Health inspection·December 4, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who were identified as a candidate for scheduled toileting (a structured approach aimed at helping individuals manage their bladder [organ that stores urine] control by prompting them to use the toilet at regular intervals), participated in a toileting retraining plan in accordance with facility policy and the physician's order for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 not to attain Resident 1's highest functional level.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD- a progressive lung condition that blocks airflow, making it hard to breathe) with acute exacerbation (sudden worsening), need for assistance with personal care, and adult failure to thrive (a condition where an older adult loses appetite, weight, and interest in activities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/20/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. The MDS indicated Resident 1 required setup or clean-up assistance with eating, required supervision or touching assistance with oral hygiene, and was dependent on staff with toileting hygiene. The MDS indicated Resident 1 was in a urinary toileting program (a structured plan, often for elderly or cognitively impaired individuals, using techniques like scheduled voiding [using the bathroom at set intervals], habit training, or prompted voiding [behavioral technique involving facility staff regularly asking or reminding the resident to use the toilet on a schedule] to help manage urinary incontinence [loss of bladder control], improve bladder control, reduce accidents, and increase independence by establishing regular, timed trips to the toilet). During a review of Resident 1's Bowel (the long, muscular tube in your abdomen [intestines] that finishes digesting food, absorbs water and nutrients, and eliminates waste [feces] from the body) and Bladder Program Screener dated 7/10/2025, timed at 4:20 p.m., the Bowel and Bladder Program Screener indicated a score of 14, which, according to the established scoring criteria, scores of 7 to 14, identifies the resident as a Candidate for Scheduled Toileting (timed voiding). During a review of Resident 1's Bowel and Bladder Status and Plan of Care dated 8/9/2025, timed 2:52 p.m., the Bowel and Bladder Status and Plan of Care indicated that Resident 1 was placed on a scheduled toileting program for 90 days. The documented interventions included offering a bedpan or toileting upon awakening, before and after meals, and at bedtime and record (document each occurrence); Inform charge nurse of any adverse changes in condition; Review resident's elimination pattern quarterly and as needed to evaluate whether a change in plan of care is necessary. The evaluation dated 7/10/2025, indicated Resident would benefit from a scheduled toileting for 90 days to reduce the risk of falls related to unassisted Page 1 of 3 056133 056133 12/04/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attempts to use the bathroom. During a review of Resident 1's Interdisciplinary Team (IDT- a group of healthcare professionals from various disciplines who collaborate to address a resident's comprehensive need) Narrative document dated 8/9/2025, timed 2:55 p.m., the IDT Narrative document indicated that an Interdisciplinary Team Conference was conducted related to Resident 1's Bowel and Bladder Status, including the implementation of a scheduled toileting plan. The IDT Narrative document indicated that based on the resident's annual assessment dated [DATE], the resident (Resident 1) was identified as having the potential to benefit from a scheduled toileting plan. The IDT Narrative document further indicated that the facility staff spoke with the resident (Resident 1) and a series of scheduled times throughout the day was established for staff to offer toileting assistance. During a review of Resident 1's Physician's Order dated 8/9/2025, timed 3:12 p.m., the Physician's Order indicated a scheduled toileting plan for 90 days, documented as a one-time order to remain in effect for 90 days. During an interview on 12/1/2025 at 12:30 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that he (CNA 1) was assigned to Resident 1 today (12/1/2025). CNA 1 stated that he (CNA 1) was not informed that Resident 1 was on a scheduled toileting plan. CNA 1 continued to state that today (12/1/2025) was the first day CNA 1 was assigned to Resident 1. During an interview on 12/1/2025 at 12:46 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that she (LVN 1) is the permanent charge nurse for Resident 1. When asked if LVN 1 was aware whether Resident 1 was on a scheduled toileting plan, LVN 1 stated that she did not know and stated that the MDS Nurse (MDSN) would be responsible for knowing which residents are on a scheduled toileting plan. During a concurrent interview and record review on 12/1/2025 at 1:30 p.m., with the MDSN, Resident 1's Bowel and Bladder Program Screener dated 7/10/2025, nursing progress notes and licensed nurses notes from 8/9/2025 to 11/30/2025 were reviewed. The MDSN stated that upon admission and quarterly (every three months), residents are assessed for bowel and bladder continence using the facility's Bowel and Bladder Program Screener. If a resident is identified as incontinent, the resident is further assessed to determine if the resident can benefit from a scheduled toileting (toileting retraining) plan. The MDSN stated that there are currently no residents on a scheduled toileting plan. The MDSN reviewed Resident 1's medical records and reviewed Resident 1's Bowel and Bladder Program Screener dated 7/10/2025 and stated that Resident 1 was identified as a candidate for a scheduled toileting program. The MDSN further reviewed Resident 1's nursing progress notes and licensed nurses notes from 8/9/2025 to 11/30/2025 and stated that there was no documented evidence that a scheduled toileting program was initiated for Resident 1. The MDSN continued to state that physician orders are not necessary for a resident to be placed on a scheduled toileting program, as it is considered a nursing intervention. All staff providing care to the resident are responsible for implementing the toileting program, and charge nurses (assigned to the resident) should document Resident 1's progress with scheduled toileting retraining each shift. During an interview on 12/1/2025 at 4:26 p.m., with the Director of Nursing (DON), the DON stated that a scheduled toileting plan is important to help residents retrain bladder and bowel function and reduce reliance on adult briefs. The DON stated that the facility failed implement a scheduled toileting plan for Resident 1, despite Resident 1 being assessed as a candidate for scheduled toileting and having a Physician's Order. The DON further stated that charge nurses are responsible for knowing which residents are on a scheduled toileting program and for monitoring their progress to ensure the plan is implemented correctly. During a review of the facility's policy and procedure (P&P) titled Urinary Continence and Incontinence- Assessment and Management, last reviewed on 1/8/2025, the P&P indicated the physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the 056133 Page 2 of 3 056133 12/04/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few extent possible. As indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. As appropriate, based on assessing the category and causes on incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try and manage incontinence. Incontinence care should be individualized at night in order to maintain comfort and skin integrity and minimize sleep disruption. The staff will document the results of the toileting trial in the resident's medical record 056133 Page 3 of 3