West Hills Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at West Hills Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF627Aug 29, 2025

  Based on interview and record review, the facility failed to ensure a safe and orderly discharge was provided to two of three sampled residents (Resident 1, who had severely impaired cognition [the mental action or process of acquiring knowledge and understanding through thought, experience and the senses], lacked capacity to understand and make decisions, and required staff assistance for all Activities of Daily Living [ADL - basic tasks that individuals perform to maintain their daily lives] and Resident 2, who also required staff assistance for all ADLs) by failing to:1. Ensure that the post-discharge destination and continuing care provider were capable of meeting the needs of Resident 1 and Resident 2 prior to discharge. 2. […]

• Actual harm, isolatedF600Apr 16, 2025

  Based on observation, interview, and record review, the facility failed to protect the residents ' right to be free from abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of four sampled residents (Residents 1 and 2) when on 4/12/2025, Residents 1 and 2, while in their wheelchairs in a hallway, Resident 2 grabbed Resident 1 ' s right arm while Resident 1 grabbed Resident 2 ' s arm. The residents (Residents 1 and 2) then pushed against each other ' s hands and arms, and each resident (Residents 1 and 2) received abrasions (when the surface layers of the skin have been broken). This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility. […]

• Actual harm, isolatedF600Oct 29, 2021

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was unable to make safe decisions due to poor judgement related to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This can cause inability to feel pain, heat intolerance, pain, discomfort, and mobility difficulties), used a wheelchair for mobility, and needed staff assistance with activities of daily living (ADLs, such as: transfers, locomotion, personal hygiene, eating, and dressing), had the right to be free from neglect (the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) to prevent injuries while in the patio in the heat. […]

• Actual harm, isolatedF689Oct 29, 2021

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was unable to make safe decisions due to poor judgement related to his diagnosis of dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), had polyneuropathy (is the damage to multiple nerves outside of the brain and central nervous system. This can cause inability to feel pain, heat intolerance, pain, discomfort, and mobility difficulties) used a wheelchair for mobility, and needed staff assistance with activities of daily living (ADLs, such as: transfers, locomotion, personal hygiene, eating, and dressing), received the necessary supervision and assistance to prevent injuries while in the patio in the heat. […]

• No harm, potential for more than minimal, widespreadF880Aug 14, 2026

  Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. Staff followed enhanced barrier precautions (EBP - infection control guidelines requiring staff to wear gown and gloves during high contact-care for residents with wounds, indwelling medical devices or those carrying resistant germs) for two of two sampled residents (Resident 10 and Resident 3): a. When Certified Nursing Assistant 4 (CNA 4) and Certified Nursing Assistant 5 (CNA 5) did not wear a gown before performing incontinence care for Resident 10. b. […]