Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookdale Westlake Village during CMS and state inspections, most recent first.
The facility failed to maintain appetizing food temperatures for residents receiving room tray service. Food committee notes documented ongoing complaints about the temperature of room-delivered meals, and a resident reported that meals were not always warm and staff would not reheat them. Observations of the tray line showed significant delays between food preparation, holding in satellite kitchen steam tables, plating, and delivery, with some trays sitting for extended periods before leaving the kitchen. A test tray taken from a room tray cart showed multiple hot items at only lukewarm temperatures while one vegetable item was not warm, despite facility policy requiring that food and beverage temperatures be maintained during transport.
The facility failed to consistently implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP) and outbreak surveillance. One resident with a midline catheter receiving IV antibiotics had an EBP care plan and door signage requiring gown and gloves for high-contact device care, yet an LPN flushed the midline and disconnected the IV without wearing a gown. Another resident with pressure ulcers on both buttocks and EBP orders for wounds received extensive morning care, including toileting, hygiene, and dressing, from a CNA who did not wear a gown despite posted EBP instructions, and an LPN later wore an isolation gown out of the room and discarded it in a treatment cart trash before re-gowning. Separately, during a scabies outbreak, only one resident with Norwegian scabies was listed on the infection control log even though multiple residents were diagnosed with or treated for scabies or received prophylactic treatment; infection line lists, contact tracing forms, and outbreak tracking tools were incomplete, missing, or not clearly linked to the specific outbreak, and leadership acknowledged that dermatologic infections were not being captured correctly in the infection tracking system.
A resident with severe cognitive impairment, total incontinence, and multiple comorbidities was left in stool and urine for an extended period when CNAs were unclear about assignment coverage during a short-staffed morning shift. The resident’s room smelled of stool, and although an LPN entered to apply powder under the breasts, incontinence care was not provided until later, when a CNA discovered a large bowel movement soiling the perineal area, bed pad, and sheet. Upon cleaning, staff observed red, open thigh creases and deep red, excoriated skin over the buttocks extending to the lower back, despite a care plan requiring regular incontinence checks and perineal cleansing.
The facility failed to maintain an adequate supply of washcloths and towels for residents’ daily hygiene, leading staff to use disposable incontinence wipes or paper towels instead of proper linens. A cognitively intact resident with muscle weakness and pressure ulcers, who required assistance with ADLs and was care-planned to use washcloths with step-by-step guidance, was observed being fully washed with disposable wipes because no washcloths or towels were available. Checks of linen closets on both floors found no washcloths or towels, and CNAs reported this shortage occurred several days a week, leaving residents unable to wash until laundry was completed. The Director of Housekeeping and the Administrator acknowledged the ongoing problem, citing laundry practices, lack of backup stock, and staff discarding or hoarding linens, while multiple residents and an RN confirmed repeated mornings without washcloths or towels and unresolved concerns raised in resident council meetings.
A resident with diabetes was given the wrong insulin type and dose by an agency LPN, who administered short-acting insulin instead of the prescribed long-acting insulin. The error was discovered after the resident questioned the dosage, leading to a hospital visit for observation. The facility's policy on medication verification was not followed.
Failure to Maintain Appetizing Food Temperatures for Room Tray Service
Penalty
Summary
The facility failed to ensure food was served at appetizing temperatures, affecting residents who received meals on room trays. Food committee meeting notes over several months documented resident complaints about food temperatures for room tray deliveries, and residents met with dietary leadership to discuss adjusting the food delivery route. One resident reported that while the food was seasoned well, it was not always warm enough and staff would not reheat it; the resident obtained a microwave to heat her food but was not allowed to keep it and therefore had to eat the food as served. The Director of Dining Services (DDS) explained that all food was cooked in the main kitchen, transported to satellite kitchens, held on steam tables, and then plated for both dining room and room tray service, with insulated plates and covers used to help maintain warmth. Direct observation of the lunch tray line showed delays between food leaving the main kitchen, being placed in the satellite kitchen steam tables, and being plated and delivered, particularly for room trays. On one day, a cart left the main kitchen at 11:32 A.M., arrived at the second-floor satellite kitchen at 11:37 A.M., and food was not placed in the steam table until 11:43 A.M.; dining room meals were plated first at 11:58 A.M., and room trays were not plated until 12:22 P.M., with the first cart of room trays not leaving until 12:37 P.M., meaning at least one tray sat for 15 minutes before leaving the kitchen. On another day, a test tray placed on the last cart of room trays was delivered and immediately temperature-checked, revealing crumb baked sole at 147°F, chicken tenders at 120°F, green beans at 109°F, braised lima beans at 119°F, fruit at 56°F, and cream of cauliflower soup at 131°F. The DDS confirmed that several items were only lukewarm and that the green beans were not warm, and facility policy required that food and beverage temperatures be maintained during transport.
Failure to Implement Enhanced Barrier Precautions and Track Scabies Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, including Enhanced Barrier Precautions (EBP) and proper tracking of infections, specifically scabies. For one resident with a midline catheter receiving IV cefazolin for a prosthetic joint infection, the care plan and physician orders required EBP, including use of gown and gloves for high-contact care and device care. During an observed medication administration, an LPN flushed the resident’s midline catheter and disconnected the IV antibiotic without donning an isolation gown, despite an EBP sign on the resident’s door stating that staff must wear gloves and a gown for high-contact activities including device care and use. The LPN reviewed the sign and confirmed she had not worn a gown during the procedure. Another resident with stage 3 and stage 2 pressure ulcers on the buttocks, who required assistance with mobility, toileting, dressing, and hygiene, also had orders for EBP related to wounds. During observed morning care, a CNA provided extensive hands-on assistance, including helping the resident to stand and ambulate to the bathroom, removing a urine-soiled brief, and performing full hygiene and dressing care. The resident had dressings on both buttocks that were rolling up and not fully intact. The CNA did not don an isolation gown at any point during this high-contact care, despite an EBP sign at the room entrance specifying that gloves and gown were required for dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and wound care. Later, during wound care for the same resident, both the LPN and CNA initially donned gowns and gloves, but the LPN exited the room wearing the gown, removed it outside the room to obtain more supplies, and disposed of it in the treatment cart trash before returning and donning a new gown. The resident stated this was the first time staff had worn a gown for any care. The DON stated that isolation gowns were to be removed and disposed of in the trash can prior to exiting a resident room on EBP. The facility also failed to properly track and document a scabies outbreak in its infection control log and related surveillance tools. One resident was diagnosed with Norwegian (crusted) scabies and treated with ivermectin, and the infection control log listed only this resident for scabies. Additional residents were later diagnosed with or treated for scabies, including residents who complained of itching and rash, were evaluated by dermatology, and were prescribed ivermectin, permethrin cream, and other topical treatments, with some placed in contact precautions. However, these additional residents were not included on the infection control log. Interviews with the social worker, administrator, DON, and county health department disease investigators revealed that multiple residents were treated for scabies or prophylactically treated, but the facility’s infection tracking documents, line lists, and contact tracing forms were incomplete, missing, or not clearly associated with a specific outbreak period. The DON acknowledged that the infection control log did not capture dermatological infections when reports were run from the electronic medical record and that the facility needed to do a better job of tracking infections. Review of outbreak-related tools and checklists from the state health department showed that daily skin assessments for all at-risk persons and prophylactic treatment documentation for contacts, including staff and family, were not fully completed, and sample line lists and data sheets were left blank or only partially filled out. The administrator confirmed that emails and other records related to the scabies outbreak were not saved correctly and that some documentation could not be provided or was only available in pieces.
Failure to Provide Timely Incontinence Care Resulting in Prolonged Soiling
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was always incontinent of bowel and bladder and required extensive assistance with mobility and transfers. The resident, admitted with diagnoses including chronic kidney disease, muscle weakness, overactive bladder, anxiety disorder, and polyneuropathy, was care planned to be checked as required for incontinence and to have the perineum washed, rinsed, and dried. On the morning in question, surveyors observed the resident awake in bed in a room that smelled of stool; the resident stated she had “pooped a little” and that a staff member had said she would return shortly. Later that morning, an LPN entered the room only to apply powder under the resident’s breasts and then left, without addressing the incontinence. At approximately 10:00 A.M., a CNA providing incontinence care found the resident with a large bowel movement extending into the perineal area, with the bed pad and sheet soiled with stool and urine. After the stool was removed, the resident’s bilateral thigh creases were observed to be red and open along the crease lines, and the buttocks were deep red and excoriated over the entire buttocks to the lower back. The CNA reported she had started her shift at 8:00 A.M. and had not yet seen the resident, as another staff member was supposed to cover until her arrival. Another CNA, who started at 6:30 A.M., stated there had been a call-off and only two CNAs on duty, and she did not realize she was assigned to cover this resident; although she delivered the resident’s breakfast tray, she did not check or change the resident and only told her someone would be with her. The DON stated residents should be checked for incontinence at least every two hours and changed immediately if lying in stool.
Ongoing Lack of Washcloths and Towels Limits Residents’ Ability to Perform Daily Hygiene
Penalty
Summary
The facility failed to ensure a sufficient supply of washcloths and towels was available for residents’ morning care and as needed, resulting in residents being washed with disposable wipes or unable to wash at all. One cognitively intact resident, admitted with diagnoses including myocardial infarction, muscle weakness, and stage three and stage two pressure ulcers to the buttocks, required assistance with ADLs and incontinence care. This resident’s care plan included instructions for staff to provide simple, step-by-step guidance for self-care tasks such as using a washcloth to wash the face. During observed morning care, the CNA assisting this resident used disposable wipes intended for incontinence care to wash the resident’s face and entire body because there were no clean washcloths or towels available, despite the resident expressing a preference to have at least a washcloth for the face. Further observations on both floors of the skilled nursing facility showed that the linen closets on all halls contained no washcloths or towels for resident use. CNAs confirmed that these closets were the only storage areas for washcloths and towels on their respective floors and reported that this lack of linens occurred on multiple days, with residents sometimes having to wait until laundry was completed before they could be washed for the day. The Director of Housekeeping explained that laundry staff worked an eight-hour shift starting between 7:00 and 8:00 a.m., and that they washed tablecloths and napkins first upon arrival. She confirmed that there were no clean towels or washcloths available that morning for any residents, that she ordered linens monthly, and that staff frequently threw linens away. She also confirmed there was no backup supply in stock and that staff reported the lack of towels and washcloths two to three times per week. Interviews with nursing staff and residents corroborated that the shortage of washcloths and towels was an ongoing issue. A registered nurse stated that on some days there were no washcloths or towels in the mornings, and that residents could only use wipes for their bottoms. Multiple residents reported that there were times they could not wash up in the mornings due to the lack of washcloths and towels, with one resident stating they had to use paper towels instead. The Administrator acknowledged awareness of the ongoing problem and stated that it was especially an issue when agency staff worked, as they either discarded linens or hoarded them in certain residents’ rooms. Resident council minutes documented unresolved concerns about insufficient towels and toilet paper in residents’ bathrooms and for showers, and noted that the council had previously met with the Administrator about the towel issue.
Medication Error in Diabetes Management
Penalty
Summary
The facility failed to ensure that medications to treat diabetes were administered as ordered by the physician, resulting in a significant medication error for a resident with diabetes mellitus. The resident had physician orders for Novolog FlexPen to be administered with meals and Insulin Detemir to be administered at bedtime. On the night of the incident, the resident was mistakenly given the wrong type of insulin by an agency nurse, who administered short-acting insulin (Novolog) instead of the prescribed long-acting insulin (Insulin Detemir). This error was discovered after the resident questioned the nurse about the dosage, leading to the realization that the long-acting insulin was out of stock. The resident's blood sugar was checked and found to be 125, prompting a virtual consultation with the physician and the resident's request to be sent to the hospital for observation. The resident returned to the facility without new orders from the hospital. Interviews confirmed the medication error, and it was noted that the agency nurse involved was not to return to the facility. The facility's policy on medication administration requires staff to verify the correct medication and dose before administration, which was not followed in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westlake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crocker Pointe Health And Rehabilitation | 0.6 mi | — | 1 | 0 |
| Lutheran Home | 1.5 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Westlake | 1.6 mi | ★★★★★ | 8 | 0 |
| Joshua Tree Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Rae Ann Suburban | 1.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.