Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Granada Hills Convalescent during CMS and state inspections, most recent first.
Two residents had beds placed against the wall, which RN 1 identified as a restraint because it limited movement and access to getting out of bed on only one side. For one resident, the chart showed a preference for the bed near the wall, but there was no physician order, informed consent, or restraint assessment. For the other resident, the bed was placed against the wall due to room space limits, and there was also no physician order, informed consent, restraint assessment, or care plan.
Incomplete person-centered care plans for medication self-administration, bed restraint use, and DM management: A resident with severe cognitive impairment had no care plan for self-administering meds, and OTC ointment was left at the bedside without an order. Another resident had a bed placed against the wall, which the RN described as a restraint, but there was no order, consent, assessment, or care plan. A third resident with DM had a non-specific blood sugar goal despite repeated elevated readings and individualized treatment orders.
Failure to Follow BP Medication Hold Parameters: A resident with ESRD and hypertensive heart disease had physician orders for losartan and midodrine with specific SBP hold parameters. MAR review showed multiple doses were documented as given when BP readings were outside the ordered parameters, and the DSD, LVN, and DON confirmed the medications should have been held per the orders and facility medication administration policy.
A facility failed to keep resident rooms and common areas free of accident hazards when equipment and furniture were placed on top of fall mats for three residents with low bed/floor mat orders, including residents with fractures, osteomyelitis, psychosis, and severe cognitive impairment. Staff observed a side table, wheelchair, IV pole, and walker on the mats, and the DON and RN stated the mats should be clear. The facility also left menthol/zinc oxide ointment at one resident’s bedside despite no self-administration order and no ability to self-administer, and an unattended bottle of Advil was left on an activity room table where multiple residents were present.
A resident with ESRD, hypertensive heart disease, and severe cognitive impairment received losartan and midodrine despite ordered SBP hold parameters. MAR review showed losartan was given when SBP was below 120 mmHg and midodrine was given when SBP was above 120 mmHg. The DSD and DON confirmed the medications should have been held, and an LVN stated she was aware of the parameters but may have signed by mistake.
Improper Puree Consistency on Trayline: A cook prepared puree items that were watery and did not hold their shape for a puree tray, including baked zucchini and garlic bread. The cook and DSS initially stated the tray passed the spoon test, but later acknowledged the items did not pass the spoon-tilt test and did not meet IDDSI Level 4 standards. The facility’s recipes and diet manual required pureed foods to be smooth, cohesive, and tested before service, and the DSS stated the facility had recently transitioned to IDDSI.
Puree diet foods were found too watery and failed the spoon tilt test when puree baked fresh zucchini and puree garlic bread were plated during trayline observation. CK 1 stated she checked the puree consistency, but the items did not hold their shape, and the DSS later stated the meal did not pass IDDSI Level 4 testing. Facility recipes and policy required pureed foods to be smooth, cohesive, lump-free, and to pass IDDSI tests before serving.
Call Light Left Out of Reach: A resident with impaired cognition, limited mobility, and high fall risk had the call light resting on the floor beside the bed instead of within reach. RN and DON both stated the call light should always be within the resident’s reach so the resident could summon help when needed, and the care plan included keeping the call light within reach.
Nonfunctioning Wall Clock in Resident Room: The facility failed to ensure a working wall clock in a resident’s room. The resident had HF, depression, hyperlipidemia, and dementia, and was observed in the room while the clock was not functioning. CNA reported she was unaware of the issue and said broken items should be reported to maintenance, while the MS was also unaware of the problem. The DON stated a functioning clock is important for residents’ reality orientation, especially for residents with dementia.
Resident Unaware of Grievance Process: A resident with DM, hypothyroidism, psychosis, peripheral neuropathy, hyperlipidemia, HTN, and osteoarthritis stated he did not know how or where to file a grievance and asked for help with the process. The SSD and DON acknowledged that residents who do not know the grievance process may have issues that go unresolved, while the facility policy states residents and representatives are to receive written information on how to file grievances upon admission.
Unlabeled Urinal Left at Bedside: A resident with frequent urine and stool incontinence, moderate cognitive impairment, and infection risk factors had a urinal bottle hanging at the bedside without a name or room number label. RN and DON stated urinals must be labeled to prevent switching between residents and cross-contamination that can lead to UTI, and the facility policy required urinals to be labeled with the resident's name or room number.
A resident with a PICC line for IV antibiotics had a dressing that was not labeled with the last change date and was observed to be soiled and peeling off. RN and DON stated the dressing should have been dated and changed immediately when compromised, but there was no physician order for PICC dressing changes and no care plan intervention addressing dressing changes.
Missing Dialysis Weights Documented: A resident with ESRD and dependence on dialysis had no documented pre- or post-dialysis weights on the dialysis communication record for a scheduled treatment. The LVN and DON confirmed the omission, and the facility policy required documentation of both weights for each dialysis treatment.
Clean Linen Removed From Unattended Linen Cart: A resident with impaired cognition and no capacity to make her own decisions was observed removing clean linens from a covered, unattended linen cart in the hallway and carrying them away. CNA reported the resident does this often and becomes upset if staff take the linen away, while the IP stated staff had asked her to stop because it is against infection control policy.
Late NOMNC Delivery for Two Residents: The facility failed to give the NOMNC to two residents’ representatives at least 2 days before Medicare Part A skilled coverage ended. One resident had atherosclerotic heart disease, seizures, and GERD, and the other had Parkinson’s disease, COPD, and atherosclerotic heart disease; both had documentation indicating impaired decision-making capacity and involved representatives/guardians. The SSD stated the notices were not provided in a timely manner and should have been given 2 days before the last covered day.
Bedroom Space Requirements Not Met: The facility failed to ensure 19 of 21 multiple resident rooms met the 80 sq ft per resident requirement. Surveyors observed residents in the rooms and noted adequate space for movement and care, while RN and DON interviews confirmed space limitations and difficulty placing beds, furniture, and equipment. The Adm reviewed a waiver request for room size and beds per room, and the facility policy required bedrooms to meet federal and state space standards.
The facility failed to ensure residents were free from physical restraints by not obtaining physician orders, performing assessments, or obtaining informed consent for bed placement against the wall, affecting six residents with various medical conditions.
A facility failed to rotate insulin injection sites for four residents, leading to potential skin trauma. Despite policies and guidelines emphasizing site rotation, insulin was repeatedly administered in the same areas, confirmed by the DON. This oversight affected residents with type 2 diabetes and other conditions, risking skin discoloration and swelling.
The facility failed to ensure a safe environment by improperly using fall mats and not securing equipment. Several residents' fall mats were obstructed by heavy items, reducing their effectiveness and increasing injury risk. Additionally, a portable AC unit's panel was not secured, posing a hazard in a resident's room.
The facility failed to ensure proper rotation of insulin injection sites for several residents, leading to significant medication errors. The DON confirmed that licensed nurses did not adhere to the facility's policy and manufacturer's guidelines, resulting in repeated injections in the same areas, which could cause skin trauma.
The facility failed to maintain an effective infection prevention and control program, resulting in several deficiencies. A resident's nasal cannula oxygen tubing was not labeled with the date it was last changed, and another resident's oxygen tubing was found on the floor. Enteral feeding kits were improperly stored, and a glucometer was not cleaned after use. Additionally, water temperatures were below recommended levels to prevent Legionella growth.
A resident with dementia and impaired cognition had their call light inaccessible, caught between the mattress and siderail, contrary to the care plan and facility policy. The DON confirmed the call light should have been within reach to ensure timely assistance.
A resident receiving enteral feeding was at risk of contamination due to the facility's failure to cap the Y adapter tubing when not in use. The resident, with conditions including GERD and dysphagia, was unable to make decisions or communicate effectively. The facility's policy required capping the tubing to prevent infection, which was not followed, as confirmed by the LVN and DON.
A facility failed to provide appropriate respiratory care for a resident by not obtaining a physician's order for the use of a BIPAP machine and allowing the BIPAP mask and tubing to be on the floor, risking respiratory infection. The resident had acute respiratory conditions requiring careful management, but the care plan did not include BIPAP use, contrary to facility policy.
A resident with dementia and gastrostomy status was at risk due to a failure in medication administration via G-tube. The facility's policy required flushing the tube with water between medications to prevent drug interactions. However, an LVN was observed not following this procedure, which was confirmed by the DON. This oversight could lead to health complications for the resident.
A resident's drug regimen was not adequately monitored for adverse effects of the anticoagulant Apixaban. Despite a care plan intervention to monitor for symptoms like discolored urine and black tarry stools, this was not done as it was not included in the MAR. The DON confirmed the absence of monitoring orders, contrary to the facility's anticoagulation policy.
The facility failed to discard nine boxes of expired BinaxNOW COVID-19 Antigen Self-Test kits, increasing the risk of misdiagnosis and delayed care. An LVN and the DON acknowledged the oversight, and the IP confirmed the kits were past the expiration extension set by the CDC. The facility's policy requires regular checks and proper disposal of expired products.
A resident with severe cognitive impairment and total dependence on staff did not receive prescribed restorative nursing assistance due to an inaccurate entry in the electronic health record. The charge nurse failed to correctly enter the order for splint application, resulting in the order not appearing in the restorative record flowsheet. This led to a delay in care as the assigned RNA was unaware of the new order.
The facility failed to meet the federal requirement of 80 square feet per resident in 19 rooms, although residents and staff reported no issues with space. A waiver was submitted, asserting adequate space for care and mobility. A portable HVAC unit was noted to crowd one resident's room, but staff reported no difficulties in performing duties.
Beds Placed Against Wall Without Required Orders or Consent
Penalty
Summary
The facility failed to ensure two residents were free from the use of a physical restraint when their beds were placed against the wall without the required physician’s order, informed consent, restraint assessment, or, for one resident, a person-centered care plan. The report identifies the bed placement against the wall as a restraint because it limited the residents’ freedom of movement by restricting access to getting out of bed on only one side. Resident 6 was admitted and later readmitted with diagnoses including psychosis, idiopathic autonomic neuropathy, and osteoarthritis. The resident’s H&P indicated the resident had the capacity to understand and make decisions, while the MDS indicated impaired vision, severe cognitive impairment, lower extremity impairment, and use of a wheelchair in the facility. During observation, the resident’s bed was placed against the wall on the right side. RN 1 stated this placement limited mobility and was a form of restraint, and also stated there was no physician’s order, informed consent from the resident or representative, or restraint assessment for the bed placement. The resident’s care plan noted that the resident preferred the bed next to the wall and included an intervention that informed consent would be obtained and verified by a licensed nurse. Resident 19 was admitted and readmitted with diagnoses including hypotension, orthostatic hypotension, and muscle spasm. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment with dependence to partial assistance for mobility and ADLs. During observation, the resident’s bed was placed close to the wall on the right side. RN 1 stated the bed was placed against the wall because of space limitations and that this limited the resident’s ability to get out of bed on only one side, making it a restraint. RN 1 also stated there was no physician’s order, informed consent, restraint assessment, or care plan for the bed placement. The DON stated both residents’ bed placement should have had a physician’s order, informed consent, and restraint assessment, and for Resident 19, a care plan, to ensure safe use and honor the resident’s right to informed consent.
Incomplete person-centered care plans for medication self-administration, bed restraint use, and DM management
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three sampled residents. For one resident, the record showed admission and readmission diagnoses including dysphagia, GERD, and adult failure to thrive. The H&P stated the resident did not have capacity to understand and make decisions, while the MDS indicated severe cognitive impairment. A self-administration assessment dated 11/15/2025 found the resident was not capable of self-administering medications due to physical limitations. The OSR did not show an order for Menthol and Zinc Oxide topical ointment, yet two tubes of the ointment were observed on the bedside drawer during a concurrent observation. The RN stated there was no physician order for the ointment and no care plan for medication self-administration, and the DON stated such a care plan should have been developed if the resident was assessed for competency to self-administer medications. For another resident, the record showed diagnoses including hypotension, orthostatic hypotension, and muscle spasm. The H&P stated the resident did not have capacity to understand and make decisions, and the MDS indicated severe cognitive impairment with dependence to partial assistance for mobility and ADLs. During observation, the resident’s bed was placed close to the wall on the right side. The RN stated the bed was placed against the wall because of space limitations, that this limited the resident’s ability to get out of bed to one side only, and that it was a form of restraint. The RN also stated there was no physician’s order, informed consent, restraint assessment, or care plan for the bed placement, and the DON stated these were needed to ensure safe use and honor the resident’s right to informed consent. For the third resident, the record showed diagnoses including DM, with physician orders for Novolog sliding scale, Lantus, and Actos. The MDS indicated severe cognitive impairment and the resident required setup or clean-up assistance with eating and oral hygiene. The care plan for risk of hypoglycemia and hyperglycemia included a goal that the resident would have no unrecognized signs or symptoms of hypo- or hyperglycemia, comply with the therapeutic diet, and maintain blood sugar within normal range, but the DON stated this goal was not specific to the resident and that there should be a resident-specific blood sugar range. The MAR showed multiple blood sugar readings above 250 mg/dL in October and November 2025. The DON stated the provider establishes individualized diabetic treatment plans and that licensed nurses should communicate with the physician when blood sugars are consistently outside the resident-specific range.
Failure to Follow Blood Pressure Medication Hold Parameters
Penalty
Summary
Licensed nursing staff failed to follow physician-ordered hold parameters for losartan and midodrine for Resident 7, a resident admitted with end stage renal failure and hypertensive heart disease. The resident’s MDS dated 11/01/2025 indicated severe cognitive impairment and need for assistance with daily care. Physician orders directed losartan 25 mg on specific days with a hold parameter for systolic blood pressure less than 120 mmHg, and midodrine 5 mg three times daily with a hold parameter for systolic blood pressure greater than 120 mmHg. Review of the 10/2025 and 11/2025 MARs showed multiple instances where losartan was documented as given when blood pressure readings were below the hold parameter, and midodrine was documented as given when blood pressure readings were above the hold parameter. During interview and record review, the DSD stated these medications should have been held on the identified dates and that the check marks indicated they were given when they should have been held. LVN 3 stated she was aware of the hold parameters and may have signed by mistake, and the DON confirmed losartan was administered when it should not have been given. The facility policy stated medications are to be administered in accordance with prescriber orders, including any required time frame.
Accident Hazards and Unsecured Medications
Penalty
Summary
The facility failed to keep resident rooms free of accident hazards by placing equipment and furniture on top of fall mats for three residents who had low bed and floor mat orders. Resident 23 was admitted with a fractured left femur, lack of coordination, and a history of falling; the resident’s assessments showed impaired cognition, wheelchair use, dependence for mobility and ADLs, and high fall risk. The record also showed an order for a low bed with bilateral floor mats every shift, and staff observed a side table on one mat and a wheelchair on the other. CNA 1 and the DON both stated the mats should be free of objects because hard items on top of the mats could cause injury if the resident fell. Resident 39 was admitted with acute osteomyelitis of the left ankle and foot, lack of coordination, and acquired absence of left toes. The resident’s H&P indicated no capacity to understand and make decisions, and the MDS showed moderately impaired cognition with substantial to supervision assistance needed for mobility and ADLs. The resident had an order for a low bed with bilateral floor mats every shift and was assessed as high risk for falls. Staff observed an IV pole and side table on one floor mat and a walker on the other, and RN 1 and the DON stated that equipment should not be placed on the mats because it could cause injury if the resident fell. Resident 6 had diagnoses including psychosis, idiopathic autonomic neuropathy, and osteoarthritis, with impaired vision and severe cognitive impairment noted on the MDS. The resident had an order for a low bed with a left floor mat every shift and a care plan intervention to provide a safe and hazard-free environment. During observation, a wheelchair was found on the resident’s floor mat. RN 1 and the DON stated the mat should not have equipment or furniture on top of it because it compromises the mat and could result in injury if the resident rolled from bed. The facility also failed to keep medications secured and inaccessible. Resident 43 had dysphagia, GERD, and adult failure to thrive, lacked capacity to understand and make decisions, and had severe cognitive impairment. The resident was not ordered to self-administer menthol and zinc oxide topical ointment, and the self-administration assessment stated the resident was not capable of self-administering medications due to physical limitations. Despite this, two tubes of the ointment were observed on the bedside drawer, and RN 1 stated there was no physician order and that medications should not be left at the bedside. In addition, a bottle of Advil was observed unattended on a table in the activity room while multiple residents were present. The activity assistant stated the bottle did not belong there and had been left in error. The administrator stated facility policy requires medications to be locked and inaccessible to residents, and the facility’s medication storage policy stated medications are stored in locked compartments.
Medication Hold Parameters Not Followed for Blood Pressure Medications
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when ordered hold parameters were not followed for losartan and midodrine. Resident 7 was admitted with diagnoses including ESRD and hypertensive heart disease and was severely cognitively impaired, requiring supervision for eating and moderate assistance with upper body dressing and personal hygiene. Physician orders directed losartan 25 mg on specific days with a hold parameter for SBP less than 120 mmHg, and midodrine 5 mg three times daily with a hold parameter for SBP greater than 120 mmHg. The care plan directed staff to administer medications as prescribed and monitor blood pressure as ordered. Review of the 10/2025 and 11/2025 MARs showed losartan was documented as given when SBP readings were 116/70, 100/64, 107/54, 112/55, and 112/55, all below the hold parameter. Midodrine was documented as given when SBP readings were 121/76, 123/78, and 124/72, all above the hold parameter. During interview, the DSD stated these medications should have been held and that the check marks indicated they were given when they should have been held. LVN 3 stated she was aware of the hold parameters but may have signed by mistake and could not remember whether the medication was given. The DON confirmed losartan was administered when it should not have been given and stated it was important to hold it to prevent lowering blood pressure further.
Improper Puree Consistency on Trayline
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency when CK 1 prepared puree items that did not meet the facility’s established IDDSI Level 4 standards. During trayline observation, pureed baked fresh zucchini and pureed garlic bread were observed to be watery and not hold their shape when plated. CK 1 later demonstrated the spoon test for these items, and both fell off the spoon and did not hold their shape, although CK 1 stated the puree plate passed the test and the Dietary Service Supervisor agreed at that time. The report states that the facility’s menu for the puree diet included pureed wheat spaghetti, pureed zesty meat sauce, pureed baked fresh zucchini, and pureed garlic bread. A photo of the puree plate taken during lunch showed the puree items, and CK 1 later stated there should not be liquid separating from the solid and that the puree garlic bread and baked zucchini did not pass the spoon tilt test. CK 1 also stated she would have added dry mashed potatoes to make the items thicker. The DSS stated he oversees the kitchen and that the facility had changed to IDDSI about 2 to 3 months earlier, and that they were trying to adopt the new policies. The facility’s recipes and diet manual required Level 4 pureed foods to be smooth, cohesive, lump-free, not watery, and to pass IDDSI testing before serving. The DSS stated he checked the puree consistency before placing it in the oven and should have checked it after removing it from the oven, and he acknowledged that the puree plate from lunch did not pass the puree consistency for the spoon-tilt test. The DON stated that when puree consistency is too thick or too watery, residents could aspirate, choke, and find the diet not appetizing and may not eat it.
Puree Diet Foods Served Too Watery and Failed IDDSI Level 4 Testing
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs when puree baked fresh zucchini and puree garlic bread were watery and did not pass the spoon tilt test for residents on a puree diet/IDDSI level 4. The deficiency was identified during observation, interview, and record review, and involved seven of seven residents on the puree diet. The report states this practice had the potential to result in decreased food and nutrient intake, aspiration, and choking. The facility menu spreadsheet dated 11/17/2025 showed that residents on the puree diet were to receive pureed wheat spaghetti, pureed zesty meat sauce, pureed baked fresh zucchini, and pureed garlic bread. During trayline observation, the puree baked fresh zucchini and puree garlic bread were watery and did not hold their shapes when plated. During a concurrent interview, CK 1 stated she followed the recipe and performed a spoon test, but the plated zucchini and garlic bread fell off the spoon and did not hold their shape, even though she stated the puree plate passed the test. The Dietary Service Supervisor agreed at that time that the puree plate passed the test. Later interviews and record review showed the DSS stated he checked the puree mixture before it went into the oven and should have checked it after removal from the oven. He stated the puree plate from the lunch meal did not pass the spoon-tilt test and that the pureed diet should be blended, hold its shape, and not be too sticky or watery. The facility recipes and IDDSI Level 4 policy required pureed foods to be smooth, cohesive, lump-free, not watery, and to pass IDDSI testing before serving, and the IDDSI guidance reviewed by surveyors stated Level 4 pureed food should hold its shape and not have liquid separate from the solid.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to keep the call light within reach for one resident who was reviewed under accommodation. Resident 39 was admitted with diagnoses including acute osteomyelitis of the left ankle and foot, lack of coordination, and acquired absence of left toes. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS showed moderately impaired cognition and a need for substantial to supervision assistance with mobility and ADLs. The resident was also assessed as high risk for falls, and the care plan included placing the call light within reach. During a concurrent observation and interview, Resident 39 was seen in the room with bilateral floor mats in place, and the call light button was on the left side of the bed resting on the floor. RN 1 stated the call light should always be within reach so the resident could call for help if needed, and that failing to ensure this could result in the resident being unable to ask for help and falling while reaching for the call light on the floor. The DON also stated the call light should always be within the resident’s reach and that it was everyone’s responsibility to ensure this. The facility policy stated residents are to be provided with a means to call staff for assistance from the bed, toileting/bathing facilities, and from the floor.
Nonfunctioning Wall Clock in Resident Room
Penalty
Summary
The facility failed to ensure a functioning wall clock in Resident 10’s room. Resident 10 was admitted with diagnoses including heart failure, depression, hyperlipidemia, and dementia. Her MDS indicated adequate hearing and vision and that she could usually make herself understood and usually understand others. During an observation, the wall clock in the room was noted to be not functioning while Resident 10 was seen walking inside the room, fixing her bed, and watching television. During interview, CNA 1 stated she was unaware the wall clock was not working and said she typically checks the time on her phone, adding that broken items such as a wall clock are to be reported to maintenance. Resident 10 stated she could not recall when the wall clock stopped functioning and said she would usually ask staff about the time. The Maintenance Supervisor stated he was unaware of the wall clock not functioning, and the DON stated that issues with equipment or wall clocks are reported to maintenance and that a functioning clock is important for residents’ reality orientation, especially for residents with dementia. The facility policy stated wall clocks are to be properly installed, inspected, maintained, and promptly repaired or replaced to ensure accurate timekeeping and resident safety.
Resident Unaware of Grievance Process
Penalty
Summary
The facility failed to ensure that one of nine sampled residents, Resident 6, who participated in the Resident Council meeting, was aware of the facility's grievance policy and procedures. Resident 6's admission record showed admission on 1/30/2019 with diagnoses including DM, hypothyroidism, psychosis, peripheral neuropathy, hyperlipidemia, HTN, and osteoarthritis. The MDS dated 11/02/2025 indicated the resident had adequate hearing and vision and was usually able to make self-understood and usually understand others. During an observation and interview on 11/17/2025 at 1:53 p.m., Resident 6 stated that he did not know how or where to file a grievance and asked for help with the process. During interviews, the SSD stated that residents not knowing the grievance process may put residents at risk for not having their care and service needs met and that resident issues could go unresolved. The DON stated that filing grievances is handled by different departments depending on the type of grievance, that the process is reviewed monthly, and that when residents do not know how to file grievances, it can potentially limit their ability to file a grievance and affect the quality of care. The facility policy stated residents and their representatives have the right to file grievances orally or in writing, and that written information on how to file a grievance or complaint is provided upon admission.
Unlabeled Urinal Left at Bedside
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate services and assistance to prevent urinary tract infections when the resident's urinal bottle was left unlabeled. Resident 39 was admitted with diagnoses including osteomyelitis of the left ankle and foot, type 2 diabetes mellitus, and lack of coordination. The resident's history and physical indicated the resident did not have the capacity to understand and make decisions, and the MDS showed moderate cognitive impairment, substantial to supervision assistance needs for mobility and ADLs, and frequent incontinence of urine and stool. The resident also had an order for enhanced barrier precautions due to a RUA PICC line and left second toe wound, and the care plan identified the resident as at risk for infection due to a history of pyelonephritis and gross hematuria. During a concurrent observation and interview, the resident's urinal bottle was seen hanging at the right upper side rails of the bed without a label showing the resident's name or room number. RN 1 stated the urinal should be labeled with the resident's name or room number to prevent switching of urinals with other residents and cross-contamination that can lead to UTI. The DON later stated the urinal should have been labeled to prevent cross-contamination among residents and that it was the responsibility of all staff to ensure urinals were labeled to control infection such as UTI. The facility policy on labeling and management of urinals stated urinals must be labeled with the resident's name or room number.
PICC Line Dressing Not Labeled, Soiled, and Without Dressing Change Order
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids for a resident when needed was not met for Resident 39, who was admitted with acute osteomyelitis of the left ankle and foot, type 2 DM, and peripheral vascular disease. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated moderate cognitive impairment, substantial to supervision assistance with mobility and ADLs, frequent incontinence of urine and stool, and IV antibiotics with IV access. The OSR included orders to monitor the IV site for signs and symptoms of infection and infiltrate every shift, but it did not include any order for PICC line dressing changes. The care plan identified the resident as at risk for infection due to the invasive device and included monitoring for signs and symptoms of infection, but it did not include an intervention to change the PICC line dressing. During observation on 11/17/2025, RN 1 observed the resident’s PICC line dressing was not labeled with the insertion date or last dressing change and was soiled and peeling off. During interview, RN 1 stated the dressing should have been labeled with the date it was last changed and should have been changed immediately because it was compromised and soiled. RN 1 also stated there was no physician order for PICC line dressing changes and no care plan intervention for dressing changes. The DON stated staff should have dated the PICC line dressing and that a compromised, soiled, or loose dressing should be changed immediately. The facility policy stated dressing changes should occur at established intervals or immediately if the dressing integrity is compromised, and documentation should include the date and time the dressing was changed.
Missing Dialysis Weights Documented
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required dialysis treatment. Resident 7 was admitted with diagnoses including ESRD and dependence on dialysis, and the MDS dated 11/01/2025 indicated the resident was severely cognitively impaired, required supervision with eating, moderate assistance with upper body dressing and personal hygiene, and received dialysis treatments. Physician orders dated 3/12/2024 directed dialysis on Mondays, Wednesdays, and Fridays at 3:45 p.m. at a dialysis facility. During review of Resident 7's Dialysis Communication Record for 11/17/2025, there was no documented pre-dialysis or post-dialysis weight. In a concurrent interview and record review, the LVN and DON confirmed the missing weights and stated that when information is missing, the process is to call the dialysis center to obtain it. The facility policy titled Dialysis Information, last reviewed 1/10/2025, indicated there should be documentation of a pre-dialysis and post-dialysis weight for each dialysis treatment.
Clean Linen Removed From Unattended Linen Cart
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when Resident 10 was observed removing clean linens from a covered clean unattended linen cart located in the facility hallway. On 11/18/2025 at 8:05 a.m., Resident 10 removed five cloth blue pads, five pillowcases, and two sheets from the cart and proceeded down the hallway with the linen. Resident 10's admission record showed diagnoses including depression, allergic rhinitis, and dementia, and the MDS dated 8/12/2025 indicated impaired cognition. The H&P dated 11/18/2025 stated Resident 10 did not have the capacity to understand and make her own decisions, and the care plan dated 10/10/2025 directed staff to cue, anticipate needs, reorient, and supervise Resident 10 as needed. During interview, CNA 2 stated Resident 10 was not supposed to take the linen because of infection control, but if staff took it from her she cried and got mad, and that Resident 10 takes the linen all the time anyway. IP 1 stated Resident 10 had been taking linen from the linen cart to make her own bed and that staff had asked her to stop because doing so is against infection control policies. The facility's Infection Control Program policy stated the facility shall establish an infection control program to provide a safe sanitary and comfortable environment and transmission of disease and infection, and the Laundry and Linen policy stated the purpose is safe and aseptic handling, washing, and storage of linen, including washing hands after handling soiled linen and before handling clean linen.
Late NOMNC Delivery for Two Residents
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) at least two days before the termination of Medicare Part A skilled services for two sampled residents. For Resident 9, the record showed admission on 9/18/2018 and readmission on 7/11/2025, with diagnoses including atherosclerotic heart disease, seizures, and GERD. The H&P dated 7/12/2025 stated the resident did not have the capacity to understand and make decisions, while the MDS dated 8/17/2025 indicated the resident could make self-understood and understand others, had intact cognition, and had a family member and legal guardian involved in assessment and goal setting. The SBNR showed the last covered day of Part A service was 8/28/2025, but the NOMNC was provided to Representative 1 on 8/27/2025 at 3 p.m. For Resident 17, the record showed admission on 7/7/2023 and readmission on 7/5/2025, with diagnoses including Parkinson's disease, COPD, and atherosclerotic heart disease. The H&P dated 7/11/2025 stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident usually could make self-understood and understand others, had severe cognitive impairment, and had family, a significant other, and a legal guardian participating in assessment and goal setting. The SBNR showed the last covered day of Part A service was 8/29/2025, but the NOMNC was provided to Representative 2 on 8/28/2025 at 3:15 p.m. During interview, the SSD stated the NOMNCs were not provided in a timely manner and should have been given two days before the last Medicare Part A non-coverage dates.
Bedroom Space Requirements Not Met
Penalty
Summary
The facility failed to ensure that 19 of 21 multiple resident bedrooms met the requirement of at least 80 square feet per resident. The deficient rooms identified were Rooms 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, and 22. During the survey, the evaluator observed residents in multiple resident bedrooms and noted that residents had adequate space to move freely, and nursing staff had enough space to provide care, with room for beds, side tables, dressers, and resident care equipment. During interviews, RN 1 stated that one room had 4 beds with 4 residents and that space was limited, which was why the beds were close to the wall. The DON stated the facility had issues with room size affecting the placement of equipment and furniture in the rooms. The Administrator reviewed a letter dated 11/17/2025 requesting a waiver for room size and beds per room, and stated a waiver request had been made for all rooms except certain listed rooms. The facility policy stated bedrooms must measure at least 80 square feet per resident in double rooms and at least 100 square feet in single rooms, with variance waivers possibly in effect.
Failure to Obtain Proper Authorization for Bed Placement as Restraint
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment. This deficiency was identified for six out of nine sampled residents during a review of the physical restraints care area. The facility did not obtain a physician's order, perform an assessment, develop a care plan, or obtain informed consent for the placement of beds against the wall, which restricted the residents' freedom of movement and violated their rights. For Resident 10, the facility admitted the resident with diagnoses including dementia, low back pain, and psychosis. The resident had severely impaired cognition and required assistance with activities of daily living. Observations revealed that the resident's bed was placed against the wall, restricting movement. The facility did not have a care plan addressing this placement, nor was there a physician's order or informed consent obtained. Similar deficiencies were noted for Residents 31, 6, 15, 32, and 25, who had various medical conditions and required different levels of assistance. In each case, the bed placement against the wall was considered a restraint, and the necessary assessments and consents were not completed. The facility's policy on the use of restraints, last reviewed in April 2024, defines physical restraints and outlines the requirements for their use, including a physician's order and informed consent. However, the facility did not adhere to these policies, as evidenced by the lack of documentation and assessments for the residents involved. Interviews with staff, including the Director of Nursing, confirmed that the bed placement against the wall was considered a restraint and that the appropriate procedures were not followed.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating insulin injection sites for four residents, leading to potential adverse effects. Resident 11, admitted with type 2 diabetes mellitus and other conditions, received insulin injections repeatedly in the same areas of the abdomen over several weeks. This practice was against the facility's policy and the manufacturer's guidelines, which both emphasized the importance of rotating injection sites to prevent skin trauma and other complications. Similarly, Resident 144, who also had type 2 diabetes and chronic kidney disease, received insulin injections in the same area of the abdomen on consecutive days. The Director of Nursing (DON) confirmed that the licensed nurses failed to rotate the injection sites, which could lead to skin discoloration, swelling, and trauma. The facility's policy and the manufacturer's guidelines both required site rotation to minimize skin injury. Residents 33 and 28 experienced the same issue, with insulin injections administered repeatedly in the same areas. Resident 33, with type 2 diabetes and heart failure, and Resident 28, with type 2 diabetes and impaired cognition, both had their insulin administered without proper site rotation. The DON acknowledged the oversight and reiterated the necessity of rotating injection sites to prevent skin damage, as outlined in the facility's policy and the manufacturer's instructions.
Improper Use of Fall Mats and Unsecured Equipment in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for several residents by improperly using fall mats. For multiple residents, including those with high fall risk and cognitive impairments, fall mats were obstructed by heavy medical equipment and furniture, such as side tables and oxygen concentrators. This improper placement compromised the mats' effectiveness, as the weight of the items caused permanent indentations, reducing the mats' ability to cushion falls and increasing the risk of injury if residents were to fall onto the equipment or furniture. In one instance, a resident with a history of falls and cognitive impairments was found with a wheelchair and overbed table placed on top of their fall mat. The Director of Nursing confirmed that such placement could damage the mat and diminish its protective function. Similarly, another resident's fall mat was obstructed by a side table and an oxygen concentrator, which was acknowledged by both a Certified Nursing Assistant and the Director of Nursing as a practice that could lead to increased injury risk during a fall. Additionally, the facility failed to secure a portable air conditioning unit's exhaust panel in a resident's room, posing a potential hazard. The panel, which was part of the installation kit, was not properly secured and fell onto the resident's bed. This oversight was recognized by the Maintenance Supervisor and the Director of Nursing, who both stated that the panel should have been secured to prevent it from falling and causing injury.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. The deficiency was identified during a review of insulin care for four residents, where it was found that licensed nurses did not rotate subcutaneous insulin administration sites as required. This practice is contrary to the facility's policy and procedure, which mandates the rotation of injection sites to prevent skin trauma and other adverse effects. The Director of Nursing (DON) confirmed that the failure to rotate injection sites constitutes a medication error. Resident 11, admitted with type 2 diabetes mellitus and other conditions, received insulin injections repeatedly in the same areas of the abdomen over several months. The DON acknowledged multiple instances where the licensed nurses failed to rotate the injection sites, which is against the facility's guidelines and the manufacturer's instructions. Similar issues were found with Resident 144, who also received insulin injections in the same area without proper site rotation, as confirmed by the DON. Residents 33 and 28 also experienced similar deficiencies in insulin administration. Resident 33's records showed repeated insulin injections in the same abdominal areas, while Resident 28's records indicated repeated injections in the upper arm and abdomen without proper rotation. The DON verified these findings and reiterated that the licensed nurses should have rotated the injection sites to prevent skin trauma, as per the facility's policy and the manufacturer's guidelines.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One deficiency involved Resident 15, whose nasal cannula oxygen tubing was not labeled with the date it was last changed. This oversight was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the tubing should be changed daily. The Director of Nursing (DON) also confirmed that the staff should date the oxygen tubing to ensure timely replacement for infection control purposes. Another deficiency was observed with Resident 32, whose nasal cannula oxygen tubing was found on the floor, and the nebulizer tubing was not labeled with the date it was last changed. The Infection Preventionist (IP) and the DON both stated that the oxygen tubing should be kept off the floor and replaced if it touches the floor to prevent infection. Additionally, the nebulizer tubing should be dated to track when it needs to be changed. Further deficiencies included the improper storage of enteral feeding kits, as two opened kits were mixed with unopened ones in the medication room, which should have been discarded to prevent infection. A Licensed Vocational Nurse (LVN) failed to clean a glucometer with an antiseptic wipe after use, which is necessary to prevent the spread of bloodborne diseases. Lastly, the facility's water temperature logs indicated temperatures below the recommended level to prevent Legionella growth, with consistent readings of 109 degrees Fahrenheit, which predisposes the facility's water system to developing Legionella.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a pad call light was within reach for one resident, which could potentially delay care and services. The resident, who was admitted with diagnoses including dementia, depression, and mild protein-calorie nutrition, had severely impaired cognition and required substantial assistance with activities of daily living. The resident's care plan included an intervention to place the call light within reach due to the risk of falls related to balance problems and mental status. During an observation, the call light was found caught between the mattress and the siderail, not within the resident's reach. The Director of Nursing acknowledged that the call light should have been accessible to the resident. The facility's policy stated that the call system should be functional and within reach at all times, with calls for assistance answered promptly. However, this policy was not adhered to in this instance, leading to the deficiency.
Failure to Cap Feeding Tube Y Adapter
Penalty
Summary
The facility failed to ensure appropriate care for a resident receiving enteral feeding, leading to a potential contamination risk. The deficiency was identified during an observation where a resident's feeding tube was found disconnected and the Y adapter tubing was not capped. This was contrary to the facility's policy, which requires that tubing be capped when not in use to prevent infection. The Licensed Vocational Nurse (LVN) acknowledged that the tubing should have been capped or placed in a clean plastic bag for infection control. The resident involved had been admitted with diagnoses including gastro-esophageal reflux disease and dysphagia, and was receiving continuous gastrostomy tube feeding. The resident's medical records indicated they lacked the capacity to make decisions and rarely had the ability to communicate effectively. The Director of Nursing confirmed that the Y adapter should be capped when not in use to prevent gastrointestinal infection, aligning with the facility's policy on enteral feeding safety precautions.
Failure to Ensure Proper Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 32, who required the use of a bilevel positive airway pressure (BIPAP) machine. The deficiency was identified during a survey where it was observed that there was no physician's order for the use of the BIPAP machine for Resident 32. This lack of a physician's order is critical as it ensures the machine is set correctly to provide the necessary therapy. Additionally, the BIPAP mask and tubing were found on the floor, which poses a risk of respiratory infection. Resident 32 was admitted with diagnoses including acute respiratory failure with hypercapnia, pleural effusion, and dependence on supplemental oxygen. The resident's care plan included interventions for respiratory risk related to chronic obstructive pulmonary disease (COPD) and acute hypoxemic hypercapnia respiratory failure, but did not include the use of a BIPAP machine. The facility's policies require a physician or qualified healthcare provider to evaluate and confirm the need for BIPAP therapy, which was not adhered to in this case.
Failure to Flush G-tube Between Medications
Penalty
Summary
The facility failed to accurately and safely provide pharmaceutical services to a resident during medication administration via a gastrostomy tube (G-tube). The resident, who was admitted with diagnoses including dementia, gastrostomy status, and chronic pain syndrome, was dependent on staff for all activities of daily living and received feeding through a G-tube. The facility's policy required medications to be administered separately with a flush of 10 ml of water between each medication to prevent drug interactions and ensure full absorption. However, during an observation, a Licensed Vocational Nurse (LVN) was seen administering medications without flushing the G-tube between them, contrary to the facility's policy. The resident's care plan and physician orders specified the need for flushing the G-tube with water before and after medication administration. Despite these instructions, the LVN failed to flush the tube between medications, which was acknowledged during an interview with the Director of Nursing. This oversight had the potential to place the resident at risk of health complications due to drug interactions and delays in care provision. The facility's policy on administering medications through an enteral tube was not followed, leading to this deficiency.
Failure to Monitor Anticoagulant Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not adequately monitoring the use of the anticoagulant Apixaban. This deficiency was identified for a resident who was admitted with diagnoses including atrial fibrillation and long-term use of anticoagulants. The resident's care plan included an intervention to monitor for adverse effects of anticoagulant use, such as discolored urine, black tarry stools, and other symptoms, but this monitoring was not conducted as it was not included in the Medication Administration Record (MAR). During a review, the Director of Nursing (DON) confirmed that there was no order for monitoring the adverse effects of Apixaban, and no monitoring had been done since the medication was ordered. The facility's policy on anticoagulation required assessment for signs or symptoms of adverse drug reactions, but this was not followed. The lack of monitoring had the potential to predispose the resident to adverse effects of anticoagulant use, such as bleeding.
Expired COVID-19 Test Kits Not Discarded
Penalty
Summary
The facility failed to properly manage expired COVID-19 test kits, specifically nine boxes of BinaxNOW COVID-19 Antigen Self-Test kits with an expiration date of 1/18/2024, which were stored in the Medication Room. During an observation and interview, a Licensed Vocational Nurse (LVN) acknowledged the presence of these expired test kits and stated that expired medications and test kits should be disposed of to prevent adverse effects and false diagnoses. The Director of Nursing (DON) also observed the expired test kits and mentioned that there was an extension on their use, but they should have been discarded to avoid false test results. The Infection Preventionist (IP) confirmed that the test kits should have been discarded as they were past the expiration extension set by the CDC. The facility's policy and procedure on expired products, last reviewed on 4/12/2024, requires staff to regularly check for expiration dates during inventory audits and before use, and to segregate and mark expired products for proper disposal. The failure to adhere to this policy increased the risk of misdiagnosis and delayed care for residents and staff.
Inaccurate EHR Entry Leads to Delay in Care
Penalty
Summary
The facility failed to accurately enter the order for a Restorative Nursing Assistance (RNA) program in the electronic health record (EHR) for a resident, leading to incomplete and inaccurate medical documentation. The resident, who was admitted with diagnoses including dementia, gastrostomy status, and chronic pain syndrome, had severely impaired cognition and was totally dependent on staff for all activities of daily living. The resident had physician orders for passive range of motion (PROM) exercises and the application of splints, which were not accurately reflected in the restorative record flowsheet. This discrepancy was observed during a review of the resident's records and confirmed by the Restorative Nursing Assistant (RNA 1) and the Director of Nursing (DON). The issue arose because the charge nurse did not correctly enter the new order for the application of splints in the EHR, resulting in the order not populating in the restorative record flowsheet. Consequently, the RNA assigned to the resident was unaware of the new order, leading to a delay in the provision of necessary care. The DON verified that the order entry error occurred, and the facility's policy on physician orders indicated that orders should be consistent with principles of safe and effective order writing.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 19 out of 21 resident rooms met the federal square footage requirement of 80 square feet per resident in multiple resident rooms. During a recertification survey, it was observed that these rooms, although smaller than required, allowed residents to move freely and did not impede the use of mobility aids such as wheelchairs, walkers, or canes. The facility had submitted an application for a Room Variance Waiver, acknowledging that these rooms did not meet the required size but asserting that the space was adequate for resident care, dignity, and privacy. The waiver indicated that the room sizes would not adversely affect the residents' health and safety or their ability to attain their highest practicable well-being. During interviews, both residents and staff, including CNAs and an LVN, reported no issues with the space in the rooms. A specific observation noted a portable HVAC unit in one resident's room, which the resident stated was crowding the space and was not requested by him. Despite this, the staff reported no difficulties in performing their duties due to room size. The facility's policies and procedures were reviewed, indicating compliance with federal and state requirements for room sizes, with allowances for individual variations if they met residents' special needs without adverse effects.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Granada Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Casitas Care Center | 1.1 mi | ★★★★★ | 19 | 0 |
| Rinaldi Convalescent Hospital | 1.2 mi | ★★★★★ | 42 | 0 |
| The Rehabilitation Center Of North Hills | 1.4 mi | ★★★★★ | 8 | 0 |
| Providence Holy Cross Med Ctr D/p Snf | 1.6 mi | ★★★★★ | 17 | 2 |
| Ararat Nursing Facility | 1.6 mi | ★★★★★ | 25 | 1 |
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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.