Health inspection·December 23, 2025

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 Page 1 of 5 056133 056133 12/23/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

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 056133 Page 2 of 5 056133 12/23/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 056133 Page 3 of 5 056133 12/23/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

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 056133 Page 4 of 5 056133 12/23/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 056133 Page 5 of 5