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 Topanga Terrace during CMS and state inspections, most recent first.
Improper disposal of garbage and refuse was identified when six soiled gloves were observed on the floor in the dumpster area. The DS stated the area must be kept clean to prevent attracting flies, rats, and other pests, and the HKD stated the gloves were not acceptable because they could attract rats and bring infections to residents. Facility policy and Food Code guidance both stated the trash collection area must be kept clean and garbage properly stored and disposed of to prevent vermin and rodents.
PHI on Meal Tickets Discarded in Trash: A staff member threw residents’ meal tickets into the trash during dishwashing, even though the tickets contained names, room numbers, diet orders, and food allergy information. The DS stated the tickets were discarded because they were wet, while the DON stated the meal tickets contained PHI and should have been shredded before disposal. The facility’s HIPAA policy addressed protection of PHI and restricted disclosure.
Coiled urinary catheter tubing prevented free urine flow for three residents with indwelling catheters. A CNA and RNs observed tubing looped or coiled with urine pooling in the tubing and catheter bags hung on bed rails rather than positioned to allow drainage. The residents had significant medical complexity, including neurogenic bladder, severe cognitive impairment, ventilator dependence, and total dependence for ADLs. The DON stated catheter tubing should not be kinked or coiled and urine flow should remain unobstructed to prevent backflow.
A resident received midodrine even though the SBP was above the ordered hold parameter, and another resident’s lidocaine patch was left on beyond the prescribed 12-hour limit. The facility also left several discontinued controlled medications in the med cart and did not reconcile them during shift counts, despite staff stating that discontinued CMs should be removed from active supply and counted by two licensed nurses.
Failure to Follow Standardized Puree Recipes: A dietary staff member prepared puree wheat spaghetti with water instead of warm milk and prepared puree zesty meat sauce with water and butter instead of milk, gravy, or low sodium broth. During a tray observation, the puree items were noted to have less flavor than the regular diet versions. The DS stated the recipes should be followed as standardized so the taste would match the regular diet, and that poor acceptance could lead to weight loss.
Unsafe food storage and prep practices were observed in the kitchen. Ice buildup was present in the walk-in freezer, several food racks were stored too close to the floor, and multiple food-contact surfaces were damaged or rusted, including racks, cutting boards, and a can opener. Thawed chicken was improperly dated, dented cans were mixed with intact cans, cold foods were above the facility’s stated range, the mixer bowl had residue and was left uncovered, trays were stacked wet, and the resident refrigerator log showed repeated temps above the limit without documented corrective action.
A resident’s MDS did not list depression in the Active Diagnoses section even though the record showed major depressive disorder, a psych note documenting sadness and a plan to start Lexapro, an active Lexapro order for depression, and a care plan focused on depression. The MDSC and DON both stated the depression diagnosis should have been included so the MDS and care plan had the needed information.
A resident with chronic respiratory failure, a trach, and a GT had an order for midodrine for hypotension, but the care plan did not address the medication. The QAN and DON both stated a care plan should have been developed for the high-risk medication, and the facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables.
A resident with chronic respiratory failure and a tracheostomy did not receive the ordered 31% FiO2 via mist collar. The resident was observed with the oxygen concentrator set at 1 LPM, while the order required blow by mist collar at 31% during the day and RT titration to keep O2 saturation above 92%. The RTD stated 1 LPM was not the correct setting to achieve the ordered FiO2.
A facility failed to ensure required training and competency documentation was completed for one of three sampled HD staff members. The HD Tech’s personnel file was missing, and the DSD and ADSD stated the file had not been completed; the DSD was unsure of the tech’s start date. The facility’s HD agreement and Personnel Files policy required documentation of qualifications, CPR, abuse prohibition training, competency validation, and other required records before assignment and prior to resident care.
Missing Signatures on Physician Telephone Orders: Two residents had physician telephone orders that were left unsigned by the prescriber. One resident had intact cognition and an order to discontinue hydrocodone-acetaminophen, while the other had severely impaired cognition and an order to discontinue modafinil via G-tube for encephalopathy. The DON confirmed the missing signatures, and the NP stated telephone orders should be signed within five days per facility policy.
Failure to post daily nurse staffing information. A staffing sheet posted near a nursing station was dated two days earlier instead of reflecting current census and nursing hours. The DSD, ADSD, and DON stated the staffing information should be updated daily, and weekend staff had forgotten to update the posting.
A resident with CHF, dysphagia, and dementia did not receive ordered bumex and carvedilol on multiple occasions because the meds were documented as pending from pharmacy and not available. The EMAR showed the doses were not given, and the ADON stated a 9 means the med was not administered and that the facility is responsible for ensuring ordered meds are always available.
A facility failed to keep medical records complete and accurately documented for two residents. One resident’s MAR showed metoprolol was given without documenting the required BP before administration, even though the order required BP and HR checks and holding the dose if parameters were not met. Another resident’s record did not list depression as a diagnosis despite MDS findings, a psych note diagnosing major depressive disorder, an active Lexapro order for depression, and a care plan addressing depressive symptoms.
A laptop was observed resting on top of a soiled linen hamper in a room with two residents who had CVCs and were dependent on staff for all ADL. The HD Tech said the laptop was his and that he placed it there, while the HDRN, QAN, and IPN stated the laptop should not be on a dirty surface and that this did not follow infection control policy requiring equipment to be separate from soiled equipment.
Failure to Offer Updated COVID-19 Vaccine: The facility failed to document that a resident with severe cognitive impairment, ESRD on dialysis, acute/chronic respiratory failure, and DM was offered an updated COVID-19 vaccine or that the vaccine was received or refused. The IPN and DON both stated the resident should have been offered the vaccine, and the facility policy required education and offering of recommended vaccine doses when CDC guidance and vaccine supply were available.
The facility failed to provide non-pharmacological interventions before administering opioid pain medication to two residents. Despite care plans and physician orders requiring such interventions, the MAR showed multiple instances where Hydrocodone-acetaminophen was given without prior non-drug methods. The DON confirmed the lack of adherence to the facility's pain assessment policy, resulting in a deficiency.
The facility failed to administer medications as prescribed for two residents, leading to potential health risks. One resident did not receive lorazepam at the prescribed time for anxiety management, and another resident was given metoprolol on dialysis days when it should have been withheld. These errors were confirmed by the nursing staff and were contrary to the facility's medication administration policies.
A facility failed to ensure non-pharmacological interventions were attempted before administering lorazepam to a resident with severe cognitive impairment and respiratory failure. Despite a care plan outlining interventions like repositioning and music therapy, documentation showed lorazepam was given without these attempts. Interviews with staff confirmed the importance of such interventions to avoid unnecessary medication and adverse effects, but the facility's policy lacked guidance on this practice.
The facility failed to develop comprehensive care plans for two residents, one with vision impairment and another using insulin for diabetes management. The first resident's visual impairment was not addressed in a care plan, despite being noted in assessments. The second resident's care plan did not reflect changes after the resident and family requested to discontinue blood sugar checks and insulin. The facility's policy on care planning was not followed, leading to deficiencies in person-centered care.
Two residents with limited English proficiency were not provided with communication boards at their bedsides, hindering their ability to communicate needs to staff. Despite facility policies ensuring access to communication aids, these residents faced challenges in expressing their needs, such as assistance when soiled, due to the absence of these aids.
A resident with visual impairment was not properly communicated to the nursing staff, resulting in a lack of care planning and increased risk of falls. Despite the resident's condition being noted in the Social Services-Admission-Evaluation, it was not shared with the Interdisciplinary Team, leading to a deficiency in care.
A resident with a history of diabetes, traumatic brain injury, and hypertension was administered Metoprolol despite a physician's order to hold the medication if the heart rate was below 60 bpm. On two occasions, the resident's heart rate was below this threshold, yet the medication was given, placing the resident at risk for bradycardia. This action was against the facility's medication administration policy.
A facility failed to follow its policy on storing and discarding leftover food brought by family for a resident. An observation revealed a resident had flan and a partially eaten enchilada on an overbed table, which were not labeled or refrigerated as required. The RN confirmed the food was unsafe and could cause foodborne illness, highlighting a lapse in adhering to food safety procedures.
The facility failed to follow infection control protocols in two cases: an LVN did not wear a gown while administering medication via a gastrostomy tube to a resident on enhanced barrier precautions, and another resident's oxygen tubing was found on the floor. These actions were contrary to the facility's policies, increasing infection risk.
A resident in an LTC facility did not receive the influenza vaccine as required by the facility's policies. The resident was admitted with several diagnoses and was dependent on staff for certain activities. The Infection Preventionist Nurse mistakenly documented the vaccine administration without obtaining informed consent from the resident or their Responsible Party. The Director of Nursing confirmed the oversight, which was contrary to the facility's policy requiring documentation and informed consent during the admission process.
A resident with chronic respiratory failure was not properly offered or documented as having received the COVID-19 vaccine, leading to uncertainty about its administration. The facility's records showed discrepancies, with the IP and DON unable to confirm the vaccine's administration. Additionally, no care plan was initiated to monitor adverse effects post-vaccination, contrary to the facility's policy.
The facility failed to report an injury of unknown source within the required two-hour timeframe to the SSA for a resident with severe cognitive impairment and an acute fracture. The DON stated the injury was considered pathological, but the resident could not describe the incident, and no witnesses were present. The facility's policy mandates immediate reporting, which was not followed.
Improper Garbage Disposal in Dumpster Area
Penalty
Summary
Improper disposal of garbage and refuse was identified when six soiled gloves were observed on the floor in the dumpster area during a concurrent observation and interview with the Dietary Supervisor. The Dietary Supervisor stated it was everyone's responsibility to keep the dumpster area clean to prevent attracting flies, rats, and other pests, and stated that soiled gloves on the floor were not acceptable because they could get residents sick and spread infection. During a separate interview at the dumpster area, the Housekeeping Director stated the trash area is cleaned every morning and detail cleaned every Thursday using a power washer, and stated the gloves on the floor were not acceptable because they could attract rats that could bring infections to residents. Facility policy titled Miscellaneous Area stated the trash collection area is a potential feeding ground for vermin and rodents and must be kept clean, and Food Code 2022 stated proper storage and disposal of garbage and refuse are necessary to minimize odors and prevent waste from becoming an attractant and harborage for insects and rodents.
PHI on Meal Tickets Discarded in Trash
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential when documents containing protected health information were not shredded before being discarded. During an observation of the dishwashing process in the dish machine area, a staff member threw residents’ meal tickets into the trash. The meal tickets contained residents’ names, room numbers, diet orders, and food allergy information. During the observation and interview, the staff member stated that the process was to remove food and trash, including the menu tickets, and throw them in the trash, which was then taken out and placed in the dumpster. During interview, the Dietary Supervisor stated the staff were throwing away resident menu tickets in the trash during dishwashing because the tickets were wet. The Dietary Supervisor also stated the menu tickets contained residents’ names, room numbers, and the menu of the day, and acknowledged that the resident name was protected information that needed to be secured in a confidential bin. The DON stated the meal ticket should have been shredded prior to disposal because it contained PHI, and stated that other people would know residents’ names and diets if the tickets were not shredded. The facility policy on HIPAA stated that disclosure of PHI must be consistent with applicable laws and standards and that disclosure is only allowed under specified circumstances.
Coiled urinary catheter tubing prevented free urine flow
Penalty
Summary
The facility failed to ensure appropriate care for residents with indwelling urinary catheters by allowing catheter tubing to remain coiled or looped, which prevented urine from flowing freely into the collection bag for three residents. During observation and interview, Resident 42’s catheter tubing was looped and urine was seen filling the tubing rather than draining freely; the catheter bag was hung at the middle portion of the bedside railing. A CNA stated the tubing should not have been looped because urine buildup and backflow into the bladder could cause a UTI. RN Sup 2 and the DON also stated that catheter tubing must not be kinked or looped so urine can flow freely and backflow can be prevented. Resident 42’s record showed diagnoses including CVA, neurogenic bladder, and BPH. The MDS indicated severely impaired cognition and dependence on staff for ADLs, and the care plan and orders directed staff to check for kinks, maintain free urine flow, and provide catheter care every shift. The facility’s policy on preventing catheter-related UTI stated that proper catheter maintenance should include maintaining unobstructed urine flow. Resident 118’s record showed diagnoses including chronic respiratory failure status post tracheostomy and ventilator, hyponatremia, and ESRD on hemodialysis. The MDS indicated severely impaired cognition and dependence on staff for ADLs, and the resident had an indwelling urinary catheter for neurogenic bladder and BPH. During observation, Resident 118’s catheter tubing was looped with yellow liquid pooling in the tubing, and the collection bag was hung at the middle length of the bedside railing. A CNA stated the tubing was looped and not draining freely, and RN Sup 2 stated the tubing should not be looped because backflow could cause a UTI. Resident 63’s record showed diagnoses including dependence on a ventilator, gastrostomy, and persistent vegetative state. The resident was described as rarely or never understood and completely dependent on staff for all ADLs. The care plan directed staff to position the catheter bag and tubing below bladder level, check for kinks, and observe for signs of UTI. During observation, Resident 63’s catheter bag was hanging on the bed frame and the tubing had coils containing yellow liquid with sediment. RN Sup 5 confirmed the tubing was coiled and stated it should be straight to drain properly, and the DON stated catheter tubing should not be coiled or kinked and should remain below bladder level.
Medication Administration and Controlled Substance Handling Failures
Penalty
Summary
The facility failed to ensure a prescribed midodrine dose was held when a resident’s blood pressure was outside the ordered parameters. Resident 7 was admitted and later readmitted with chronic respiratory failure, a tracheostomy, and a gastrostomy tube, and the order for midodrine hydrochloride 10 mg via GT three times daily directed staff to hold the medication if systolic blood pressure was above 120. During review of the November 2025 MAR, midodrine was documented as administered at midnight with a blood pressure of 121/65. The QAN stated the dose should not have been given because the blood pressure was not within the ordered parameters, and the DON stated medications should be given per physician order and held when blood pressure is outside the parameters. The facility also failed to remove a lidocaine patch after the ordered duration for another resident. Resident 57 was readmitted with chronic respiratory failure with hypoxia, spinal stenosis, and functional quadriplegia, and the order directed staff to apply one 4% lidocaine patch to the right shoulder daily and remove it per schedule. The MAR showed the patch was to be applied at 9:00 a.m. and removed at 8:59 p.m. During a concurrent observation and interview, Resident 57 was found wearing a lidocaine patch dated the previous day, and LVN 3 stated she had applied it the prior morning. Resident 57 stated someone usually removes the patch at night, but no one did so the night before. LVN 3 stated the patch should have been removed in the evening because the order was to remove it after 12 hours. The facility also failed to remove discontinued controlled medications from Medication Cart 2 and failed to reconcile four controlled medications in one of the inspected medication carts. During observation, five bubble packs of discontinued controlled medications were found in the controlled medication drawer, including modafinil, hydrocodone-acetaminophen, and temazepam. The records showed the related orders for Residents 27, 30, 92, and 96 had been discontinued on prior dates. RN 4 stated discontinued medications should be given to the DON for proper disposal and that controlled medications require stricter handling and shift-to-shift counts by two licensed nurses. The pharmacy consultant stated discontinued controlled medications should be removed from active supply and handed to the DON as soon as possible, and that any controlled medication remaining in the facility after discontinuation should have been disposed of during the consultant’s prior visit. LVN 1 stated he did not count the five discontinued controlled medications because the count sheet was not located in the narcotic binder and acknowledged he forgot to remove both the medications and their count sheets. The DON stated controlled substances must be inventoried at each shift change and that discontinued controlled medications must be removed from active supply and stored separately.
Failure to Follow Standardized Puree Recipes
Penalty
Summary
The facility failed to follow standardized puree recipes and did not meet the nutritional needs of residents when puree wheat spaghetti and puree zesty meat sauce were prepared with water instead of the ingredients listed in the recipes. During a test tray observation, the puree wheat spaghetti and puree zesty meat sauce were noted to have less flavor than the regular diet versions. The Dietary Supervisor and staff reviewed the facility’s standardized recipes for Pureed (IDDSI Level 4) starch and casserole items, which called for warm fluid such as milk, gravy, or low sodium broth for the puree zesty spaghetti and warm milk for the puree wheat spaghetti. During interview, [NAME] 1 stated she used only water and thickener for the puree wheat spaghetti and added a little butter, water, and thickener when cooking the zesty meat sauce. The Dietary Supervisor stated the recipes should be followed as standardized so the taste would be the same as the regular diet, and stated residents might not like the food and would not eat, resulting in weight loss. The facility’s Food Preparation policy stated food shall be prepared by methods that conserve nutritive value, flavor, and appearance and that approved recipes standardized to meet the resident census will be used. The diet manual also stated water is not used because it dilutes flavors and results in a poorly accepted product.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen. During observation, thick ice buildup was seen on the pipes and air curtains in the walk-in freezer. The Dietary Supervisor stated the freezer was supposed to be kept free of ice buildup and that the ice could interfere with acceptable freezer temperatures and spoil food products. Facility policy also stated that refrigerator and freezer coils should be cleaned regularly. Food storage racks were not maintained 6 inches above the floor. In the walk-in freezer, two racks were measured at 4 inches and 5 inches from the floor, and in the dry storage area, two racks were measured at 5 inches from the floor. The Dietary Supervisor stated the racks needed to be 6 inches or more from the floor to allow proper cleaning and prevent mold growth under the racks. The facility’s food storage policies and Food Code requirements stated food and food containers were to be stored at least 6 inches above the floor. Kitchen equipment and food-contact surfaces were found in poor condition or improperly maintained. Six green racks in the walk-in refrigerator had chips, rust, and discoloration, and chopping boards were scratched and chipped. The can opener blade was rusted. Thawed chicken in the walk-in refrigerator was dated 11/11/2025, and staff described a process for labeling thawed food with pull and use-by dates. Dented cans were observed stored with non-dented cans in both the area by the walk-in freezer and the dry storage area. Parmesan cheese and a cheese sandwich were observed at temperatures above the facility’s stated cold holding range. A mixer had dirt residue in the bowl and was not covered, clean trays in the dishwashing area were stacked wet, and the resident refrigerator temperature log showed multiple temperatures above 41 F without documented corrective action.
MDS omitted resident’s depression diagnosis
Penalty
Summary
The facility failed to ensure that one sampled resident’s diagnosis of depression was reflected in the Active Diagnoses section of the MDS. Resident 74 was admitted with diagnoses including chronic respiratory failure with hypoxia and ESRD. The resident’s MDS, dated [DATE], indicated intact cognition, reported little interest or pleasure in doing things, felt down, depressed, or hopeless, and required moderate or substantial assistance for most ADLs, but it did not list depression as an active diagnosis. Record review showed that Resident 74 had a psychiatric progress note dated 9/23/2024 documenting an episode of major depressive disorder and a plan to start Lexapro due to depression manifested by verbalization of sadness. The Order Summary Report showed an active order for Lexapro 10 mg at bedtime for depression manifested by persistently verbalizing sadness, and the care plan titled for depression also identified a goal to decrease episodes of depression. During interview, the MDSC stated depression should have been included in the MDS because the resident was taking an antidepressant and was diagnosed with depression. The DON stated the MDS should include the diagnosis of depression so the plan of care would have all needed information.
Failure to Care Plan for Midodrine Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 7 that addressed the resident’s use of midodrine. Resident 7 was originally admitted on 9/2/2025 and re-admitted on 10/4/2025 with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy tube. The MDS dated 9/8/2025 indicated the resident had moderately impaired cognition for daily decision-making and was dependent on staff for ADLs including bed mobility, transfers, eating, walking in the room, dressing, toileting, and personal hygiene. The Order Summary Report showed an order dated 9/2/2025 for midodrine hydrochloride 10 mg via GT three times a day for hypotension, with instructions to hold the medication if systolic blood pressure was above 120 mmHg. During interview and record review on 11/20/2025, the QAN stated Resident 7 did not have a care plan for midodrine but one should have been developed because midodrine is considered a high-risk medication. The DON also stated there should have been a care plan developed for midodrine when the physician ordered it. The facility’s Care Plans, Comprehensive Person-Centered policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident within seven days of completion of the comprehensive assessment.
Incorrect Oxygen Setting for Resident with Tracheostomy
Penalty
Summary
The facility failed to ensure Resident 103 received the physician-ordered 31% FiO2 via a trach mist collar. Resident 103 was admitted with chronic respiratory failure and an encounter for attention to tracheostomy, and the MDS indicated the resident’s cognitive skills for daily decision making were intact. During observation, Resident 103 was found in bed sleeping with a tracheostomy and attached trach mask for supplemental oxygen, and the oxygen was set at 1 LPM. A later observation with the RTD also showed the oxygen concentrator set at 1 LPM. During concurrent interview and record review, the resident’s order summary showed respiratory treatment for blow by mist collar at 31% as tolerated during the day and a separate order for the RT to titrate FiO2 to keep oxygen saturation above 92% with checks every shift. The RTD stated that 1 LPM was not the correct setting to achieve 31% FiO2 and maintain oxygen saturation above 92%, and stated the resident’s oxygen should be set at 2 to 2.5 LPM. The care plan directed oxygen via tracheostomy mask at 31% during the day, and the facility policy listed 6 L/min as equivalent to 31% FiO2.
Missing HD Staff Competency and Personnel File Documentation
Penalty
Summary
The facility failed to follow its policy by not ensuring documentation of completion of training and competency for one of three sampled hemodialysis staff members, a Hemodialysis Technician. During interview and record review, the technician’s staff file was requested and was found to be missing. The DSD and ADSD stated that the file had not been completed at that time, and the DSD was unsure of the technician’s start date. The DSD also stated that the Hemodialysis RN was supposed to notify and email new HD staff information to the facility before the staff member began providing resident care so the facility could provide the required training and competency review. The facility’s hemodialysis agreement with the dialysis company stated that the company would provide written evidence of each representative’s qualifications and experience, including training, licensure, CPR certification, and abuse prohibition training as required by the facility. The DON stated that it was important for the facility to have all contracted staff files for everyone’s safety and that completion of training regarding facility policy and procedures should be done prior to the start of resident care. The facility’s Personnel Files policy required personnel records for employees and contracted staff to be accurate, complete, and in regulatory compliance, and listed required documentation such as background check verification, TB/health screening, competency validation, proof of orientation or competency in required procedures, and mandatory training completion.
Missing Signatures on Physician Telephone Orders
Penalty
Summary
The facility failed to follow its policy and procedure by not ensuring that physician telephone orders were signed by the prescriber within five days for two sampled residents. Resident 27 was admitted with diagnoses including type 2 diabetes mellitus, hypertension, and hyperlipidemia, and had intact cognitive skills for daily decision making on the MDS. A physician telephone order dated 11/13/2025 at 4:56 p.m. directed discontinuation of hydrocodone-acetaminophen 5-325 mg, but the signature line for the physician was left blank. During interview and record review, the DON confirmed that the prescriber’s signature was missing from the order. Resident 92 was admitted with diagnoses including type 2 diabetes mellitus, hypertension, and encephalopathy, and had severely impaired cognitive skills for daily decision making on the MDS. A physician telephone order dated 10/30/2025 at 12:00 p.m. directed discontinuation of modafinil 200 mg via G-tube for encephalopathy, but the physician signature line was also left blank. The DON confirmed the missing signature and stated that all physician telephone orders must be signed within five days. The NP stated he was the provider who placed the order and that telephone orders should be reviewed and signed within five days to verify accuracy and prevent medical errors.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing information was posted daily on 11/17/2025. During an observation on 11/17/2025 at 1:45 p.m., a document titled, Nursing Staff Per Shift and Hours, dated 11/15/2025, was observed posted in front of nursing station 2 instead of current staffing information. During interviews on 11/19/2025 and 11/20/2025, the DSD, ADSD, and DON stated that the nursing staffing information should be updated daily to reflect the current resident census and nursing hours, and that the weekend staff responsible for posting had forgotten to update the posting in the morning of 11/17/2025. A review of the facility policy, Nursing Hours Posting, revised 1/15/2025, indicated that the facility shall post daily nurse staffing information with the required federal elements in a highly visible public area.
Medication Not Available for Resident With CHF
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when bumex and carvedilol were not readily available on three different days in September 2025, resulting in the resident not receiving those medications on those days. The resident had been admitted in 2015 and readmitted with diagnoses including CHF, dysphagia, and dementia. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated the resident rarely understood others, rarely could make herself understood, and was dependent on staff for activities of daily living such as toileting, dressing, and putting on/taking off footwear. The order summary showed bumex 1 mg daily for CHF and carvedilol 12.5 mg twice daily for HTN with hold parameters for low SBP or HR. The EMAR documented entries showing bumex and carvedilol were not given on the identified dates, and progress notes stated the medications were pending from pharmacy. During interview, the ADON stated a 9 in the EMAR means the medication was not given, pending on pharmacy means the medication was not available, and licensed nurses must reorder medications when the resident has five days left to allow time for verification and delivery. The ADON also stated the facility is responsible for ensuring medications are always available and that it is a medication error if a resident did not receive or at least was not offered the medications as ordered.
Incomplete Documentation of Medication Parameters and Depression Diagnosis
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two sampled residents. For one resident with diagnoses including type 2 DM, HTN, and dizziness, the MAR for 9/9/2025 showed metoprolol tartrate 25 mg was administered, but the blood pressure section was marked NA instead of documenting a BP reading before the dose. The physician order for metoprolol required the medication to be held if SBP was below 110 or HR was below 60, and the ADON stated BP and HR must be taken before each administration. During concurrent review, the ADON stated NA means not available/applicable and, if the resident did not want the BP taken, the medication should have been held to avoid hypotension and dizziness. The facility policy on documentation stated staff are to document relevant findings in the clinical record specific to each resident’s needs and conditions and to chart only what they see and hear related to a resident. For another resident admitted with chronic respiratory failure with hypoxia and ESRD, the medical record did not include depression in the list of diagnoses. The resident’s MDS indicated little interest or pleasure in doing things and feeling down, depressed, or hopeless, and a psychiatric progress note documented major depressive disorder with Lexapro started for depression manifested by verbalization of sadness. The Order Summary Report showed an active Lexapro order for depression, and the care plan addressed depression manifested by persistently verbalizing sadness. The DON stated the diagnosis of depression should be included in the resident’s medical record, and without it staff would lack information about the resident and could have an incomplete plan of care.
Laptop Placed on Soiled Linen Hamper
Penalty
Summary
The facility failed to maintain appropriate infection control practices for two residents when a work computer laptop was observed resting on top of a soiled linen hamper in a room occupied by residents with central venous catheters. Resident 2 was admitted with acute and chronic respiratory failure, ESRD, and dependence on renal dialysis, and the MDS indicated moderately impaired cognitive skills for daily decisions and dependence on staff for all ADL. Resident 34 was admitted with chronic respiratory failure with hypoxia, ESRD, and dependence on renal dialysis, and the MDS indicated a persistent vegetative state with no discernible consciousness and dependence on staff for all ADL. During a concurrent observation and interview, the HD Tech stated the laptop was his and that he placed it on top of the soiled linen hamper. The HDRN stated the laptop should not have been placed on the hamper and should have been kept in a clean area, and explained that doing so created a risk for contamination and spread of infection. The QAN stated placing a laptop on the soiled linen hamper was not following infection control because the hamper is a contaminated or dirty surface. The IPN stated it was not acceptable to place a laptop on the soiled linen hamper and described the hamper as dirty. The facility policy stated equipment must be separate from soiled equipment.
Failure to Offer Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to offer an updated COVID-19 vaccine to one sampled resident, Resident 2, and could not provide documentation that the resident was offered or received the vaccine in 2024 or 2025. Resident 2 was originally admitted on 5/22/2019 and readmitted on 11/12/2025 with diagnoses including acute and chronic respiratory failure with hypoxia, end stage renal disease, and type 2 diabetes mellitus. The MDS dated [DATE] indicated the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for all ADLs. During interview and record review with the Infection Preventionist Nurse, Resident 2's Immunization Report did not show receipt or refusal of an updated COVID-19 vaccine, and the IPN stated the resident should have been offered the vaccine to prevent infection. The IPN also stated Resident 2 had risk factors for complications from COVID-19 because she was on dialysis and had acute respiratory failure and CHF. The DON stated Resident 2 should have been offered an updated COVID-19 vaccination and that without it, the resident was more likely to be infected, have debilitating symptoms, and could potentially spread the virus to other residents. The facility policy stated the facility must educate and offer recommended vaccine doses as soon as CDC recommendations are released and doses are available.
Failure to Provide Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering as-needed opioid pain medication to two residents, Resident 204 and Resident 26. For Resident 204, the care plan initiated on 10/15/2024, indicated the use of non-pharmacological pain-relieving remedies such as positioning, relaxation therapy, and heat and cold application. However, the Medication Administration Record (MAR) showed that Hydrocodone-acetaminophen was administered multiple times without any documented attempts of non-pharmacological interventions. Licensed Vocational Nurse 1 confirmed that these interventions were not attempted, acknowledging the importance of such measures to prevent unnecessary medication and potential adverse side effects. Resident 26, who had diagnoses including chronic respiratory failure and pain in the leg, also did not receive non-pharmacological interventions prior to the administration of PRN pain medication. The care plan for Resident 26 included similar non-drug interventions, and the physician's orders required documentation of these attempts before administering medication. Despite this, the MAR indicated that Hydrocodone-acetaminophen was administered numerous times in September and October 2024 without prior non-pharmacological interventions. The Director of Nursing confirmed that the licensed staff did not offer any non-drug methods to reduce pain as ordered by the physician. The facility's policy and procedure on pain assessment, last reviewed in January 2024, emphasized the importance of assessing residents for pain and providing adequate management, including non-pharmacological interventions. The policy required documentation of the effectiveness of any interventions, whether medication or non-drug methods. The failure to adhere to these policies and procedures resulted in a deficiency, as the facility did not ensure that non-pharmacological interventions were attempted and documented before administering opioid pain medication to the residents.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to administer medications as prescribed for two residents, leading to potential health risks. For Resident 24, who was admitted with acute and chronic respiratory failure and had severely impaired cognition, the facility did not follow the physician's orders for administering lorazepam. The medication was prescribed to be given at midnight to manage anxiety, but it was administered at various other times without notifying the physician. This deviation from the prescribed schedule was acknowledged by the Licensed Vocational Nurse and the Director of Nursing, who confirmed that the nurses did not follow the physician's orders. For Resident 70, who was admitted with end-stage renal disease and other serious health conditions, the facility failed to hold doses of metoprolol as ordered on dialysis days. The medication was supposed to be withheld at 2:00 p.m. on days when the resident received dialysis, but it was administered on three occasions. This oversight was confirmed by the Licensed Vocational Nurse and the Director of Nursing, who acknowledged that administering metoprolol on dialysis days could lead to low blood pressure. The facility's policies and procedures for medication administration and care of dialysis residents were not adhered to in these cases. The policies clearly stated that medications should be administered according to the prescriber's written orders and that medications on dialysis days should only be held by physician's order. The failure to follow these guidelines resulted in the administration of medications contrary to the physician's orders, potentially compromising the residents' health.
Failure to Attempt Non-Pharmacological Interventions Before Administering Lorazepam
Penalty
Summary
The facility failed to ensure that licensed nurses attempted non-pharmacological interventions before administering as-needed lorazepam to a resident. The resident, who was admitted with acute and chronic respiratory failure and had severely impaired cognition, was dependent on staff for activities of daily living. The care plan for the resident included non-pharmacological interventions such as repositioning, deep breathing exercises, and music therapy to alleviate anxiety. However, the facility did not document attempts of these interventions before administering lorazepam on multiple occasions. During interviews, both the Licensed Vocational Nurse and the Director of Nursing acknowledged the importance of attempting non-pharmacological interventions prior to medication administration to prevent unnecessary use and potential adverse side effects. The facility's policy on psychoactive medications did not include guidance on non-pharmacological interventions, which contributed to the deficiency. This oversight had the potential to place the resident at increased risk of experiencing adverse side effects from lorazepam.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with vision impairment. The resident, admitted with diagnoses including depression and chronic respiratory failure, was found to have intact cognitive skills but was dependent on staff for various daily activities. Despite the resident's visual impairment being noted in the Social Services-Admission-Evaluation, there was no care plan initiated to address this condition. Licensed Vocational Nurse 1 confirmed the resident's inability to see clearly during an assessment, and it was acknowledged that a Change of Condition should have been triggered to assess the resident's needs and risks. The Social Services Director admitted to not discussing the resident's vision issues with the Interdisciplinary Team, resulting in a lack of a care plan to meet the resident's needs. The facility also failed to create an individualized care plan for a resident using insulin for diabetes management. The resident, admitted with type 2 diabetes and other conditions, was receiving insulin injections as per a sliding scale. However, after the resident and a family member requested to discontinue blood sugar checks and insulin administration, the facility did not update the care plan to reflect these changes. The Director of Nursing acknowledged that a care plan should have been developed to include goals and interventions for insulin use and to document the resident's refusal of blood sugar checks and insulin injections. This oversight resulted in a lack of monitoring and necessary services for the resident. The facility's policy on Interdisciplinary Team Guidelines and Care Planning, which emphasizes the inclusion of appropriate team members in the care planning process, was not followed in these cases. The policy requires that care plans include the resident's strengths, goals, life history, and preferences, and that residents and their representatives participate in establishing care goals and outcomes. The failure to adhere to these guidelines led to deficiencies in providing person-centered care for the residents involved.
Failure to Provide Communication Aids for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide communication devices or boards at the bedsides of two residents, Resident 22 and Resident 350, who had limited English proficiency. This deficiency was identified through observations, interviews, and record reviews. Resident 22, who was diagnosed with dementia and dysphagia, was noted to have a preferred language other than English and required an interpreter to communicate with healthcare staff. Despite this, no communication board was available at the resident's bedside, as confirmed by a registered nurse. The resident's care plan indicated a communication problem and the need for a communication board to maintain the current level of communication function. Similarly, Resident 350, who was admitted with type two diabetes mellitus, difficulty in walking, and spinal stenosis, also faced communication barriers due to language differences. The resident's care plan highlighted a communication problem and the need for a translator and communication board. However, during an observation, it was found that no communication board was present at the resident's bedside. The resident expressed difficulty in communicating with staff due to the language barrier, which led to unmet needs, such as being unable to verbalize the need for assistance when soiled. The facility's policy on Limited English Proficiency, last reviewed in January 2024, stated that reasonable steps would be taken to ensure meaningful access for individuals with limited English proficiency, including providing interpreters and communication aids at no cost. Despite this policy, the lack of communication boards for the two residents prevented effective communication with staff, potentially delaying necessary care and treatment.
Failure to Communicate Resident's Visual Impairment
Penalty
Summary
The facility's Interdisciplinary Care Team failed to effectively communicate and collaborate regarding a resident's visual impairment, leading to a deficiency in care. Resident 93, who was admitted with diagnoses including depression and chronic respiratory failure, was found to be visually impaired during an assessment. Despite this, the nursing staff was not informed of the resident's condition, and no care plan was developed to address the resident's visual impairment. This lack of communication and care planning was confirmed through interviews with the nursing staff and the Social Services Director, who acknowledged that the resident's visual impairment was not communicated to the Interdisciplinary Team or included in the care conference. The deficiency was further highlighted by the fact that the resident's visual impairment was noted in the Social Services-Admission-Evaluation but not communicated to the nursing staff, resulting in a lack of awareness and appropriate care planning. The facility's policies on care planning and fall/accident mitigation were not followed, as the resident's risk factors, such as potential falls due to visual impairment, were not addressed. This oversight had the potential to lead to serious injury for the resident due to the inability to see.
Failure to Adhere to Physician's Order for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the physician's order regarding the administration of Metoprolol. The resident, who was comatose and had a history of type 2 diabetes mellitus, traumatic brain injury, and hypertensive chronic disease, had a physician's order to hold Metoprolol if the heart rate was less than 60 beats per minute. However, on two occasions, the medication was administered despite the resident's heart rate being below the specified threshold. During a review of the Medication Administration Record for October 2024, it was found that the resident's heart rate was 50 bpm in the morning and 59 bpm in the evening on the same day, yet Metoprolol was administered both times. This action was contrary to the physician's order and placed the resident at risk for bradycardia, which could lead to serious health complications. The facility's policy on medication administration, which requires medications to be administered as prescribed, was not followed in this instance.
Failure to Follow Food Safety Procedures for Resident's Outside Food
Penalty
Summary
The facility failed to adhere to its policy regarding the storage and disposal of leftover food brought in by family members for a resident. During an observation and interview, it was noted that a resident had an overbed table with a clear cup containing flan and a container with a partially eaten enchilada, which were brought by the family the previous day. The Certified Nursing Assistant confirmed the presence of these food items, and the Registered Nurse verified that the food belonged to the resident. The facility's policy, last reviewed on January 17, 2024, mandates that prepared food brought in for residents must be consumed within one hour to prevent foodborne illness, with any unused food to be disposed of immediately. However, the food items in question were not labeled with a date or time, making it impossible to determine how long they had been in the resident's room. The Registered Nurse acknowledged that the food was not safe for consumption and could potentially cause foodborne illnesses, indicating a failure to follow the facility's food safety procedures.
Infection Control Lapses in Medication Administration and Oxygen Tubing Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed in two instances. In the first instance, a Licensed Vocational Nurse (LVN 3) did not don a gown before administering medications via a gastrostomy tube to a resident on enhanced barrier precautions (EBP). This resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, was readmitted with conditions including chronic respiratory failure and dependence on a ventilator. Despite a sign indicating EBP requirements and the facility's policy mandating gown use for high-contact activities, LVN 3 administered the medication without wearing a gown, acknowledging the oversight during an interview. In the second instance, the facility did not maintain proper infection control regarding a resident's oxygen tubing. The resident, admitted with atrial fibrillation and pneumonitis, was observed with their nasal cannula oxygen tubing on the floor. A Licensed Vocational Nurse (LVN 4) confirmed the observation and stated the need to replace the tubing. The Director of Nursing (DON) later affirmed that oxygen tubing should be kept off the floor to prevent infection, aligning with the facility's standard precautions policy. These deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in adherence to infection control protocols. The facility's policies on enhanced barrier precautions and standard precautions were not followed, increasing the risk of infection for the residents involved.
Failure to Administer and Document Influenza Vaccine
Penalty
Summary
The facility failed to implement its policies and procedures related to the influenza vaccine for one of the sampled residents, identified as Resident 93. The deficiency was identified during an interview and record review, which revealed that Resident 93 was admitted to the facility with diagnoses including encephalopathy, abnormal posture, and depression. The Minimum Data Set (MDS) indicated that Resident 93 had intact cognitive skills for daily decision-making but was dependent on staff for certain activities. Despite this, the resident was not in the facility during the influenza vaccination season, and there was no documentation of the influenza vaccine being administered to Resident 93 on the Medication Administration Record (MAR) for the specified date. The Infection Preventionist Nurse (IP) acknowledged that there was no informed consent obtained from Resident 93 or her Responsible Party (RP) regarding the administration of the influenza vaccine. The IP admitted to mistakenly documenting that the vaccine was administered. The Director of Nursing (DON) confirmed that licensed staff are required to offer the influenza vaccination to all residents upon admission, but Resident 93 did not receive it. The facility's policy indicated that residents or their responsible parties should be informed about the vaccinations during the admission process, and documentation should be promptly recorded in the MAR, which was not adhered to in this case.
Failure to Administer and Document COVID-19 Vaccine
Penalty
Summary
The facility failed to offer the COVID-19 vaccination to a resident, identified as Resident 43, which placed the resident at a higher risk of acquiring and transmitting the virus. Resident 43 had been admitted to the facility with chronic respiratory failure and was dependent on a respirator. The resident's cognitive skills were intact, and they were dependent on staff for daily activities. The facility's records indicated that a verbal consent for the COVID-19 vaccine was obtained from the resident's family member, and the vaccine was reportedly administered on a specific date. However, discrepancies were found in the documentation regarding the administration of the vaccine. The Immunization Record suggested that the Infection Preventionist Nurse (IP) administered the vaccine, but the Medication Administration Record (MAR) did not reflect this, and the progress notes indicated that another nurse administered the vaccine. Both the IP and the Director of Nursing (DON) were unable to confirm who administered the vaccine or if it was administered at all. The responsible party for Resident 43 also expressed uncertainty about whether the vaccine was given. Additionally, the facility failed to initiate a care plan to monitor potential adverse effects following the administration of the COVID-19 vaccine to Resident 43. The IP acknowledged that normally a care plan would be developed post-vaccine administration, but this was not done for Resident 43. The facility's policy required efforts to vaccinate unvaccinated residents within a week of admission, but it appears this was not effectively implemented for Resident 43.
Failure to Report Injury of Unknown Source Within Required Timeframe
Penalty
Summary
The facility failed to implement its policy and procedures for reporting a reasonable suspicion of a crime in accordance with Section 1150B of the Act. Specifically, the facility did not report an injury of unknown source within two hours to the State Survey Agency (SSA) for a resident who was observed with left hand swelling, purplish discoloration, and pain. The resident, who had severe cognitive impairment and required extensive assistance with daily activities, was found to have an acute fracture of the 4th metacarpal. Despite the injury being identified on 4/10/2024, the facility did not report it to the SSA until 4/16/2024, well beyond the required two-hour window. The Director of Nursing (DON) stated that the facility did not report the injury within the required timeframe because they determined it was a pathological fracture rather than a result of abuse or mistreatment. However, the resident was unable to describe what happened, and no staff or other residents witnessed the incident. The facility's policy mandates immediate reporting of any injury of unknown source to local law enforcement and the SSA within two hours, which was not followed in this case.
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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.
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Nursing homes near Canoga Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Hills Health And Rehabilitation Center | 0.4 mi | ★★★★★ | 17 | 1 |
| Canyon Oaks Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 24 | 0 |
| West Valley Post Acute | 1.4 mi | ★★★★★ | 57 | 0 |
| Holiday Manor Care Center | 1.7 mi | ★★★★★ | 21 | 0 |
| Stoney Point Healthcare Center | 2.5 mi | ★★★★★ | 4 | 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.