Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eisenberg Village during CMS and state inspections, most recent first.
Failure to Monitor Orthostatic BP with Antipsychotic Use: Two residents receiving antipsychotic meds had no documented orthostatic BP monitoring despite physician orders and care plan directions to watch for orthostatic hypotension. One resident had a history of syncope, dementia, and CKD with Zyprexa ordered and side-effect monitoring required; the other had dementia and psychosis with olanzapine ordered, repeated orthostatic BP orders in the eMAR/MAR, and a pharm recommendation for weekly checks. Staff and the DON confirmed the monitoring was not completed or documented as ordered.
CAA assessments were not completed within the required 14-day timeframe for 7 sampled residents. The MDS nurse confirmed the CAAs were still being modified after the deadline for residents with significant cognitive impairment and extensive ADL dependence, including residents with dx such as dementia, Alzheimer’s disease, CVA, dysphagia, malnutrition, and metabolic encephalopathy.
Pain medication administration was not documented on the MAR for a resident with low back pain and severe cognitive impairment. Tramadol PRN was removed from the controlled drug record on multiple occasions, but there was no corresponding MAR entry, and the DON confirmed that without MAR documentation there was no record of pain assessment before or after the medication was given. The facility’s pain management policy required PRN pain meds to be documented with the dose, time, pain scale rating, resident response, and follow-up pain scale within one hour.
A resident with severe cognitive impairment had Tramadol removed from the cart on multiple occasions, but the CDR and MAR did not match, with some doses missing from the MAR and others documented more than an hour after removal. Another resident with dementia and psychosis was prescribed olanzapine, and the ordered orthostatic BP monitoring was not documented on the MAR despite a pharmacist recommendation and staff confirmation that the order had been entered incorrectly in the eMAR.
Medication labeling and storage were deficient when an eye drop was kept past the manufacturer’s discard timeframe, a Midodrine bubble pack label did not match the eMAR order for hold parameters, and multiple psychotropic medications lacked required black box warning identification on bubble packs and MARs. The issues involved residents with glaucoma, hypotension, Alzheimer’s disease, depression, bipolar disorder, and severe cognitive impairment, and included LPN and RN observations as well as DON and pharmacist review.
Food storage, equipment sanitation, and clean-area controls were deficient in the dietary department. An open box of peanuts was found exposed, dented cans were stocked with regular inventory, food processor blades and a vegetable dicer had visible debris, one disc blade was damaged with a jagged edge, and personal items plus a soiled rag were observed in areas holding clean and sanitized cookware. The DSM and DS1 acknowledged the items should not have been stored or left in those locations.
A facility failed to ensure a binding arbitration agreement was explained to 4 residents' representatives in a way they could understand. The residents had dementia and severe cognitive impairment, and family members signed the arbitration paperwork electronically during admission without understanding what it was or that it was voluntary. Staff stated the arbitration form was included within the admission packet and was only explained if families asked questions, which did not match the facility policy requiring it to be separate and verbally explained.
Failure to Knock Before Entering Resident Room: An LVN entered a resident’s room during med pass without knocking before entry. The resident was able to make self-understood and understand others, and required substantial/maximal assistance with ADLs. The LVN stated she should have knocked as a sign of respect and that the resident’s dignity and privacy should be promoted at all times.
Survey Results Not Accessible to Residents: Survey results binders were observed in dining room corners and reflected only the last survey date, despite the Administrator stating additional surveys had occurred. Five residents said they were not aware of the most recent survey results or where to find them. The facility policy required the most recent survey, complaint investigations, and any plan of correction to be available in prominent, accessible public areas.
Failure to Monitor Orthostatic BP as Ordered: A resident with syncope, dementia, and CKD was prescribed Zyprexa with an order to monitor for side effects each shift, including orthostatic hypotension. The care plan also directed staff to monitor for orthostatic hypotension every shift, but the record lacked documented evidence that orthostatic BP monitoring had been performed after re-admission, and an RN confirmed the intervention was not implemented.
A resident with hypotension and dysphagia had an order for Midodrine 5 mg PO BID, to be held only if SBP was greater than 120 mmHg. During record review, the resident’s BP was 110/56 mmHg at the scheduled dose time, but the dose remained in the bubble pack and was documented as held instead of administered. The RN stated the medication should have been given per the order and identified the omission as a medication error.
Failure to Notify Physician When SSTI Criteria Were Not Met: A resident was prescribed erythromycin ophthalmic ointment for blepharitis, but the IPN determined the SSTI criteria were not met. The IPN did not notify the physician, and there was no documentation in the chart showing physician notification by any member of the care team. The DON stated the ordering physician should be notified when infection criteria are not met and that the notification should be documented in the medical record.
A resident with dementia and Alzheimer's, whose primary language was Farsi, was not provided with a communication board, hindering communication with staff. The resident's care plan included the use of a communication board, but it was unavailable, and no staff spoke Farsi. The facility's policy required communication tools for non-English speakers, but this was not adhered to.
The facility failed to lock wheelchair brakes for two residents, both with severe cognitive impairments and high fall risk, as per their care plans. Observations revealed unlocked brakes, confirmed by staff, despite the facility's policy requiring locked brakes for seated residents. Interviews with the DSD and DON reiterated the importance of this safety measure.
A medication cart was found unlocked and unattended in the nurse's station, with residents and staff passing by. The MDSN and LVN 1 confirmed the cart belonged to an LVN on lunch, and both acknowledged it should be locked to prevent unauthorized access. The DON reiterated the importance of keeping medication carts locked when unattended, in line with the facility's policy.
Two residents were found to be on psychotropic medications without specific, measurable target behaviors as required by facility policy. One resident, non-verbal, was prescribed Zoloft for verbalization of sadness, while another was on Seroquel for sudden verbal agitation without clear indicators of psychosis. The facility failed to clarify these orders, leading to inaccurate monitoring and potential risks.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate due to the omission of Sinemet and Terazosin for a resident with multiple diagnoses. Miscommunication among nursing staff led to the incorrect holding of these medications, despite physician orders to administer them.
A resident with Parkinson's disease and BPH did not receive prescribed medications due to miscommunication among nursing staff. RN 1 and LVN 4 were instructed to hold medications contrary to physician's orders, leading to significant medication errors. The DON confirmed the medications were not administered as required.
The facility failed to label several food items with a use by date, including oatmeal, powdered sugar, quinoa, bulgur, cream of wheat, lemon curd, chicken, and ground beef, as observed with the Dietary Supervisor. Additionally, expired chlorine test strips were used to check the sanitizing solution, as noted with the Kitchen Supervisor. These practices could lead to foodborne illness and compromised dishware sanitation.
A facility failed to follow infection control guidelines in three instances: a nurse left a resident's room wearing an isolation gown, a housekeeper entered a room under droplet precautions without eye protection, and an LVN did not wash hands between administering eye drops to a resident. These actions were against the facility's policies, potentially increasing the risk of infection spread.
A resident with dementia and a suprapubic catheter repeatedly refused catheter care, but the facility failed to notify the physician as required. The resident's cognitive skills were severely impaired, and they were dependent on staff for personal care. Despite multiple refusals documented in the Treatment Administration Record, there was no record of physician notification, which is a deficiency in communication and care management.
The facility failed to develop care plans for a resident refusing to wear a mask while on contact/droplet precautions and another resident refusing care for a suprapubic catheter. The first resident, with severe cognitive impairment, was observed without a mask despite physician orders. The second resident, also with severe cognitive impairment, refused catheter care multiple times, and there was no documentation of physician notification or updated care plans. These deficiencies could delay necessary care and increase infection risk.
A facility failed to update a resident's care plan after the removal of an indwelling urinary catheter. The resident, with severe cognitive impairment and multiple diagnoses, had their catheter discontinued per a physician's order. Despite this, the care plan was not revised to reflect the change, as confirmed by staff interviews and record reviews.
A facility failed to provide a communication device in a language understood by a resident with severe cognitive impairment and multiple medical conditions. Despite the care plan's intervention to provide a communication board in Farsi, the resident did not have access to one, hindering effective communication and potentially leaving the resident's needs unmet.
A resident at risk for pressure ulcers was found to be lying on a low air loss mattress (LALM) that was not properly monitored for functionality. The resident, who was severely cognitively impaired and dependent on staff, had a care plan requiring the use of a LALM for skin management. However, staff failed to document the monitoring of the LALM, and the physician's order was not properly recorded, leading to a lack of follow-through. This oversight was confirmed by the DON, who acknowledged the absence of documentation and monitoring.
A facility failed to act on a Pharmacy Consultant's recommendation to clarify the behavior manifestation for Seroquel use in a resident with dementia and psychotic disorders. The resident's Seroquel order lacked a specific behavior to monitor, leading to inaccurate monitoring and potential exposure to side effects. Despite facility policies requiring clarification of inappropriate psychotropic medication orders, the facility did not follow up on the recommendation.
A facility failed to remove a discontinued medication, amlodipine, from a medication cart, risking accidental administration to a resident with hypertensive heart disease and cognitive impairment. The medication was supposed to be removed immediately upon discontinuation, as per facility policy, but was found during an inspection.
The facility failed to ensure hospice service provision for two residents, lacking documentation of hospice staff visits and not providing required hospice care training to staff, as confirmed by the DON and MRTM.
Failure to Monitor Orthostatic Blood Pressure for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to monitor orthostatic blood pressure for two residents who were prescribed antipsychotic medications. For one resident, the record showed a history of syncope, dementia, and chronic kidney disease, and the physician order report included Zyprexa 2.5 mg by mouth twice daily with an order to monitor for side effects including orthostatic hypotension. During interview and record review, the resident’s chart did not contain documented evidence that orthostatic blood pressure monitoring had been performed since re-admission, and the RN confirmed that it was not performed. For the second resident, the record showed diagnoses including dementia and psychosis, severe cognitive impairment, and use of antipsychotic medication. The care plan included monitoring for side effects of olanzapine, including orthostatic hypotension. Physician orders included olanzapine and repeated orders to monitor orthostatic blood pressure for psychotropic medications. However, review of the MARs showed no orthostatic blood pressures were taken during the period reviewed, and the MRA and DON confirmed there were no documented orthostatic blood pressure entries in the resident’s MARs since the order was placed. The pharmacist had recommended weekly orthostatic blood pressure checks for the second resident because olanzapine can cause orthostatic hypotension. During interviews, nursing staff stated the order had been entered incorrectly into the eMAR and that the order should have appeared as a task for licensed nurses to complete on Saturdays. Facility policies reviewed during the investigation stated orthostatic vital signs shall be taken and recorded when ordered by the physician, and that psychotherapeutic medications require monitoring for therapeutic effectiveness and adverse consequences.
CAA Assessments Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to ensure Care Area Assessments (CAAs) were completed within the required timeframe for 7 of 7 sampled residents. The report states that the CAAs for residents 38, 56, 57, 58, 64, 82, and 84 were not completed no later than 14 calendar days from the Assessment Reference Date (ARD) as required by the CMS RAI User’s Manual. During interview and record review, the MDS nurse confirmed that each resident’s CAA should have been completed within 14 days of the ARD, but the worksheets were still modified after the required completion dates. Resident 38 was admitted with diagnoses including sepsis, metabolic encephalopathy, dementia, and hypertension, and the MDS showed severely impaired cognitive skills and need for moderate assistance with ADLs. Resident 56 was admitted with Alzheimer’s disease, dementia, overactive bladder, and hypertension, and the MDS showed severely impaired cognitive skills with moderate to maximum ADL assistance needs. Resident 57 had diagnoses including metabolic encephalopathy, dementia, and UTI, with severely impaired cognitive skills and dependence for ADLs. Resident 58 had dementia, CVA, dysphagia, and hypertension, with severely impaired cognitive skills and dependence for ADLs. Resident 64 was admitted with dementia, anxiety disorder, osteoporosis, and breast cancer, and the MDS showed severely impaired cognitive skills with moderate to maximum ADL assistance needs. Resident 82 was admitted with dementia, severe protein-calorie malnutrition, osteoarthritis, and dysphagia, and the MDS showed severely impaired cognitive skills with maximum ADL assistance needs. The report also identifies Resident 84 among the sampled residents affected by the same failure, but the narrative provided is cut off before the resident-specific details are fully listed.
Pain Medication Administration Not Documented
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not met for a resident admitted with diagnoses including low back pain. The resident’s MDS dated 12/18/2025 indicated severe cognitive impairment with skills required for daily decision making, and the resident required maximal assistance with eating and dressing. The physician ordered Tramadol 50 mg PRN every 12 hours for moderate to severe generalized pain on 12/15/2025, and the care plan for pain, initiated 12/12/2025, included a goal that the resident would demonstrate pain relief 30-60 minutes after intervention and directed staff to give Tramadol as ordered and observe for effectiveness and report unrelieved pain. Review of the CDR showed Tramadol was removed from the blister pack on 2/13/2026 at 5 p.m., 2/14/2026 at 5 p.m., 2/15/2026 at 5 p.m., and 2/20/2026 at 5 p.m., but these administrations were not documented on the 2/2026 MAR. During observation and record review, LVN 4 verified the discrepancies and stated the nurse should sign the CDR, give the medication, and then sign the MAR. The DON and LVN 1 stated that if pain medication administration is not documented on the MAR, there is no record of pain assessment before or after the medication was given, and the DON confirmed that no pain assessment was documented for those dates and times. The facility policy titled Pain Management, last reviewed 1/29/2026, required PRN pain medication to be documented on the MAR with the drug, time, dose, pain scale rating, resident response, and subsequent pain scale within one hour.
Medication Record Discrepancies and Missing Orthostatic BP Monitoring
Penalty
Summary
The facility failed to keep the Controlled Drug Record (CDR) and Medication Administration Record (MAR) consistent for a resident who had an order for Tramadol 50 mg every 12 hours as needed for moderate to severe generalized pain. The resident was severely cognitively impaired and required maximal assistance with daily activities. The CDR showed Tramadol removed from the medication cart on multiple dates, but the MAR did not show administration on several of those dates, and on other dates the MAR documented administration more than one hour after the medication was removed. During the medication cart observation and record review, the LVN and DON confirmed the discrepancies and described the expected process as signing the CDR, administering the medication, and then signing the MAR. The DON also stated that if the MAR was not signed, then pain was not assessed for those dates and times. The facility also failed to transcribe a physician's order onto the MAR for orthostatic blood pressure monitoring for a resident receiving olanzapine for psychosis. The resident had diagnoses including dementia and psychosis and was severely impaired in cognition. The care plan included monitoring for side effects of olanzapine such as orthostatic hypotension. The physician's orders included orthostatic blood pressure monitoring for psych medications, but the MARs did not show orthostatic blood pressures being taken from the time the order was entered until the date of review. The pharmacist had recommended weekly orthostatic blood pressure monitoring for the olanzapine order in the medication regimen review. During interviews, the MRA stated there were no documented orthostatic blood pressures in the MARs, and the DON confirmed there were no orthostatic blood pressure entries since the order was placed. The DON stated the order had been entered incorrectly in the eMAR as a nursing order rather than a physician order, and RN 4 stated she should have checked the eMAR to ensure the task appeared for the licensed nurses to complete on Saturdays. LVN 10 stated she did not remember taking orthostatic blood pressures for the resident and that such monitoring would normally appear in the eMAR for the licensed nurses to perform.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles when an eye drop medication for a resident with glaucoma was found on the medication cart with an open date that exceeded the manufacturer’s discard timeframe. The resident’s record showed an order for Latanoprost ophthalmic solution for glaucoma, and the MAR showed the medication was administered during the period reviewed. During the medication cart observation, the eye drops were present on the First Floor Team Two medication cart with an open date of 12/29/2025. The DON reviewed the manufacturer’s instructions and confirmed the medication should have been discarded after six weeks of opening, and that the resident received the medication beyond that timeframe. A second labeling issue involved a resident with hypotension who had an order for Midodrine 5 mg twice daily with instructions to hold the medication if systolic blood pressure was greater than 120 mmHg. During a medication pass, the resident’s blood pressure was 101/62 mmHg and the LVN administered Midodrine. Afterward, the Midodrine bubble pack was reviewed and the label stated to hold the medication if systolic blood pressure was less than 120 mmHg, which did not match the physician’s order in the eMAR. The nurse acknowledged the discrepancy and stated she followed the eMAR order, while RN 1 stated the inaccurate label was a lapse by the pharmacy and could potentially cause a medication error. The facility also failed to ensure prescription labels for medications with black box warnings were identified as such for four sampled residents. One resident with severe cognitive impairment and no decision-making capacity had Sertraline without a black box warning on the bubble pack or MAR. Another resident with Alzheimer’s disease, major depressive disorder, and bipolar disorder had Remeron without a black box warning on the bubble pack or MAR. A third resident with Alzheimer’s disease, depression, and a history of falls had Lexapro without a black box warning on the bubble pack or MAR. A fourth resident with severe cognitive impairment and dependence for many ADLs had Zyprexa and Mirtazapine bubble packs without black box warning labels. The pharmacist verified that Zyprexa and Mirtazapine carried black box warnings, and facility policy stated medications bearing a black box warning must be identified on prescription labels.
Food Storage, Equipment Cleaning, and Clean Area Contamination
Penalty
Summary
Food storage and kitchen sanitation practices were found deficient during observations and record review. In the dry storage area, an open cardboard box contained a punctured clear plastic bag of peanuts with loose peanuts exposed in the bottom of the box. The Dietary Services Manager stated dry foods should be covered and sealed to maintain freshness, prevent contamination, and reduce potential vectors for pests. The facility policy on General Sanitation stated kitchen areas shall be kept clean and protected from rodents, roaches, flies, and other insects, and the FDA Food Code was cited for requiring food to be protected from contamination by storage in packages, covered containers, or wrappings. In the same dry storage area, several canned goods were observed with dents, including mandarin oranges, beets, and strawberry preserves, and one can of mandarin oranges had a label that appeared soaked and stained by liquid. The Dietary Services Manager stated cans should be inspected upon delivery and compromised cans should be discarded or returned to the vendor before being stocked. The manager also stated dented cans may be a sign of compromised integrity and may promote foodborne illness. The FDA Food Code was cited for stating that food in hermetically sealed containers that are swelled or leaking is adulterated and that dented cans may present a serious potential hazard. In the kitchen preparation area, food-contact equipment was observed with residual debris, including disc blades and a manual vegetable dicer with off-white fibers and dried white debris on the grid and plunger. A separate disc blade was observed with a torn or chipped piece and a jagged sharp edge protruding from it. The Dietary Services Manager stated blades should be cleaned more thoroughly and agreed the damaged tip was not acceptable because it could fall into food and pose a physical contaminant. In addition, personal items and other contaminants were observed in clean and sanitized areas, including a sealed metal water canteen and rubber gloves hanging on a rack with clean pans, a paper cup with liquid on a shelf above the clean area of the dishwashing station, and a soiled rag left in the sanitized/clean area while dishes were air drying. Dietary staff stated these items should not be in the clean area and posed a risk to cross contamination.
Arbitration Agreement Not Properly Explained to Representatives
Penalty
Summary
The facility failed to ensure the binding arbitration agreement was explained to residents' representatives in a form and manner they could understand for 4 sampled residents. Each of the 4 residents had diagnoses that included dementia, and their MDS assessments indicated they were severely impaired in cognition with skills required for daily decision making. The records showed that each arbitration agreement was signed by a family member or representative rather than the resident. For Resident 10, Resident 16, Resident 33, and Resident 68, the arbitration agreements were signed electronically by family members during the admission process. Interviews with the family members showed they were unaware of the arbitration agreement or did not know what it was, and several stated they were asked to sign admission paperwork so the resident could be admitted. One family member requested a copy of the agreement after the fact, and another stated she signed without asking questions. The Admissions Director stated the arbitration agreement is emailed with the admission packet and that the admissions department explains the arbitration process only if the family has questions. The Admissions Assistant stated the arbitration agreement was included in the middle of the admission paperwork, was not separate from the admission documents, and that the responsible party could not complete the signing process without signing each required form. The facility policy stated the arbitration agreement must be separate from the admission agreement, clearly labeled as voluntary, not embedded within admission paperwork, and verbally explained as voluntary and not required for admission or continued care; the Admissions Director and Admissions Assistant confirmed they did not follow those practices.
Failure to Knock Before Entering Resident Room
Penalty
Summary
The facility failed to provide care in a manner that maintained a resident’s dignity and respect when a licensed nurse did not knock before entering Resident 24’s room during a medication administration observation. Resident 24 was originally admitted on 11/20/2023 and later readmitted with diagnoses including hypotension and dysphagia. The resident’s MDS dated 11/13/2025 indicated the resident could make self-understood and understand others, and required substantial/maximal assistance from staff for activities of daily living. During a concurrent medication pass observation and interview on 2/24/2026, Licensed Vocational 3 sanitized her hands, obtained a blood pressure machine from the medication cart, and entered Resident 24’s room and proceeded to the bedside without knocking on the door prior to entry. After taking the resident’s blood pressure, she returned to the medication cart and began preparing the resident’s morning medications. During interview, LVN 3 stated she should have knocked prior to entering the room as a sign of respect for the resident’s private space and stated the resident’s dignity and privacy should be promoted at all times. The facility policy titled Residents/Patient Dignity and Privacy, last reviewed on 1/29/2026, stated the facility provides care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal privacy and includes knocking on doors before entering and announcing your presence.
Survey Results Not Properly Posted for Resident Review
Penalty
Summary
The facility failed to promote resident rights to examine the results of the most recent survey by not posting reports for surveys, certifications, and complaint investigations from the three preceding years, along with any plan of correction in effect, in areas that were prominent and accessible to the public. During observation on 2/25/2026, survey results binder 2 was seen in the corner wall of the second-floor dining room, and survey results binder 1 was seen in the corner wall of the first-floor dining room. Both binders showed the facility's last survey as having been conducted on 3/6/2025. During the resident council task meeting interview on 2/24/2026, five residents stated they were not aware of the most recent survey results or where they were located. During interview on 2/26/2026, the Administrator stated that surveys had been conducted after 3/6/2025 and that the facility is responsible for updating the survey results binders whenever a survey is conducted. The Administrator also stated that the survey results binder is meant to provide open communication so staff, residents, and families are informed of the facility's current compliance status. The facility policy reviewed on 1/29/2026 stated that the most recent licensing visit report, complaint investigations, and related follow-up plan of correction should be available in prominent and accessible public areas for review.
Failure to Monitor Orthostatic Blood Pressure as Ordered
Penalty
Summary
The facility failed to implement a comprehensive care plan for Resident 3 by not ensuring orthostatic blood pressure monitoring was carried out in accordance with the physician's order. Resident 3 was originally admitted on 2/18/2019 and re-admitted on 2/11/2026 with diagnoses including syncope, dementia, and chronic kidney disease. The MDS dated 11/21/2025 indicated severely impaired cognition for daily decision-making and maximal assistance to dependent status for ADLs. The physician order report included an order dated 2/11/2026 for Zyprexa 2.5 mg by mouth twice daily, along with an order dated 2/12/2026 to monitor for side effects once per shift, including orthostatic hypotension. The care plan dated 2/17/2026 stated the resident would have no adverse effect from psychotropic medication and directed staff to monitor Zyprexa side effects every shift, including orthostatic hypotension. During interview and record review on 2/26/2026, RN 1 stated the resident's care was not implemented because the medical record did not contain documented evidence that orthostatic blood pressure monitoring had been performed since re-admission.
Medication Error: Midodrine Not Given Within Ordered Blood Pressure Parameters
Penalty
Summary
Resident 24 was admitted with diagnoses including hypotension and dysphagia and was assessed as able to make self-understood and understand others, while requiring substantial to maximal assistance with activities of daily living. The physician order for Midodrine 5 mg orally twice daily specified that the medication was to be held only if systolic blood pressure was greater than 120 mmHg. During interview and record review, the resident’s blood pressure on 2/23/2026 at 4:30 p.m. was 110/56 mmHg, but the scheduled Midodrine dose remained in the bubble pack and was documented as held rather than administered. The RN stated the medication should have been given because the systolic blood pressure was below 120 mmHg, and identified the omission as a medication error. The facility policy stated medications must be administered in a timely manner and in accordance with the attending physician’s written or verbal orders.
Failure to Notify Physician When SSTI Criteria Were Not Met
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for one resident who was prescribed erythromycin ophthalmic ointment for blepharitis. Resident 26 was admitted with diagnoses including dementia, Parkinsons disease, and major depressive disorder. The resident’s MDS indicated she could make herself understood and understand others, and the H&P stated she was able to make her own needs known and make her own medical decisions. A physician order dated 2/21/2026 prescribed erythromycin ointment 5 mg/gram, thin layer, to the eye twice daily. During review of the Infection Surveillance Checklist and progress notes, the Infection Preventionist Nurse stated the Skin and Soft Tissue Infection criteria were not met for the resident. She stated she did not notify the physician that the criteria were not met and that there was no documentation in the resident’s progress notes showing physician notification by any member of the health care team. The DON stated the antibiotic review is completed when antibiotics are ordered, the checklist is used to determine whether infection criteria are met, and the ordering physician should be notified when criteria are not met, with that notification documented in the medical record. The facility’s policies on Documentation - General and Antimicrobial Stewardship stated that meaningful charting should reflect care and treatment and that prescribers are expected to prescribe antibiotics based on the best available evidence, with the Infection Preventionist responsible for infection surveillance and MDRO tracking.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication board for a resident whose primary language was Farsi, which hindered effective communication between the resident and the staff. The resident, who was diagnosed with unspecified dementia and Alzheimer's disease, required assistance with daily activities and had a care plan that included the use of a communication board as an intervention for communication impairment. However, during an observation, it was found that the communication board was not available at the resident's bedside or at the nurses' station, and no staff members on duty spoke Farsi. The deficiency was further highlighted during interviews with the Certified Nursing Assistant (CNA) and the Social Services Designee (SSD), who confirmed the absence of a Farsi communication board and the lack of Farsi-speaking staff. The Director of Nursing (DON) acknowledged the importance of the communication board in overcoming language barriers and ensuring the resident's needs were understood. The facility's policy on interpreter services emphasized the need for communication tools for non-English speaking residents, but the lack of a communication board for the resident indicated a failure to adhere to this policy.
Failure to Lock Wheelchair Brakes for Resident Safety
Penalty
Summary
The facility failed to adhere to its policy on wheelchair use by not ensuring that the wheelchair brakes were locked while residents were seated, which was observed in two of the three sampled residents. Resident 2, who has a history of unspecified convulsion-seizures, dementia with psychotic disturbance, Parkinson's disease with dyskinesia, and muscle weakness, was found sitting in a wheelchair with the left brake unlocked. The resident's care plan indicated a high risk for falls and injury, yet during an observation, the MDS Nurse and a Certified Nursing Assistant confirmed the brake was not engaged, contrary to the facility's safety protocols. Similarly, Resident 3, diagnosed with unspecified dementia with agitation and Alzheimer's disease, was also observed sitting in a wheelchair with the left brake unlocked. The resident's care plan highlighted a risk for falls due to dementia, and during observations, both the MDS Nurse and a Certified Nursing Assistant noted the unlocked brake. Interviews with the Director of Staff Development and the Director of Nursing confirmed that both brakes should be locked when residents are seated in wheelchairs, although the DSD mentioned that one brake could be unlocked if staff were supervising. The facility's policy, however, mandates that brakes should be locked when residents remain in the same location.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that a medication cart was locked while it was left unattended, which was observed with one of the two sampled medication carts, referred to as Medication Cart A. On February 27, 2025, at 11:24 a.m., Medication Cart A was observed parked in the nurse's station, unlocked and unattended, with residents and other facility staff walking by. This observation was confirmed by the Minimum Data Set Nurse (MDSN) at 11:25 a.m., who acknowledged that the cart was indeed unlocked and unattended. Further confirmation came from Licensed Vocational Nurse 1 (LVN 1) at 11:30 a.m., who stated that the cart belonged to LVN 2, who was on lunch, and reiterated that the cart should always be locked to prevent unauthorized access. The Director of Nursing (DON) also confirmed during an interview that medication carts should be kept locked when unattended for safety reasons. A review of the facility's policy on the storage of medications, updated in January 2017, indicated that medications should be stored securely and only accessible to authorized personnel, with medication carts required to be locked or attended.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary use of psychotropic medications, as required by their policy and procedure. Resident 61 was prescribed Zoloft for depression, with the indication being verbalization of sadness. However, the resident was non-verbal and unable to express feelings, making the indication for Zoloft incorrect and unclear. The MDS Coordinator and LVN confirmed that the resident's inability to verbalize sadness meant there was no specific behavior to monitor, leading to inaccurate monitoring and an inability to measure the medication's effectiveness. Resident 64 was prescribed Seroquel for a psychotic disorder with delusions due to dementia, manifested by sudden verbal agitation. However, the MDS indicated that the resident did not exhibit potential indicators for psychosis such as hallucinations and delusions. The facility's Pharmacy Consultant recommended clarifying the target behavior, as sudden verbal agitation could occur for various reasons unrelated to psychosis. The Director of Nursing acknowledged that the facility failed to follow up on the recommendation to clarify the order, resulting in inaccurate monitoring and an inability to measure the medication's efficacy. The facility's policy on psychotropic medication assessment and monitoring requires that such drugs are used only when necessary and at the lowest effective dose. The policy also mandates that the IDT team assesses and monitors the appropriateness, effectiveness, and side effects of psychotropic medications. In both cases, the facility did not adhere to its policy, as the psychotropic medication orders lacked specific, measurable target behaviors, leading to potential risks for the residents involved.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate during a medication administration task. This was due to two medication errors out of 32 opportunities for a resident with multiple diagnoses, including diabetes mellitus, BPH, Parkinson's disease, dysphagia, and a G-Tube. The errors involved the omission of Sinemet and Terazosin, which were not administered as per the physician's orders. The deficiency was identified during a review of the resident's Medication Administration Record (MAR) and confirmed by the Director of Nursing (DON). The MAR indicated that Sinemet and Terazosin were not given on the specified date and time, despite the physician's orders to administer these medications. The DON confirmed that the medications were marked as 'Not Administered: On Hold' in the MAR, which was contrary to the physician's instructions. Interviews with nursing staff revealed a miscommunication regarding which medications were to be held or administered. RN 1 stated they were instructed by the night RN supervisor to hold all medications except for potassium chloride, blood sugar checks with insulin, and the ipratropium-albuterol breathing treatment. However, the physician, during a phone interview, clarified that medications for BPH and Parkinson's disease should have been given. This miscommunication led to the omission of necessary medications, contributing to the facility's failure to maintain an acceptable medication error rate.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically for a resident with Parkinson's disease and benign prostatic hyperplasia (BPH). The resident, who was severely impaired in cognition and dependent on staff for daily activities, did not receive prescribed medications including Sinemet, terazosin, and finasteride as ordered by the physician. These medications were crucial for managing the resident's Parkinson's disease and BPH. The deficiency occurred when Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 4 (LVN 4) did not administer the medications as per the physician's orders. RN 1 and LVN 4 were instructed by the night RN supervisor to hold all medications except for potassium chloride, insulin, and ipratropium-albuterol treatment. This instruction was contrary to the physician's orders, which specified that medications for BPH and Parkinson's disease should be given. The failure to administer these medications was confirmed through interviews and record reviews. The Director of Nursing (DON) confirmed that the medications were not given as indicated by the medication administration record, which showed the medications as 'Not Administered: On Hold'. The facility's policy on medication administration required that medications be administered in a timely manner and in accordance with the physician's orders, which was not followed in this case.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety by not labeling several food items with a use by date. During an observation and interview with the Dietary Supervisor, it was noted that containers of oatmeal, powdered sugar, quinoa, bulgur, cream of wheat, lemon curd, chicken, and ground beef were not labeled with a use by date. The Dietary Supervisor acknowledged that the absence of these labels could lead to residents consuming food past its use by date, potentially causing illness. Additionally, the facility did not ensure that the chlorine test strips used to check the sanitizing solution were not expired. During an observation with the Kitchen Supervisor, it was found that the test strips used to measure the concentration of the sanitizing solution in the dishwasher had expired. The Kitchen Supervisor confirmed that expired test strips could compromise the effectiveness of the sanitizing solution, which is essential for cleaning and sanitizing dishware. The facility's policies and procedures indicated that dietary items should be labeled and dated, and sanitizing solutions should maintain the manufacturer's recommended concentration.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to observe infection control guidelines when a registered nurse (RN) was observed leaving a resident's room during a medication pass while still wearing an isolation gown. This occurred with a resident who was on enhanced barrier precautions (EBP) due to the presence of a G-Tube. The RN exited the room without removing the isolation gown, which then came into contact with the medication cart. This action was contrary to the facility's policy, which requires the removal of PPE before leaving a resident's room to prevent the spread of infection. In another instance, a housekeeper entered a resident's room, which was under contact and droplet precautions due to a respiratory syncytial virus (RSV) infection, without wearing the required eye protection. The room had clear signage indicating the need for a gown, mask, gloves, and eye protection. The housekeeper was observed cleaning the room without the necessary eye protective equipment, which was confirmed by the Infection Prevention Nurse. This was against the facility's policy for contact and droplet precautions, which mandates the use of eye protection to prevent the spread of infection. Additionally, a licensed vocational nurse (LVN) failed to follow the facility's policy for administering eye drops. The LVN did not wash hands between administering drops to each of a resident's eyes, which could lead to cross-contamination. The facility's policy requires handwashing before treating each eye to prevent infection. The LVN was unaware of this requirement, and the Infection Preventionist was also not aware of the need for hand hygiene between treatments of each eye.
Failure to Notify Physician of Resident's Refusal of Catheter Care
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusal of suprapubic catheter care, which is a deficiency in communication and care management. The resident, who was admitted with diagnoses including unspecified dementia and retention of urine, had a suprapubic catheter in place. The resident's Minimum Data Set indicated severely impaired cognitive skills and a dependency on staff for various personal care tasks. Despite the resident's refusal of catheter care on multiple occasions, there was no documentation of physician notification, as required by the facility's policy. The Director of Nursing confirmed that the licensed staff were responsible for notifying the physician about the resident's refusal of care, but acknowledged the absence of such documentation. The facility's policy on indwelling catheter care mandates the development and re-evaluation of a care plan, including physician communication regarding changes in the resident's condition. The lack of notification placed the resident at increased risk for infection due to the absence of appropriate care.
Failure to Develop and Implement Care Plans for Resident Non-Compliance and Catheter Care
Penalty
Summary
The facility failed to develop a care plan for a resident who refused to wear a mask while on contact/droplet precautions due to exposure to Respiratory Sinus Virus (RSV). The resident, who had severely impaired cognition and required moderate assistance for most activities of daily living, was observed without a mask in a common area, despite physician orders for mask use. The Infection Preventionist and Director of Nursing confirmed that there was no care plan addressing the resident's non-compliance with mask-wearing, which could delay necessary care and services. Another deficiency involved the facility's failure to address a resident's refusal of care for a suprapubic indwelling catheter. The resident, who had severe cognitive impairment and was dependent on staff for personal care, refused treatment for the catheter's surrounding skin on multiple occasions. The Director of Nursing acknowledged that there was no documentation of notifying the resident's physician about the refusals, and the care plan did not reflect current interventions such as monitoring for hematuria and checking for signs of infection. The facility's policies required comprehensive care plans with measurable objectives and timetables to meet residents' needs, which were not followed in these cases. The lack of updated care plans and implementation of interventions could lead to inadequate care and increased risk of infection for the residents involved.
Failure to Revise Care Plan After Catheter Removal
Penalty
Summary
The facility failed to revise the care plan for a resident following the removal of an indwelling urinary catheter. The resident, who was originally admitted on January 25, 2024, and readmitted on October 12, 2024, had diagnoses including sepsis, metabolic encephalopathy, and chronic kidney disease. The Minimum Data Set (MDS) dated October 19, 2024, indicated that the resident had severely impaired cognition and required maximal assistance for various activities of daily living. A physician order dated November 3, 2024, instructed the discontinuation of the indwelling urinary catheter. Despite the removal of the catheter, the care plan, which was created on October 14, 2024, was not updated to reflect this change. During an observation on December 3, 2024, a Certified Nursing Assistant confirmed that the catheter had been discontinued. However, the care plan still addressed the risks associated with having an indwelling catheter. Both the Licensed Vocational Nurse and the Minimum Data Sheet Coordinator acknowledged that the care plan should have been revised to accurately reflect the resident's current condition. The Director of Nursing also confirmed that the care plan needed to be updated after the catheter was removed.
Failure to Provide Communication Device in Resident's Language
Penalty
Summary
The facility failed to provide a communication device in a language understood by a resident, identified as Resident 22, which led to a deficiency in communication care. Resident 22, who was admitted and readmitted to the facility with diagnoses including sepsis, metabolic encephalopathy, and chronic kidney disease, had a preferred language of Farsi. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognition and required maximal assistance for daily activities. Despite these needs, the facility did not provide a communication board in Farsi, as observed during a surveyor's visit. During the survey, it was noted that the resident's care plan, which addressed the language barrier, included an intervention to provide a communication board. However, this intervention was not implemented, as confirmed by the Social Service Director and the Director of Nursing. The absence of a communication board meant that staff could not effectively communicate with the resident, potentially leaving the resident's needs unmet. The facility's policy on interpreter services, which required communication boards for residents unable to communicate, was not adhered to in this case.
Failure to Monitor Low Air Loss Mattress Functionality
Penalty
Summary
The facility failed to ensure the proper functioning of a low air loss mattress (LALM) for a resident, which is crucial for preventing pressure ulcers. The resident, who was severely cognitively impaired and dependent on staff for daily activities, was at risk for developing pressure ulcers. The resident's care plan included the use of a LALM for skin management, but the staff did not monitor the functionality of the mattress as required. During an observation, it was noted that the LALM was powered on, but its display was not showing any information, indicating a potential malfunction. Licensed staff were required to monitor the LALM every shift and document this in the resident's Treatment Administration Record (TAR) or Medication Administration Record (MAR). However, there was no documentation of such monitoring for the resident, and the physician's order for the LALM was not properly recorded, leading to a lack of follow-through. The Director of Nursing confirmed that the staff did not notice the LALM was off and failed to document its monitoring, which could result in the development of pressure injuries.
Failure to Clarify Seroquel Use for Resident
Penalty
Summary
The facility failed to act upon a recommendation from the Pharmacy Consultant (PC) to clarify the behavior manifestation for the use of Seroquel for one of the residents, identified as Resident 64. The resident was admitted with diagnoses including major depressive disorder, dementia, and psychotic disorders. The Minimum Data Set (MDS) indicated that the resident's cognitive skills for daily decision-making were severely impaired, and the resident was taking antipsychotic and antidepressant medications. The physician's order for Seroquel was based on the resident's psychotic disorder with delusions due to dementia manifested by sudden verbal agitation. The Pharmacy Consultant's Monthly Regimen Review (MRR) noted that Resident 64 had been on Seroquel with a target behavior of sudden verbal agitation and recommended clarifying what the resident said and how this presented a danger to self and others. However, the facility did not follow up on this recommendation. During interviews, both LVN 5 and the Director of Nursing (DON) acknowledged that the Seroquel order did not specify the behavior to monitor, and sudden verbal agitation was not a clear indication for administering Seroquel. The lack of a clear indication and measurable target behavior led to inaccurate monitoring and potential exposure of the resident to side effects. The facility's Policies & Procedures (P&P) for psychotropic medication assessment and monitoring require that psychotropic drugs are used only when necessary and at the lowest effective dose. The P&P also state that the PC reviews the appropriateness of psychotropic medication orders and that any inappropriate orders should be clarified with the attending physician. Despite these guidelines, the facility failed to act on the PC's recommendation, resulting in a deficiency in the monitoring and administration of Seroquel for Resident 64.
Failure to Remove Discontinued Medication from Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to accepted professional principles, as evidenced by the presence of a discontinued medication in a medication cart. Specifically, a medication cart on the second floor contained a blister pack of amlodipine, a medication used to lower blood pressure, which had been discontinued for a resident. The medication was not removed from the cart after the discontinuation order was issued, which was confirmed during an observation and record review with a registered nurse. The resident involved had a history of hypertensive heart disease and was severely impaired in cognition, requiring assistance with daily activities. The physician's order for amlodipine was discontinued on a specific date, yet the medication remained in the cart, posing a risk of accidental administration. The Director of Nurses confirmed that the facility's policy required immediate removal of discontinued medications to prevent medication errors, which was not followed in this instance.
Deficiencies in Hospice Service Provision and Training
Penalty
Summary
The facility failed to ensure the provision of hospice services for two residents, leading to deficiencies in documentation and training. For Resident 1, the facility did not have documented evidence that hospice staff signed the Interdisciplinary Team Sign-in Sheet upon arrival, despite the resident being admitted to hospice care. This was confirmed during an interview and record review with the Director of Nursing (DON), who acknowledged the absence of the sign-in sheet in the resident's hospice binder. Similarly, for Resident 3, the facility did not have a hospice Interdisciplinary Team Sign-in Sheet in the resident's hospice binder, indicating a lack of documented evidence that hospice staff provided care from the date of hospice admission. The DON and the Medical Records Team Leader (MRTM) both confirmed the absence of the sign-in sheet and acknowledged that medical records should have conducted audits to ensure the presence and completion of these sheets. Additionally, the facility did not ensure that the hospice agency provided training programs in hospice care for facility staff, as required by the contractual agreement. Interviews with two Certified Nursing Assistants (CNAs) revealed that they had not received any training from the hospice agency. The DON confirmed that the hospice contract included a provision for training programs, but the facility had not been aware of or implemented this aspect of the agreement.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 3,735 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Reseda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tarzana Health And Rehabilitation Center | 0.9 mi | ★★★★★ | 29 | 0 |
| Park View Nursing And Subacute | 0.9 mi | ★★★★★ | 7 | 0 |
| Grancell Village Of The Jewish Homes For The Aging | 1.1 mi | — | 5 | 0 |
| Joyce Eisenberg Keefer Medical Center D/p Snf | 1.1 mi | ★★★★★ | 28 | 0 |
| Woodland Care Center | 1.5 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.