Westside Oaks Rehabilitation & Nursing Center

In the surveyor’s words

From the most serious findings on record at Westside Oaks Rehabilitation & Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Apr 1, 2026

  Based 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. […]

• Immediate jeopardy, widespreadF867Apr 1, 2026

  Based 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. […]

• Immediate jeopardy, patternF600Apr 1, 2026

  Based 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). The facility failed to ensure sufficient safeguards and supervision to protect the residents' right to be free from neglect, 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… […]

• Immediate jeopardy, patternF689Apr 1, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF600Jul 2, 2025

  Based 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. […]