Westside Oaks Rehabilitation & Nursing Center

Inspectors wroteBased on a review of facility and resident records, facility job descriptions, policies and procedures, and interviews with residents, staff and medical professionals, the facility's Administration failed to provide oversight of the facility in a manner that ensured necessary interventions, including adequate supervision and sufficient safeguards, were in place to prevent avoidable accidents, by failing to ensure that CNAs A, B, D, RN E and the DON implemented the facility's Smoking/Vaping policy to prevent four oxygen dependent residents (#1, #2, #3 and #4) out of four residents reviewed for smoking, from storing cigarettes and lighters in their rooms, and to prevent two oxygen-dependent residents (#1 and #2) from smoking in their rooms while oxygen was in use. [...]

Inspectors wroteBased on a review of facility and resident records, staff interviews, a review of the facility's policies titled Quality Assessment and Performance Improvement (QAPI) Policy and Risk Management, and a review of QAPI meeting documentation, the facility failed to have an effective QAPI process that used adverse event data and safety information related to smoking and oxygen use, to identify a Root Cause Analysis (RCA) and develop relevant performance improvement activities to prevent similar future events. Resident #1, with a known history of smoking in his room while using oxygen, was again found smoking in his room while using oxygen. His nasal cannula ignited and he sustained second-degree facial burns and respiratory distress requiring emergent transport to an acute care hospital burn unit for treatment. [...]

Inspectors wroteBased on a review of facility and resident records, resident and staff interviews, and a review of the facility's policies titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and Smoking/Vaping, the facility failed to protect the residents' right to be free from neglect/deprivation of services by Certified Nursing Assistants (CNAs) A, B, D, Registered Nurse (RN) E and the Director of Nursing (DON). [...]

Inspectors wroteBased on a review of facility and resident records, resident and staff interviews, and a review of the facility policy titled Smoking/Vaping, the facility failed to ensure residents received adequate supervision and sufficient safeguards to prevent avoidable accidents, by failing to ensure that CNAs A, B, D, RN E and the DON implemented the facility's Smoking/Vaping policy to prevent four oxygen dependent residents (#1, #2, #3 and #4) out of four residents reviewed for smoking, from storing cigarettes and lighters in their rooms, and to prevent two oxygen-dependent residents (#1 and #2) from smoking in their rooms while oxygen was in use. [...]

Inspectors wroteBased on a review of facility documents, resident and staff interviews, and a review of the facility's policy titled Adverse Incident Reporting, the facility failed to ensure the timely reporting of an adverse incident for one (Resident #1) of four residents reviewed. The facility failed to report an adverse incident that occurred on 2/27/26 in which Resident #1 sustained second degree facial burns and respiratory distress after smoking in his room while on oxygen, requiring his transfer to an acute care facility burn unit for treatment.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide accurate Preadmission Screening and Resident Reviews (PASRRs) for seven (Residents #23, #62, #63, #65, #76, #101, and #167) of eight residents sampled for PASRRs and identified with a mental disorder (MD) and/or intellectual disability (ID), and failed to ensure that the residents were properly evaluated and received care and services in a setting appropriate for their needs.

Inspectors wroteBased on observations, interviews, record reviews, and a review of facility policies and procedures, the facility failed to ensure that eight (Residents #5, #34, #11, #166, #91, #19, #82, and #159) of 73 sampled residents received appropriate ADL (activities of daily living) care necessary to maintain good grooming, by failing to ensure fingernails were clean/trimmed/clipped, hair was shampooed, and/or facial hair was removed.

Inspectors wroteBased on review of staff records, and interviews conducted with the Administrator, the facility, which is licensed for 180 beds, failed to ensure the full-time social worker was qualified, and failed to verify educational requirements were met, with the potential to negatively impact the overall health, safety, and quality of life to all 172-residents present during the recertification survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one (Resident #82) of 73 residents in the total survey sample was provided with adequate and comfortable lighting at his bedside. Inadequate lighting can result in an increased risk for falls/accidents as well as potential psychological distress (anxiety/depression).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents requiring respiratory care received such care, consistent with professional standards of practice, by failing to ensure that two (Residents #54 and #49) of two residents reviewed for respiratory care, received oxygen at the flow rate prescribed by their physicians.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Ensure privacy curtains were provided to five (Residents #192, #116, #5, #82 and #105) of 30 residents sampled for privacy curtains, and 2) Ensure privacy curtains were not stained for two (Rooms 9B and 9D) of 32 privacy curtains observed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a call light or hand bell was within reach for three (Residents #13, #43 and #149) of 73 sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a safe environment for two (Residents #17 and #79) of 172 residents currently living in the facility, by failing to keep sharp, potentially dangerous items out of resident rooms.

Inspectors wroteBased on a review of facility and resident records, the facility's policy and procedure titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and interviews with staff and outside medical professionals, the facility failed to protect Resident #1's right to be free from neglect, by failing to ensure adequate supervision and safeguards to prevent the resident, with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), from consuming his incontinence pad, choking and dying. On June 20, 2025 at 1:49 PM, Resident #1 was found in his bed unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. [...]

Inspectors wroteBased on a review of facility and resident records, facility's policy and procedure titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and interviews with staff and outside medical professionals, the facility failed to conduct a thorough investigation to rule out abuse or neglect after one (Resident #1) of one resident with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), who chewed and consumed incontinence briefs and disposable incontinence pads, was found unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. As a result of the incident, Resident #1 died. [...]

Inspectors wroteBased on a review of facility and resident records, facility job descriptions, policies and procedures, and interviews with staff and medical professionals, the facility's Administration failed to provide oversight of the facility in a manner that ensured necessary interventions, including supervision, were in place for Resident #1's safety when he had a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), and consistently chewed/consumed his briefs and disposable incontinence pads. On June 20, 2025 at 1:49 PM, Resident #1 was found in his bed unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. [...]

Inspectors wroteBased on a review of facility and resident records, staff interviews, and review of the Quality Assurance and Performance Improvement (QAPI) plan, the facility failed to have an effective QAPI process that used adverse event data to identify a Root Cause Analysis (RCA) and develop relevant performance improvement activities to prevent similar future events. Resident #1, with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), who chewed and consumed briefs and disposable incontinence pads, was found unresponsive with feces and bits of blue plastic resembling incontinence pads in his mouth. As a result of the incident, Resident #1 died. [...]

Inspectors wroteBased on a review of facility and resident records, a review of the facility's policy and procedure titled Care Plan-Comprehensive, and interviews with staff and medical professionals, the facility failed to develop and implement a comprehensive person-centered care plan detailing a focused problem area and specific interventions needed to protect one (Resident #1) of one resident with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), from consuming incontinence pads. This affected one (Resident #1) of three residents reviewed for behavioral issues, from a total of 52 residents with behavioral care plans.

Inspectors wroteBased on a review of facility and resident records, the facility's policy titled Charting and Documentation, and interviews with staff, the facility failed to maintain medical records for each resident that were accurately documented and reflective of one (Resident #1) of three residents reviewed for behavioral issues, from a total of 52 residents with behavioral care plans.

Inspectors wroteBased on observations, interviews and document review, the facility failed to store and prepare food in accordance with professional standards for food service safety, by failing to ensure kitchen equipment was clean and opened food was labeled, dated and sealed for 162 residents who received food from the facility's kitchen.

Inspectors wroteBased on observations, interviews, and a review of the policy and procedure for Maintenance Services, the facility failed to ensure the floors on hallways A, B and C as well as one (room [ROOM NUMBER]) of 53 rooms were safe and without accident hazards. Staff, residents, and visitors were at risk for falls due to the raised floor boards and a missing area of floor board in the aforementioned areas of the facility.

Inspectors wroteBased on observations, interviews, record review, and facility policy and procedure review, the facility failed to notify the physician for one (Resident #128) in a total sample of 43 residents, after she choked during the lunch meal she consumed in her room.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure that one (Resident #116) of 43 sampled residents received necessary services to maintain good grooming, by failing to ensure his fingernails were trimmed/clipped.

Inspectors wroteBased on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #63) of seven residents diagnosed with dementia, from a total of 31 residents in the sample, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. The facility must provide dementia treatment and services which may include, but are not limited to the following: 1. Ensuring adequate medical care, diagnosis, and supports based on diagnosis; 2. Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; and 3. [...]