Deficiency Records for West Hills Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for West Hills Health and Rehabilitation. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-18 | 2024-02-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-12-18 | 2024-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-18 | 2024-02-06 | 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 | 2023-12-18 | 2024-02-06 | N |
| Provide activities to meet all resident's needs. | Health | 2023-12-18 | 2024-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-18 | 2024-02-06 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-12-18 | 2024-02-06 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-12-18 | 2024-02-06 | 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 | 2023-12-18 | 2024-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-18 | 2024-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-18 | 2024-02-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-18 | 2024-02-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-18 | 2024-02-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-18 | 2024-02-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-18 | 2024-02-06 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-20 | 2024-02-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-20 | 2024-02-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-18 | 2023-12-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-12-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-10 | 2022-12-28 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-10 | 2022-12-28 | Y |
| 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 | 2019-08-05 | 2019-09-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-05 | 2019-09-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-30 | 2019-09-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-30 | 2019-09-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-30 | 2019-09-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-01-09 | 2018-02-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-01-09 | 2018-02-27 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-01-05 | 2018-02-27 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2018-01-05 | 2018-02-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-01-05 | 2018-02-27 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2018-01-05 | 2018-02-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-01-05 | 2018-02-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-05 | 2018-02-27 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-01-05 | 2018-02-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-05 | 2018-02-27 | N |
