 62 & 392) reviewed for advance directives. This placed residents at risk for not having health care decisions honored.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide education and training for the self-administration of an anticoagulant subcutaneous medication prior to discharge for 1 of 3 sampled residents (#2) reviewed for discharge. This placed residents at risk for an unsafe discharge.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#5) reviewed for medication administration. This placed residents at risk for adverse medication consequences.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure sufficient dietary staff were available to ensure food service was delivered in a timely manner for 1 or 1 kitchens reviewed. This placed residents at risk for unmet nutritional needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to implement care plan interventions to ensure adequate supervision was provided to prevent accidents for 1 of 3 sampled residents (#100) reviewed for hot beverage safety. This placed residents at risk for accidents.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure meals were served in a palatable and at appetizing temperatures for 2 of 2 sampled residents (#s 105 and 106) reviewed for food. This placed residents at risk for unmet nutritional needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to administer medication as ordered for 1 of 6 sampled residents (#485) reviewed for medication administration. This failure resulted in an increased potassium level and required Resident 485's hospitalization.

Inspectors wroteBased on interview and record review, it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of waterborne pathogens for 1 of 1 facility reviewed for infection control. This placed all residents at risk for exposure to waterborne pathogens.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident needs and preferences related to showers and lighting were accommodated for 4 of 6 sampled residents (#s 3, 4, 21 and 440) reviewed for ADLs and accommodation of needs. This placed residents at risk for lack of personal hygiene, an unhomelike environment and not honoring preferences.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs and to ensure resident call lights were answered timely for 1 of 1 facility and 3 of 4 sampled residents (#s 2, 68 and 71) reviewed for sufficient nurse staffing. This placed residents at risk for unmet care needs and lengthy call light response times.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure medically related social services were provided to support residents' individual needs through the assessment process and obtain personal items for 1 of 2 sampled residents (#21) reviewed for communication needs. This placed residents at risk for unmet needs and decreased dignity.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident personal refrigerators were free of expired and/or unlabeled foods for 1 of 5 residential halls and dishwasher water temperature was monitored for 1 of 1 kitchen reviewed for food safety and sanitation. This placed residents at risk for food-bourne illness.

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment.

Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively assess cognitive abilities and mood state for 1 of 2 sampled residents (#21) reviewed for communication. This placed residents at risk for unassessed needs.

Inspectors wroteBased on interview and record review, it was determined the facility failed to develop a person-centered comprehensive care plan for 1 of 2 sampled residents (#10) reviewed for respiratory care. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident care plans were revised to accurately reflect resident needs for 1 of 1 sampled resident (#18) reviewed for skin conditions. This placed residents at risk for unmet care needs.

Inspectors wrote2. Resident 4 was admitted to the facility in 2/2021 with diagnoses including multiple sclerosis (a progressive neurological disease). Resident 4's 2/2/22 Care Plan, revised 12/23/23, revealed the resident required extensive assistance for grooming and personal hygiene and preferred showers so she/he could have her/his hair shampooed. The staff were to brush Resident 4's hair daily. Resident 4's 9/27/23 Quarterly MDS revealed she/he had moderate cognitive impairment, required total assistance for bathing/showering, required extensive assistance for personal hygiene and had no rejection of care. Resident 4's 11/22/23 through 12/16/23 Shower Task Logs indicated the resident received bathing/showering on the following days: -12/2/23 and -12/9/23. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a person-centered activity program for 1 of 1 sampled resident (#21) reviewed for activities. This placed residents at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure physician orders were implemented as ordered for 1 of 1 sampled resident (#437) reviewed for edema. This placed residents at risk for worsened edema and unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the provision of appropriate equipment at a resident's bedside in the case of a complication related to a laryngectomy (surgical removal of all or part of the larynx (voicebox)), a care plan was developed with appropriate interventions for respiratory care and physician orders for respiratory equipment were followed for 2 of 3 sampled residents (#s 74 and 435) reviewed for respiratory care. This placed residents at risk for respiratory distress and unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 1 sampled resident (#21) reviewed for mood. This placed residents at risk for re-traumatization and a decrease in their quality of life.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 1 of 1 facility observed for secure medication and treatment carts. This placed residents at risk for misappropriation of medications and adverse medication consequences.

Inspectors wroteBased on observation and interview, it was determined the facility failed to provide a clean and sanitary environment for 1 of 1 kitchen observed. This placed residents at risk of receiving contaminated food.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure adequate indication and clinical rationale for the use of an antipsychotic medication for 1 of 5 sampled residents (#67) whose medications were reviewed. This placed residents at risk for receiving unnecessary psychotropic medications and experiencing adverse side effects.