Woodland Hills Healthcare and Rehabilitation

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews, record review and facility policy review, it was determined that the facility failed to keep a resident free from verbal abuse for one (Resident #30) of one resident reviewed for abuse.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews, and facility document review, it was determined that the facility failed to prevent a resident from falling while being transferred with a mechanical lift for one (Resident #60) of one resident reviewed for accidents.

Inspectors wroteSurveyor: [NAME], [NAME] Based on document review and interviews, the facility failed to ensure the necessary care, and resources were allocated to meet the needs of the residents. The facility failed to ensure the amount of hours worked by the Infection Preventionist, based on the facility and resident population, was addressed in the Facility Assessment in order to meet resident needs. This deficient practice had the potential to affect all residents of the facility. The total census was 52 residents. 1. On 12/17/2024 at 3:30 PM, this surveyor interviewed the Administrator regarding low weekend staffing. The Administrator was aware of low weekend staffing for Certified Nursing Assistants for the weekend for the 4th quarter. Several call-ins for the weekend with no replacement found. The Administrator had hired 3 weekend only staff to rectify the problem. 2. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure shower rooms were locked to ensure residents were prevented from having access to equipment or substances that could result in accidents or injuries. The facility failed to ensure the personal care storeroom, and treatment/oxygen room remained locked to prevent resident access to razors, scissors, and chemicals to reduce the risk for injury. This failed practice had the potential to cause harm to cognitive impaired residents if entry was gained. The facility failed to ensure the resident environment remains as free of accidents hazards as is possible. Findings Include: 1. On 12/15/2024 at 10:14 AM, the surveyor observed the shower room door unlocked and not closed. The surveyor noted shampoo, body wash, soap and razors inside. 2. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure all drugs and biologicals were stored in a locked compartment and permit only authorized personnel to have access for one of one medication cart.

Inspectors wroteBased on observation and interview, the facility failed to ensure kitchen vents were cleaned to provide a sanitary environment for food preparation; that floors, dish washer and kitchen walls, door and frames were free of rotten wood, chipped floor tiles, debris, dirt, grease, rust, stains, wall tiles were replaced; food items stored in the refrigerator were covered or sealed; expired food items were promptly removed from stock; ice machine and ice scoop holder were maintained in clean and sanitary condition; dietary staff washed their hands before handling clean equipment or food items and hot food items were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service for 1 of 2 meals observed.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide a safe and sanitary environment for residents. In addition, the facility failed to clean and sanitize equipment such as shower beds/chairs, electric clippers used to cut facial hair, wheelchairs, walkers, and lift equipment. These findings have the potential to affect all 52 residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure residents had a functioning call light system that would alarm, light up, and could be reset by staff, or a way to contact staff to ensure needs were met for 2 of 2 sampled (Resident #7, and Resident #30) residents.

Inspectors wroteBased on observations, record review, and interviews, it was determined the facility failed to provide snacks that were previously offered and appropriate for residents with diabetes, therefore failing to accommodate their needs, which affected the resident's quality of life for 1 (Resident #34) of 1 resident reviewed. Specifically, the facility failed to ensure Resident #34, a resident with type I diabetes, was provided snacks, other than high sugar/simple carbohydrates.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a resident without self-administration rights was not self-administering an inhaler and updraft without approval or staff presence to prevent improper usage, storage, and misappropriation of resident's own medication affecting 1 sampled (Resident #351) resident of 1 sampled.

Inspectors wroteBased on interview and record review, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASRR) for 1 (Resident #15) of 1 resident reviewed for PASRR.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a recapitulation, or summary, of stay upon discharge affecting 1of 1 sampled (Resident #49) resident to ensure sufficient information was given for safe care on discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent bathing and personal hygiene for 4 (Residents #1, #3, #4, and #5) dependent residents to maintain hygiene, prevent infection and possible skin issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and palatable food temperature for trays served to residents who receive meals in their room.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for Residents in Room #'s 311-B, 405-A & B, and 414-A. This failed practice had the potential to affect all 47 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care to maintain oxygen equipment to ensure cleanliness and minimize risk of cross contamination or infection for 2 sampled residents (R #6 and R #29) on hall 300.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure licensed nurses demonstrated competency with necessary care, treatment, safety, and services required by each resident, as evidenced by: 1. On 11/21/23 at 8:21 AM, the Surveyor observed LPN #1 administer morning medications on hall 400. LPN #1 donned gloves, opened the medication cart drawers, and pulled out medications to give to resident in room [ROOM NUMBER]-B. LPN #1 popped the tablets from the blister pack into a medication cup sitting on top of the cart for resident in room [ROOM NUMBER]-B and dropped a pill onto the surface of the cart, picked it up, and placed it in the medication cup. The Surveyor asked LPN #1 if she had sanitized the cart prior to administering the medications. LPN #1 stated answered, No, I was feeling nauseous this morning and sick to my stomach. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the refrigerated narcotic medications were stored in a permanently affixed container to prevent the potential of misappropriation of resident property. This failed practice had the potential to affect all 47 residents. The facility also failed to ensure insulin bottles were dated after opening, and that insulin vials past expiration date of opening were discarded and removed from medication cart. This failed practice had the potential to affect 8 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure that food was used prior to the use by date and that food was stored properly including the date of arrival into the facility to minimize potential for food borne illness. The failed practice had the ability to affect 65 residents who receive their meals from one of one kitchen.

Inspectors wroteBased on interview the facility failed to ensure that the facilities binding arbitration agreement was written in a language/manner that could be understood by the resident/representative, that signatures were provided attesting to the fact that the resident/representative understood the agreement, that the resident had 30 days to resend the agreement. The failed practice had the ability to affect all 47 residents who currently reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration documentation includes the selection of a neutral arbitrator and a location that is convenient for all. The failed practice had the ability to affect all 47 residents who currently reside in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for (F584) providing a homelike environment, (F677) providing nail care for resident dependent on staff, (F812) Sanitation and (F880) Infection Control. These failed practices had the potential to affect 47 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure standard infection control precautions were demonstrated during medication administration to prevent the possible transmission of communicable diseases and infections. This failed practice had the potential to affect 16 residents receiving medications on hall 400.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure call lights were placed within resident's reach to allow resident to request assistance to accommodate their individual care needs for 1 (Residents #32) of 4 sampled residents (Resident #6, #27, #29, #32) who were dependent on staff for assistance. This failed practice had the potential to affect 10 residents on 300 hall who were cognitive enough to use a call light.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure fingernails were clean and trimmed to promote good grooming and hygiene for 1 (Resident #26) of 6 (Resident #6, #26, #27, #29, #32, and #47) sampled residents who were dependent on staff for nail care. This failed practice had the potential to affect 16 residents who were dependent on staff for nail care residing on 300 Hall.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident required to wear a compression sleeve and glove received care and treatment in accordance with the physician's plan of care, for (Resident #6) of 1 case mix resident who had Lymphedema.

Inspectors wroteBased on interviews, record review, and facility menu and policy review, the facility failed to ensure the planned, written menu was followed for residents who received meals from 1 of 1 kitchen. Specifically, the facility failed to provide milk with breakfast and/or dinner as per the menu for five days. This affected all 47 residents who resided in the facility and had a physician's order for a regular diet.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to food was stored properly and dishes were maintained in clean condition and in good repair in 1 of 1 facility kitchen. Specifically, the facility: - failed to ensure food stored in the walk-in refrigerator was labeled, dated, and stored off of the floor. - failed to ensure dishes and pans were allowed to air dry before stacking/storing. - failed to ensure plates used to serve resident meals were free of chips/cracks. The failed practices had the potential to affect all 47 residents who resided in the facility and received meals from the kitchen.

Inspectors wroteBased on interviews, record review, and facility policy and document review, it was determined the facility's administration failed to ensure the staff member acting as the administrator was knowledgeable regarding abuse reporting requirements, which resulted in failure to immediately report an allegation of abuse to the state survey agency (SSA) for 1 (Resident #23) of 1 resident reviewed for abuse. Additionally, the facility's administration failed to ensure a reliable system of addressing maintenance concerns was in place during a period when no maintenance staff were employed. The failed practices had the potential to affect all 47 residents who resided in the facility.

Inspectors wroteBased on interviews and facility document review, the facility's governing body failed to employ a licensed facility administrator to be responsible for managing the facility for the period of September 2022 through 12/01/2022. This deficient practice had the potential to affect all 47 residents residing in the facility.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure 3 (Residents #4, #21, and #40) of 3 sampled residents reviewed for care plan participation were invited to attend care plan conferences to afford the residents the opportunity to participate in planning their care.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure walls in residents' rooms were maintained in good repair in order to provide a clean and homelike environment for residents who resided on 2 (100 Hall and 400 Hall) of 3 halls observed.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, it was determined that the facility failed to ensure an effective infection control program was implemented to prevent the potential spread of influenza. Specifically, the facility failed to ensure proper signage was posted on residents' doors to indicate which personal protective equipment (PPE) should be in utilized in the rooms of 7 (Residents #8, #26, #203, #42, #5, #32, and #6) of 2 residents reviewed for isolation precautions.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the state survey agency (SSA) within the required timeframe for 1 (Resident #23) of 1 sampled resident reviewed for abuse. Specifically, the facility received a report of alleged abuse involving Resident #23 on 11/27/2022 but failed to report the allegation to the SSA until 11/29/2022. Additionally, the facility failed to ensure its abuse reporting policy and procedure addressed the federally required timeframes for reporting allegations of abuse.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a resident who required extensive assistance with personal hygiene was regularly offered trimming or shaving of facial hair and trimming of nails to maintain good grooming and hygiene for 1 (Resident #44) of 2 sampled residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a monitoring for side effects of psychoactive medications was consistently provided and documented for 1 (Resident #4) of 4 sampled residents reviewed for psychoactive medications.