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Deficiency Records for West Hills Health and Rehabilitation Center
A list of the most recent deficiencies for West Hills Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for West Hills Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-08 | 2024-08-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-08-08 | 2024-08-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-08-08 | 2024-08-30 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-08-08 | 2024-08-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-08 | 2024-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-08 | 2024-08-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-08 | 2024-08-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-08 | 2024-08-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-08-08 | 2024-08-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-08-08 | 2024-08-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-08-08 | 2024-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-08 | 2024-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-08 | 2024-08-30 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-08-08 | 2024-08-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-08-13 | 2024-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-13 | 2024-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-13 | 2024-08-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-08-13 | 2024-08-30 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-07-17 | 2024-08-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-17 | 2024-08-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-07-17 | 2024-08-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-17 | 2024-08-15 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-07-17 | 2024-08-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-20 | 2024-06-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-20 | 2024-06-14 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-20 | 2024-06-14 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-05-20 | 2024-06-14 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-05-20 | 2024-06-14 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-05-07 | 2024-05-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-18 | 2024-05-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-10 | 2024-04-26 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-03-29 | 2024-04-14 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-03-20 | 2024-04-12 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-03-20 | 2024-04-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-20 | 2024-04-12 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-01-31 | 2024-02-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-27 | 2023-12-19 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-27 | 2023-12-19 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-31 | 2023-09-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-31 | 2023-09-12 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-08-31 | 2023-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-09-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-08 | 2023-08-25 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-08 | 2023-08-25 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-06-05 | 2023-06-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-05 | 2023-06-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-05 | 2023-05-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-05 | 2023-05-24 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-05 | 2023-05-24 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-02-13 | 2023-02-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-03 | 2023-01-17 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-01-03 | 2023-01-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-21 | 2022-12-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-07 | 2022-08-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-24 | 2022-08-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-23 | 2022-08-03 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-07-23 | 2022-08-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-26 | 2022-06-07 | Y |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-04-08 | 2022-06-02 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-04-13 | 2022-05-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-08 | 2022-05-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-08 | 2022-05-02 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-04-08 | 2022-05-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-08 | 2022-05-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-08 | 2022-05-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-08 | 2022-05-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-04-08 | 2022-05-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-08 | 2022-05-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-08 | 2022-05-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-08 | 2022-05-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-08 | 2022-05-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-08 | 2022-05-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-04-08 | 2022-05-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-08 | 2022-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-08 | 2022-05-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-08 | 2022-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-18 | 2022-03-18 | Y |
| Report COVID19 data to residents and families. | Health | 2022-03-18 | 2022-03-18 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-02-22 | 2022-03-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-29 | 2019-08-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-07-29 | 2019-08-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-29 | 2019-08-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-29 | 2019-08-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-29 | 2019-08-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-07-29 | 2019-08-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-07-29 | 2019-08-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-29 | 2019-08-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-29 | 2019-08-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-29 | 2019-08-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-07-29 | 2019-08-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
| Establish methods for sharing information. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-31 | 2019-08-20 | N |
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