F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to implement its policy and procedure (P&P) on abuse for an
allegation of sexual abuse for one of two sampled residents (Resident 1) by failing to: 1. Conduct a
thorough investigation into alleged sexual abuse.2. Complete and submit a written five (5) day follow-up
investigation report indicating the results of an investigation for the allegation of sexual abuse that occurred
on 12/18/2025. This deficient practice had the potential to place Resident 1 at risk for further sexual
exploitation and resulted in a delay in the investigation of a suspicion of sexual abuse.Findings: a. During a
review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1
on 4/2/2025 with diagnoses including diverticulitis (inflammation or infection of small pouches (diverticula)
in the colon, causing symptoms like lower-left abdominal pain, fever, nausea, and changes in bowel habits),
moderate protein-calorie malnutrition (a severe deficiency from not getting enough protein and calories
(energy) to meet the body's needs), overactive bladder (a common condition marked by a sudden,
uncontrollable urge to urinate, often leading to frequent bathroom trips, nighttime awakenings, and
sometimes urine leakage before reaching the toilet), and major depressive disorder (a mood disorder
characterized by persistent feelings of sadness, loss of interest, and a range of other emotional and
physical symptoms that significantly interfere with daily life). During a review of Resident 1's Minimum Data
Set (MDS- a resident assessment tool) dated 10/7/2025, the MDS indicated Resident 1 had moderate
cognitive (the mental process involved in knowing, learning, and understanding things) impairment. The
MDS indicated Resident 1 required partial/moderate assistance with toileting hygiene, lower body dressing,
and personal hygiene. During a review of Resident 1's Licensed Nurse Note dated 12/18/2025, timed at
6:26 p.m., the Licensed Nurse Note indicated Resident 1 claimed Resident 2 came into Resident 1's room
and tickled Resident 1's feet. The Licensed Nurse Notes further indicated that the Social Service Director
(SSD) is aware and will follow up to move Resident 1 to another room to avoid problems. During an
interview on 12/22/2025 at 1:15 p.m. with Resident 1, Resident 1 stated that on Wednesday evening, not
sure what time, on 12/17/2025, Resident 2 entered Resident 1's room. Resident 1 stated that Resident 1's
roommate is Resident 2's mother, consequently, Resident 2 comes in Resident 1's room often. On the
evening of 12/17/2025, Resident 1 was lying in bed with her eyes closed and awake. Resident 2 came to
Resident 1's side of the bed, placed his hand underneath Resident 1's blanket and tickled Resident 1's left
foot. Resident 1 stated that Resident 1 was startled and told Resident 2 to stop. Resident 1 stated that
when she told Resident 2 to stop, he stopped and exited the room. Resident 1 stated that she thought that
Resident 2 wanted to have sex with her. Resident 1 stated that she did not consent to be tickled by
Resident 2. Resident 1 continued to state that she did not report the incident on 12/17/2025, however she
reported the incident to Certified Nursing Assistant 1 (CNA 1) the following morning on 12/18/2025. b.
During a review of Resident 2's admission Record, the admission Record indicated the facility
Residents Affected - Few
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
056133
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056133
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
West Hills Health and Rehabilitation Center
7940 Topanga Canyon Blvd.
Canoga Park, CA 91304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
readmitted Resident 2 on 5/22/2024 with diagnoses including major depressive disorder and unspecified
dementia (a progressive state of decline in mental abilities). During a review of Resident 2's MDS dated
[DATE], the MDS indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2
required substantial/maximal assistance with toileting hygiene and partial/moderate assistance with
personal hygiene. During an interview on 12/22/2025 at 1:54 p.m., with the SSD, the SSD stated that the
SSD was made aware that Resident 2 made Resident 1 feel uncomfortable when Resident 2 tickled
Resident 2's feet on 12/18/2025 at around 9 a.m. During an interview on 12/22/2025 at 2:20 p.m., with CNA
1, CNA 1 stated that on the morning of 12/18/2025, at around 7:45 a.m., Resident 1 informed CNA 1 that
Resident 2 came into Resident 1's room and touched Resident 1's feet. CNA 1 stated that she reported the
incident to Licensed Vocational Nurse 1 (LVN 1) because she (Resident 1) was about to cry when Resident
1 was talking about the incident. CNA 1 stated that Resident 2 touching Resident 1's feet without Resident
1's permission is inappropriate. Residents should not be touching other residents without permission.
During an interview on 12/22/2025 at 2:45 p.m. with LVN 1, LVN 1 stated that on 12/18/2025 at around 8
a.m. CNA 1 reported to LVN 1 that Resident 1 reported to CNA 1 that Resident 2 touched her foot last night
(12/17/2025) and was crying. After CNA 1 reported to LVN 1, LVN 1 went to check on Resident 1. LVN 1
stated that she asked Resident 1 what happened and Resident 1 reported to LVN 1 that on the evening of
12/17/2025 Resident 2 came into Resident 1's room and tickled Resident 1's foot. LVN 1 stated that she
asked Resident 1 if Resident 2 touched her anywhere else and Resident 1 responded No. LVN 1 continued
to state that Resident 1 stated that she thought Resident 2 wanted to have sex with her (Resident 1). LVN 1
stated that after Resident 1 reported to her (LVN 1), LVN 1 reported the alleged incident to Registered
Nurse 1 (RN 1). LVN 1 further stated she reported the incident to RN 1 because the incident between
Resident 1 and Resident 2 was possibly sexual abuse, Resident 2 touched Resident 1 without Resident 1's
consent. During an interview on 12/22/2025 at 3:08 p.m. with RN 1, RN 1 stated that on 12/18/2025 at
around 8:45 a.m. LVN 1 reported to her that Resident 2 tickled Resident 1's foot without Resident 1's
consent and Resident 1 reported that she thought Resident 2 wanted to have sex with her. RN 1 stated that
Resident 2 does not have the right to tickle or touch anyone without their consent, that's a type of sexual
abuse. RN 1 stated that in RN 1's professional opinion, the alleged tickling was an alleged sexual abuse,
which is why RN 1 reported the incident to the Administrator (ADM) who is the abuse coordinator. During
an interview on 12/23/2025 at 10:19 a.m., with the ADM, the ADM stated that she (ADM) is the facility's
abuse coordinator. The ADM stated that on 12/18/2025 when the incident was reported to her (ADM) by RN
1, she did not think that the tickling of resident 1's foot by Resident 2 was sexual in nature. The ADM
continued to state that if the facility knew it was sexual in nature, she would have reported the allegation of
sexual abuse. The ADM stated that she (ADM) did not conduct a thorough investigation nor complete or
submit a written five (5) day follow-up investigation report because she (ADM) did not think the incident
reported on 12/18/2025 was abuse of any kind. During an interview on 12/23/2025 at 10:26 a.m., with the
Director of Nursing (DON), the DON stated that the facility did not suspect sexual abuse because Resident
1 and Resident 2 are friends. Resident 1 is alert and oriented and is able to defend herself. During a review
of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation, last
reviewed on 1/8/2025, indicated all reports of resident abuse (including injuries of unknown origin), neglect,
exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies
(as required by current regulations) and thoroughly investigated by facility management. Findings of all
investigations are documented and reported. If resident abuse, exploitation, misappropriation of resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056133
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056133
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
West Hills Health and Rehabilitation Center
7940 Topanga Canyon Blvd.
Canoga Park, CA 91304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
property or injury of unknown source is suspected, the suspicion must be reported immediately to the
administrator and other officials according to state law. All allegations are thoroughly investigated. The
administrator initiates investigations. Within five (5) business days of the incident, the administrator will
provide a follow-up investigation report. The follow up investigation report will provide sufficient information
to describe the results of the investigation, and indicate any corrective actions taken if the allegation was
verified. The follow-up investigation report will provide as much information as possible at the time of
submission of the report. The residents and/or representative are notified of the outcome immediately upon
conclusion of the investigation. During a review of the facility's P&P titled Abuse, Neglect, Exploitation or
Misappropriation Prevention Program, last reviewed on 1/8/2025, the P & P indicated identify and
investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation.
Event ID:
Facility ID:
056133
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056133
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
West Hills Health and Rehabilitation Center
7940 Topanga Canyon Blvd.
Canoga Park, CA 91304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to implement policies and procedures (P&P) to ensure the
reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to
report an allegation of sexual abuse for one of two sampled residents (Resident 1) to the State Survey
Agency (SSA) within the required timeframe. This deficient practice had the potential to place Resident 1 at
risk for further sexual exploitation and resulted in a delay in the investigation of a suspicion of sexual abuse.
Findings:a). During a review of Resident 1's admission Record, the admission Record indicated the facility
admitted Resident 1 on 4/2/2025 with diagnoses including diverticulitis (inflammation or infection of small
pouches (diverticula) in the colon, causing symptoms like lower-left abdominal pain, fever, nausea, and
changes in bowel habits), moderate protein-calorie malnutrition (a severe deficiency from not getting
enough protein and calories (energy) to meet the body's needs), overactive bladder (a common condition
marked by a sudden, uncontrollable urge to urinate, often leading to frequent bathroom trips, nighttime
awakenings, and sometimes urine leakage before reaching the toilet), and major depressive disorder (a
mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of other
emotional and physical symptoms that significantly interfere with daily life). During a review of Resident 1's
Minimum Data Set (MDS- a resident assessment tool) dated 10/7/2025, the MDS indicated Resident 1 had
moderate cognitive (the mental process involved in knowing, learning, and understanding things)
impairment. The MDS indicated Resident 1 required partial/moderate assistance with toileting hygiene,
lower body dressing, and personal hygiene. b). During a review of Resident 2's admission Record, the
admission Record indicated the facility readmitted Resident 2 on 5/22/2024 with diagnoses including major
depressive disorder and unspecified dementia (a progressive state of decline in mental abilities). During a
review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment.
The MDS indicated Resident 2 required substantial/maximal assistance with toileting hygiene and
partial/moderate assistance with personal hygiene. During a review of Resident 1's Licensed Nurse Note
dated 12/18/2025, timed at 6:26 p.m., the Licensed Nurse Note indicated Resident 1 claimed Resident 2
came into Resident 1's room and tickled Resident 1's feet. The Licensed Nurse Notes indicated the Social
Service Director (SSD) was aware and will follow up to move Resident 1 to another room to avoid
problems. During an interview on 12/22/2025 at 1:15 p.m. with Resident 1, Resident 1 stated that on
Wednesday evening, not sure what time, on 12/17/2025, Resident 2 entered Resident 1's room. Resident 1
stated that Resident 1's roommate is Resident 2's mother, consequently, Resident 2 comes in Resident 1's
room often. On the evening of 12/17/2025, Resident 1 was lying in bed with her eyes closed and awake.
Resident 2 came to Resident 1's side of the bed, placed his hand underneath Resident 1's blanket and
tickled Resident 1's left foot. Resident 1 stated that she was startled and told Resident 2 to stop. Resident 1
stated that when she told Resident 2 to stop, he stopped and exited the room. Resident 1 stated that she
thought that Resident 2 wanted to have sex with her. Resident 1 stated that she did not consent to be
tickled by Resident 2. Resident 1 continued to state that she did not report the incident on 12/17/2025.
However, she reported the incident to Certified Nursing Assistant 1 (CNA 1) the following morning on
12/18/2025. During an interview on 12/22/2025 at 1:54 p.m., with the SSD, the SSD stated that the SSD
was made aware that Resident 2 made Resident 1 feel uncomfortable when Resident 2 tickled Resident 1's
feet on 12/18/2025 at around 9 a.m. During an interview on 12/22/2025 at 2:20 p.m., with CNA 1, CNA 1
stated that on the morning of 12/18/2025, at around 7:45 a.m., Resident 1 informed CNA 1 that Resident 2
came into Resident 1's room and tickled Resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056133
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056133
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
West Hills Health and Rehabilitation Center
7940 Topanga Canyon Blvd.
Canoga Park, CA 91304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
1's feet. CNA 1 stated that she reported the incident to Licensed Vocational Nurse 1 (LVN 1) because
Resident 1 was about to cry when Resident 1 was talking about the incident. CNA 1 stated that Resident 2
touching Resident 1's feet without Resident 1's permission is inappropriate. Residents should not be
touching other residents without permission. During an interview on 12/22/2025 at 2:45 p.m. with LVN 1,
LVN 1 stated that on 12/18/2025, at around 8 a.m., CNA 1 reported to LVN 1 that Resident 1 reported to
CNA 1 that Resident 2 tickled her foot last night (12/17/2025) and was crying. After CNA 1 reported to LVN
1, LVN 1 went to check on Resident 1. LVN 1 stated that she asked Resident 1 what happened and
Resident 1 reported to LVN 1 that on the evening of 12/17/2025, Resident 2 came into Resident 1's room
and tickled Resident 1's foot. LVN 1 stated that she asked Resident 1 if Resident 2 touched her anywhere
else and Resident 1 responded No. LVN 1 continued to state that Resident 1 stated that she thought
Resident 2 wanted to have sex with her (Resident 1). LVN 1 stated that after Resident 1 reported to her
(LVN 1), LVN 1 reported the alleged incident to Registered Nurse 1 (RN 1). LVN 1 further stated she
reported the incident to RN 1 because the incident between Resident 1 and Resident 2 is possible sexual
abuse because Resident 2 touched Resident 1 without Resident 1's consent. During an interview on
12/22/2025 at 3:08 p.m. with RN 1, RN 1 stated that on 12/18/2025 at around 8:45 a.m. LVN 1 reported to
her that Resident 2 tickled Resident 1's foot without Resident 1's consent and Resident 1 reported that she
thought Resident 2 wanted to have sex with her. RN 1 stated that Resident 2 does not have the right to
tickle or touch anyone without their consent, that's a type of sexual abuse. RN 1 stated that in RN 1's
professional opinion, the alleged tickling was an alleged sexual abuse which is why RN 1 reported the
incident to the Administrator (ADM) who is the abuse coordinator. During an interview on 12/23/2025 at
10:19 a.m., with the ADM, the ADM stated that she (ADM) is the facility's abuse coordinator. The ADM
stated that on 12/18/2025 at around 9 a.m. when the incident was reported to her (ADM) by RN 1, she
(ADM) did not think that the tickling of Resident 1's foot by Resident 2 was sexual in nature. The ADM
continued to state that if the facility knew it was sexual in nature she (ADM) would have reported the
allegation of sexual abuse. The ADM stated that because she (ADM) did not think the incident was sexual
in nature the ADM did not report the alleged sexual abuse to the SSA. During a review of the facility's P&P
titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation, last reviewed on
1/8/2025, the policy indicated, all reports of resident abuse (including injuries of unknown origin), neglect,
or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required
by current regulations) and thoroughly investigated by facility management. If resident abuse, neglect,
exploitation, misappropriation of resident property or injury of unknown source is suspected the suspicion
must be reported immediately to the administrator and to other officials according to state law. The
administrator or the individual making the allegation immediately reports his or her suspicion to the
following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing
the facility.b. The local/state ombudsman. c. The resident's representative.d. Adult protective services
(where state law provides jurisdiction in long term care); e. law enforcement officials; f. the resident's
attending physician; g. and the facility medical director.
Event ID:
Facility ID:
056133
If continuation sheet
Page 5 of 5