Health inspection·February 4, 2026

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a resident who was assessed as clinically appropriate to self-administer medications, had a physician's order to self-administer or store medications at bedside prior to self-administering or storing medications at bedside, and demonstrated the ability to safely and securely store medications for one of seven sampled residents (Resident 2). This deficient practice had the potential for other residents to access and ingest the medications, which could result in serious health complications and had the potential to result in unsafe medication administration or omission (the act of not including something that should have been included) for Resident 2.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/15/2026 with diagnoses including cirrhosis of liver (permanent scarring that damages the liver and interferes with its functioning), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic respiratory failure (CRF - a long-term condition that happens when the lungs cannot get enough oxygen into the blood ) with hypoxia (a dangerous medical condition where your body tissues are starved of enough oxygen to function properly). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 1/20/2026, the MDS indicated Resident 2 had the ability to make her understood and understand others. The MDS further indicated that Resident 2 needed supervision or touching assistance with eating, needed moderate assistance (helper provides less than half of the effort) from staff with oral hygiene, and needed maximal assistance (helper provides more than half of the effort) from staff with bed mobility (movement) and transfer. During a review of Resident 2's Self-Administration of Medication (SAOM) dated 2/2/2026, Registered Nurse 1 (RN 1) marked to indicate that Resident 2 was fully capable of storing medications in a secure location. During a review of Resident 2's physician's orders, the physician orders indicated the following orders: May leave the medications at bedside and can self-administer medications, XyliMelts (used to relieve dry mouth) and Biotene oral gel (a thick, soothing, saliva-substitute gel that acts as a long-lasting moisturizer for dry, sticky mouths). Order Date: 2/3/2026 timed at 3:32 p.m. Biotene oral gel, give two (2) centimeters (cm - a unit of measurement) by mouth as need for dry mouth, place directly on the tongue and spread thoroughly inside the mouth. May keep medications at bedside. Resident 2 notify charge nurses before taking medication. Order Date: 2/3/2026 timed at 5:17 p.m. XyliMelts 500 mg, give one (1) tablet by mouth every two (2) hours as needed for dry mouth, place on gum line, allow to dissolve. Do not chew or swallow. May keep medications at bedside. Resident 2 to notify charge nurses before taking medications. Order Date: 2/3/2026 timed at 5:28 p.m. During a concurrent observation and interview on 2/3/2026 at 10:23 a.m., in Resident 2's room, observed Resident 2 sitting in the wheelchair next to her bed. Resident 2 stated that she needed to take medications and pointed at the bottle of XyliMelts and Biotene oral gel which were on top of the resident's bedside table. When Resident 2 was asked if she was instructed to call a nurse prior to taking the medications, Resident 2 Residents Affected - Few Page 1 of 2 056133 056133 02/04/2026 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that the nurses knew she was taking these medications and she takes them whenever she needed to. Resident 2 further stated she keeps the medication on top of her bedside table. During a concurrent observation and interview on 2/3/206 at 10:36 a.m., in Resident 2's room, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 observed XyliMelts and Biotene oral gel on top of Resident 2's bedside table. LVN 1 stated that he was not aware that the resident was taking both medications and storing them at bedside. LVN 2 stated he will check if there was a physician's order for the resident to self-administer or store them (medications) at bedside. Observed Resident 2 take a tablet of XyliMelts while LVN 2 was out of the room. When LVN 2 returned to the room, LVN 2 stated there were no orders for Resident 1 to self-administer or store XyliMelts and Biotene oral gel at bedside. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 2/4/2026 at 8:43 a.m., RN 1 reviewed Resident 2's SAOM dated 2/2/2026 and stated that RN 1 received a report from the staff on 2/2/2026 that Resident 2 had medications at her bedside and wanted to keep them at her bedside. RN 1 stated that she conducted the assessment and concluded that Resident 2 was alert and oriented and was able to correctly demonstrate how to take XyliMelts and Biotene oral gel and how often they were to be taken, so she completed most sections of the assessment including the section that indicated the resident was capable to self-administer safely including storing the medications in a secure location. RN 1 stated she did not obtain a physician's order for Resident 2 to self-administer or store the medications on the day she completed the SAOM assessment. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 2/4/2026 at 10:11 a.m., the ADON reviewed Resident 2's physician order for self-administration of medications for XyliMelts and Biotene oral gel and stated that RN 1 completed the SAOM assessment on 2/2/2026, however , RN 1 did not notify Resident 2's physician to obtain orders for the resident to self-administer or store the medications at bedside, on 2/2/2026. The ADON further stated that Resident 2's medications should be stored in a secure location for safety reasons. The ADON stated leaving medications on the bedside table had the potential to allow cognitively impaired residents access to the medications. During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, last reviewed 1/7/2026, the P&P indicated, Self-administrated medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. During a review of the facility's P&P titled, Administering Medications, last reviewed on 1/7/2026, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. 056133 Page 2 of 2