Health inspection·May 5, 2025

The following reflects the findings of the California Department of Public Health during a recertification survey of Westwood Post Acute, conducted from 4/14/2025 to 4/18/2025. Survey findings included the investigations of two Facility Reported Incidents CA00956740, CA00957232, and one Complaint CA00957316. Event ID: DJUX11. The resident census at the time of survey was 251. The total final sample size was 36. An "E" level deficiency was issued for the two Facility Reported Incidents CA00956740, CA00957232, and one Complaint CA00957316 (see F600). A "Class B" citation was issued for the following violation: F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. From 4/14/2025 to 4/18/2025, an unannounced visit was conducted at the facility for a recertification survey and to investigate two Facility Reported Incidents and one Complaint regarding abuse. Based on interview and record review the facility failed to protect two of 36 sampled residents (Resident 21 & Resident 445) from physical abuse. When: 1.Resident 231 was observed to physically hit Resident 21 2. Resident 231 was observed to physically hit Resident 445 These failures resulted in Resident 21 and Resident 445 to be physically abused by Resident 231. Findings: 1. During a review of the facility's SOC 341 (mandated report of suspected dependent adult/elder abuse form) dated 4/12/25, indicated an abuse allegation was reported to the California Department of Public Health (CDPH). SOC 341 indicated, "Victim [Resident 21]. . .suspected abuser [Resident 231]". SOC 341 indicated, "At approximately 8:05 AM on 4.12.25, Resident [231] had hit another resident [Resident 21] in the face and pushed her to the floor. CNA had witnessed the incident and immediately ran over, called for help and separated both residents". SOC 341 indicated, "Reported Type of Abuse Physical". . . Abuse resulted in Minor medical Care" During a review of Resident 231's Change in Condition Assessment dated 4/12/25, Assessment indicated, "0715 [7:15 a.m.] received resident awake, alert, and responsive. Ups and ambulates along the hallway of the unit with anger outburst with staff, pacing around the unit. . .0805 [8:05 a.m.] Resident was walking down the hallway when he struck another resident [Resident 21} in the face and pushed her to the ground. Resident [231] also tried to hit the charge nurse and chased her. . . Resident is not easily redirectable. Resident becomes very aggressive toward staff and other residents. CNA witnessed the incident. During a review of Resident 21's Change in condition assessment dated 4/12/25, assessment indicated, "Resident was hit in the face by another resident. . . Redness to the left side of face." During an interview on 4/17/25 at 9:42 a.m, with Certified Nursing Assistant (CNA) C, CNA C stated, she saw Resident 231 walking in the hallway toward the activity room and Resident 21 was walking back to her room. CNA C stated, they crossed paths (Resident 21 and 231) and out of nowhere Resident 231 slapped Resident 21 on the side of the face without being provoked and just kept walking. CNA C stated Resident 21 fell onto the floor from being slapped by Resident 231. CNA C stated, she had witnessed Resident 231 be aggressive in the past, she stated she observed him try to pick up a chair and hit her when cleaning his meal tray after a meal. During a review of the Facility's Investigative Report for Resident 21 and Resident 231's abuse incident dated, 4/15/25, report indicated, "from witness account interviews. The incident occurred between Resident [231] and Resident [21] as they crossed paths in the hallway". 2. During a review of the facility's SOC 341 dated 4/15/25, report indicated, "Victim [Resident 445] . . . Suspected Abuser [Resident 231]. . . At approximately 3:30 PM on 4.14.25. CNA was also present during the time of incident. Here is his account of the events: Resident [231], (perpetrator) was not in activities room. Resident [231] had then ran into the activities room, sat on the table where Resident [445] (victim) was sitting and slapped resident twice on her head. . . reported type of abuse physical". During a review of Resident 445's Change in condition assessment dated 4/15/25, assessment indicated, "Resident was hit by another resident in the activity room. . . at approximately 3:15 pm. [Resident 445] was sitting in the activity room watching tv and [Resident 231] went into the room and suddenly without provocation he hit her in the left forehead [sic]. . . [Resident 445] sustained a redness on the LEFT forehead". During an interview on 4/16/25, at 3:15 p.m., with Certified Nursing Assistant (CNA) H, CNA H stated, he was in the activity room on 4/15/25 at around 3:15 p.m., and witnessed Resident 231 come into the activity room table where Resident 445 was sitting calmly. CNA H stated, he saw Resident 231 out of nowhere slap Resident 445 several times. During a review of the Facility's Abuse investigation report dated, 4/17/25, report indicated, "At approximately 3:30 PM on 4.15.25 Resident [445] was sitting in the activities room participating. . . CNA was present during the time of the incident and these are his accounts of the event: Resident [231] was not in the dining room participating in activities. Resident [231] ran into the activities room, sat on the table where Resident [445] was sitting and slapped resident [445] twice on her head. During a review of the facility's Policy & Procedure (P&P) titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program" dated 2021, the P&P indicated, "Resident have the right to be free from abuse. . . this includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. . . The resident abuse, neglect and exploitation program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse. . . by anyone including. . . other residents". These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.