Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eisenberg Village during CMS and state inspections, most recent first.
A resident with dementia and Alzheimer's, whose primary language was Farsi, was not provided with a communication board, hindering communication with staff. The resident's care plan included the use of a communication board, but it was unavailable, and no staff spoke Farsi. The facility's policy required communication tools for non-English speakers, but this was not adhered to.
The facility failed to lock wheelchair brakes for two residents, both with severe cognitive impairments and high fall risk, as per their care plans. Observations revealed unlocked brakes, confirmed by staff, despite the facility's policy requiring locked brakes for seated residents. Interviews with the DSD and DON reiterated the importance of this safety measure.
A medication cart was found unlocked and unattended in the nurse's station, with residents and staff passing by. The MDSN and LVN 1 confirmed the cart belonged to an LVN on lunch, and both acknowledged it should be locked to prevent unauthorized access. The DON reiterated the importance of keeping medication carts locked when unattended, in line with the facility's policy.
Two residents were found to be on psychotropic medications without specific, measurable target behaviors as required by facility policy. One resident, non-verbal, was prescribed Zoloft for verbalization of sadness, while another was on Seroquel for sudden verbal agitation without clear indicators of psychosis. The facility failed to clarify these orders, leading to inaccurate monitoring and potential risks.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate due to the omission of Sinemet and Terazosin for a resident with multiple diagnoses. Miscommunication among nursing staff led to the incorrect holding of these medications, despite physician orders to administer them.
A resident with Parkinson's disease and BPH did not receive prescribed medications due to miscommunication among nursing staff. RN 1 and LVN 4 were instructed to hold medications contrary to physician's orders, leading to significant medication errors. The DON confirmed the medications were not administered as required.
The facility failed to label several food items with a use by date, including oatmeal, powdered sugar, quinoa, bulgur, cream of wheat, lemon curd, chicken, and ground beef, as observed with the Dietary Supervisor. Additionally, expired chlorine test strips were used to check the sanitizing solution, as noted with the Kitchen Supervisor. These practices could lead to foodborne illness and compromised dishware sanitation.
A facility failed to follow infection control guidelines in three instances: a nurse left a resident's room wearing an isolation gown, a housekeeper entered a room under droplet precautions without eye protection, and an LVN did not wash hands between administering eye drops to a resident. These actions were against the facility's policies, potentially increasing the risk of infection spread.
A resident with dementia and a suprapubic catheter repeatedly refused catheter care, but the facility failed to notify the physician as required. The resident's cognitive skills were severely impaired, and they were dependent on staff for personal care. Despite multiple refusals documented in the Treatment Administration Record, there was no record of physician notification, which is a deficiency in communication and care management.
The facility failed to develop care plans for a resident refusing to wear a mask while on contact/droplet precautions and another resident refusing care for a suprapubic catheter. The first resident, with severe cognitive impairment, was observed without a mask despite physician orders. The second resident, also with severe cognitive impairment, refused catheter care multiple times, and there was no documentation of physician notification or updated care plans. These deficiencies could delay necessary care and increase infection risk.
A facility failed to update a resident's care plan after the removal of an indwelling urinary catheter. The resident, with severe cognitive impairment and multiple diagnoses, had their catheter discontinued per a physician's order. Despite this, the care plan was not revised to reflect the change, as confirmed by staff interviews and record reviews.
A facility failed to provide a communication device in a language understood by a resident with severe cognitive impairment and multiple medical conditions. Despite the care plan's intervention to provide a communication board in Farsi, the resident did not have access to one, hindering effective communication and potentially leaving the resident's needs unmet.
A resident at risk for pressure ulcers was found to be lying on a low air loss mattress (LALM) that was not properly monitored for functionality. The resident, who was severely cognitively impaired and dependent on staff, had a care plan requiring the use of a LALM for skin management. However, staff failed to document the monitoring of the LALM, and the physician's order was not properly recorded, leading to a lack of follow-through. This oversight was confirmed by the DON, who acknowledged the absence of documentation and monitoring.
A facility failed to act on a Pharmacy Consultant's recommendation to clarify the behavior manifestation for Seroquel use in a resident with dementia and psychotic disorders. The resident's Seroquel order lacked a specific behavior to monitor, leading to inaccurate monitoring and potential exposure to side effects. Despite facility policies requiring clarification of inappropriate psychotropic medication orders, the facility did not follow up on the recommendation.
A facility failed to remove a discontinued medication, amlodipine, from a medication cart, risking accidental administration to a resident with hypertensive heart disease and cognitive impairment. The medication was supposed to be removed immediately upon discontinuation, as per facility policy, but was found during an inspection.
The facility failed to ensure hospice service provision for two residents, lacking documentation of hospice staff visits and not providing required hospice care training to staff, as confirmed by the DON and MRTM.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication board for a resident whose primary language was Farsi, which hindered effective communication between the resident and the staff. The resident, who was diagnosed with unspecified dementia and Alzheimer's disease, required assistance with daily activities and had a care plan that included the use of a communication board as an intervention for communication impairment. However, during an observation, it was found that the communication board was not available at the resident's bedside or at the nurses' station, and no staff members on duty spoke Farsi. The deficiency was further highlighted during interviews with the Certified Nursing Assistant (CNA) and the Social Services Designee (SSD), who confirmed the absence of a Farsi communication board and the lack of Farsi-speaking staff. The Director of Nursing (DON) acknowledged the importance of the communication board in overcoming language barriers and ensuring the resident's needs were understood. The facility's policy on interpreter services emphasized the need for communication tools for non-English speaking residents, but the lack of a communication board for the resident indicated a failure to adhere to this policy.
Failure to Lock Wheelchair Brakes for Resident Safety
Penalty
Summary
The facility failed to adhere to its policy on wheelchair use by not ensuring that the wheelchair brakes were locked while residents were seated, which was observed in two of the three sampled residents. Resident 2, who has a history of unspecified convulsion-seizures, dementia with psychotic disturbance, Parkinson's disease with dyskinesia, and muscle weakness, was found sitting in a wheelchair with the left brake unlocked. The resident's care plan indicated a high risk for falls and injury, yet during an observation, the MDS Nurse and a Certified Nursing Assistant confirmed the brake was not engaged, contrary to the facility's safety protocols. Similarly, Resident 3, diagnosed with unspecified dementia with agitation and Alzheimer's disease, was also observed sitting in a wheelchair with the left brake unlocked. The resident's care plan highlighted a risk for falls due to dementia, and during observations, both the MDS Nurse and a Certified Nursing Assistant noted the unlocked brake. Interviews with the Director of Staff Development and the Director of Nursing confirmed that both brakes should be locked when residents are seated in wheelchairs, although the DSD mentioned that one brake could be unlocked if staff were supervising. The facility's policy, however, mandates that brakes should be locked when residents remain in the same location.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that a medication cart was locked while it was left unattended, which was observed with one of the two sampled medication carts, referred to as Medication Cart A. On February 27, 2025, at 11:24 a.m., Medication Cart A was observed parked in the nurse's station, unlocked and unattended, with residents and other facility staff walking by. This observation was confirmed by the Minimum Data Set Nurse (MDSN) at 11:25 a.m., who acknowledged that the cart was indeed unlocked and unattended. Further confirmation came from Licensed Vocational Nurse 1 (LVN 1) at 11:30 a.m., who stated that the cart belonged to LVN 2, who was on lunch, and reiterated that the cart should always be locked to prevent unauthorized access. The Director of Nursing (DON) also confirmed during an interview that medication carts should be kept locked when unattended for safety reasons. A review of the facility's policy on the storage of medications, updated in January 2017, indicated that medications should be stored securely and only accessible to authorized personnel, with medication carts required to be locked or attended.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary use of psychotropic medications, as required by their policy and procedure. Resident 61 was prescribed Zoloft for depression, with the indication being verbalization of sadness. However, the resident was non-verbal and unable to express feelings, making the indication for Zoloft incorrect and unclear. The MDS Coordinator and LVN confirmed that the resident's inability to verbalize sadness meant there was no specific behavior to monitor, leading to inaccurate monitoring and an inability to measure the medication's effectiveness. Resident 64 was prescribed Seroquel for a psychotic disorder with delusions due to dementia, manifested by sudden verbal agitation. However, the MDS indicated that the resident did not exhibit potential indicators for psychosis such as hallucinations and delusions. The facility's Pharmacy Consultant recommended clarifying the target behavior, as sudden verbal agitation could occur for various reasons unrelated to psychosis. The Director of Nursing acknowledged that the facility failed to follow up on the recommendation to clarify the order, resulting in inaccurate monitoring and an inability to measure the medication's efficacy. The facility's policy on psychotropic medication assessment and monitoring requires that such drugs are used only when necessary and at the lowest effective dose. The policy also mandates that the IDT team assesses and monitors the appropriateness, effectiveness, and side effects of psychotropic medications. In both cases, the facility did not adhere to its policy, as the psychotropic medication orders lacked specific, measurable target behaviors, leading to potential risks for the residents involved.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate during a medication administration task. This was due to two medication errors out of 32 opportunities for a resident with multiple diagnoses, including diabetes mellitus, BPH, Parkinson's disease, dysphagia, and a G-Tube. The errors involved the omission of Sinemet and Terazosin, which were not administered as per the physician's orders. The deficiency was identified during a review of the resident's Medication Administration Record (MAR) and confirmed by the Director of Nursing (DON). The MAR indicated that Sinemet and Terazosin were not given on the specified date and time, despite the physician's orders to administer these medications. The DON confirmed that the medications were marked as 'Not Administered: On Hold' in the MAR, which was contrary to the physician's instructions. Interviews with nursing staff revealed a miscommunication regarding which medications were to be held or administered. RN 1 stated they were instructed by the night RN supervisor to hold all medications except for potassium chloride, blood sugar checks with insulin, and the ipratropium-albuterol breathing treatment. However, the physician, during a phone interview, clarified that medications for BPH and Parkinson's disease should have been given. This miscommunication led to the omission of necessary medications, contributing to the facility's failure to maintain an acceptable medication error rate.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically for a resident with Parkinson's disease and benign prostatic hyperplasia (BPH). The resident, who was severely impaired in cognition and dependent on staff for daily activities, did not receive prescribed medications including Sinemet, terazosin, and finasteride as ordered by the physician. These medications were crucial for managing the resident's Parkinson's disease and BPH. The deficiency occurred when Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 4 (LVN 4) did not administer the medications as per the physician's orders. RN 1 and LVN 4 were instructed by the night RN supervisor to hold all medications except for potassium chloride, insulin, and ipratropium-albuterol treatment. This instruction was contrary to the physician's orders, which specified that medications for BPH and Parkinson's disease should be given. The failure to administer these medications was confirmed through interviews and record reviews. The Director of Nursing (DON) confirmed that the medications were not given as indicated by the medication administration record, which showed the medications as 'Not Administered: On Hold'. The facility's policy on medication administration required that medications be administered in a timely manner and in accordance with the physician's orders, which was not followed in this case.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety by not labeling several food items with a use by date. During an observation and interview with the Dietary Supervisor, it was noted that containers of oatmeal, powdered sugar, quinoa, bulgur, cream of wheat, lemon curd, chicken, and ground beef were not labeled with a use by date. The Dietary Supervisor acknowledged that the absence of these labels could lead to residents consuming food past its use by date, potentially causing illness. Additionally, the facility did not ensure that the chlorine test strips used to check the sanitizing solution were not expired. During an observation with the Kitchen Supervisor, it was found that the test strips used to measure the concentration of the sanitizing solution in the dishwasher had expired. The Kitchen Supervisor confirmed that expired test strips could compromise the effectiveness of the sanitizing solution, which is essential for cleaning and sanitizing dishware. The facility's policies and procedures indicated that dietary items should be labeled and dated, and sanitizing solutions should maintain the manufacturer's recommended concentration.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to observe infection control guidelines when a registered nurse (RN) was observed leaving a resident's room during a medication pass while still wearing an isolation gown. This occurred with a resident who was on enhanced barrier precautions (EBP) due to the presence of a G-Tube. The RN exited the room without removing the isolation gown, which then came into contact with the medication cart. This action was contrary to the facility's policy, which requires the removal of PPE before leaving a resident's room to prevent the spread of infection. In another instance, a housekeeper entered a resident's room, which was under contact and droplet precautions due to a respiratory syncytial virus (RSV) infection, without wearing the required eye protection. The room had clear signage indicating the need for a gown, mask, gloves, and eye protection. The housekeeper was observed cleaning the room without the necessary eye protective equipment, which was confirmed by the Infection Prevention Nurse. This was against the facility's policy for contact and droplet precautions, which mandates the use of eye protection to prevent the spread of infection. Additionally, a licensed vocational nurse (LVN) failed to follow the facility's policy for administering eye drops. The LVN did not wash hands between administering drops to each of a resident's eyes, which could lead to cross-contamination. The facility's policy requires handwashing before treating each eye to prevent infection. The LVN was unaware of this requirement, and the Infection Preventionist was also not aware of the need for hand hygiene between treatments of each eye.
Failure to Notify Physician of Resident's Refusal of Catheter Care
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusal of suprapubic catheter care, which is a deficiency in communication and care management. The resident, who was admitted with diagnoses including unspecified dementia and retention of urine, had a suprapubic catheter in place. The resident's Minimum Data Set indicated severely impaired cognitive skills and a dependency on staff for various personal care tasks. Despite the resident's refusal of catheter care on multiple occasions, there was no documentation of physician notification, as required by the facility's policy. The Director of Nursing confirmed that the licensed staff were responsible for notifying the physician about the resident's refusal of care, but acknowledged the absence of such documentation. The facility's policy on indwelling catheter care mandates the development and re-evaluation of a care plan, including physician communication regarding changes in the resident's condition. The lack of notification placed the resident at increased risk for infection due to the absence of appropriate care.
Failure to Develop and Implement Care Plans for Resident Non-Compliance and Catheter Care
Penalty
Summary
The facility failed to develop a care plan for a resident who refused to wear a mask while on contact/droplet precautions due to exposure to Respiratory Sinus Virus (RSV). The resident, who had severely impaired cognition and required moderate assistance for most activities of daily living, was observed without a mask in a common area, despite physician orders for mask use. The Infection Preventionist and Director of Nursing confirmed that there was no care plan addressing the resident's non-compliance with mask-wearing, which could delay necessary care and services. Another deficiency involved the facility's failure to address a resident's refusal of care for a suprapubic indwelling catheter. The resident, who had severe cognitive impairment and was dependent on staff for personal care, refused treatment for the catheter's surrounding skin on multiple occasions. The Director of Nursing acknowledged that there was no documentation of notifying the resident's physician about the refusals, and the care plan did not reflect current interventions such as monitoring for hematuria and checking for signs of infection. The facility's policies required comprehensive care plans with measurable objectives and timetables to meet residents' needs, which were not followed in these cases. The lack of updated care plans and implementation of interventions could lead to inadequate care and increased risk of infection for the residents involved.
Failure to Revise Care Plan After Catheter Removal
Penalty
Summary
The facility failed to revise the care plan for a resident following the removal of an indwelling urinary catheter. The resident, who was originally admitted on January 25, 2024, and readmitted on October 12, 2024, had diagnoses including sepsis, metabolic encephalopathy, and chronic kidney disease. The Minimum Data Set (MDS) dated October 19, 2024, indicated that the resident had severely impaired cognition and required maximal assistance for various activities of daily living. A physician order dated November 3, 2024, instructed the discontinuation of the indwelling urinary catheter. Despite the removal of the catheter, the care plan, which was created on October 14, 2024, was not updated to reflect this change. During an observation on December 3, 2024, a Certified Nursing Assistant confirmed that the catheter had been discontinued. However, the care plan still addressed the risks associated with having an indwelling catheter. Both the Licensed Vocational Nurse and the Minimum Data Sheet Coordinator acknowledged that the care plan should have been revised to accurately reflect the resident's current condition. The Director of Nursing also confirmed that the care plan needed to be updated after the catheter was removed.
Failure to Provide Communication Device in Resident's Language
Penalty
Summary
The facility failed to provide a communication device in a language understood by a resident, identified as Resident 22, which led to a deficiency in communication care. Resident 22, who was admitted and readmitted to the facility with diagnoses including sepsis, metabolic encephalopathy, and chronic kidney disease, had a preferred language of Farsi. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognition and required maximal assistance for daily activities. Despite these needs, the facility did not provide a communication board in Farsi, as observed during a surveyor's visit. During the survey, it was noted that the resident's care plan, which addressed the language barrier, included an intervention to provide a communication board. However, this intervention was not implemented, as confirmed by the Social Service Director and the Director of Nursing. The absence of a communication board meant that staff could not effectively communicate with the resident, potentially leaving the resident's needs unmet. The facility's policy on interpreter services, which required communication boards for residents unable to communicate, was not adhered to in this case.
Failure to Monitor Low Air Loss Mattress Functionality
Penalty
Summary
The facility failed to ensure the proper functioning of a low air loss mattress (LALM) for a resident, which is crucial for preventing pressure ulcers. The resident, who was severely cognitively impaired and dependent on staff for daily activities, was at risk for developing pressure ulcers. The resident's care plan included the use of a LALM for skin management, but the staff did not monitor the functionality of the mattress as required. During an observation, it was noted that the LALM was powered on, but its display was not showing any information, indicating a potential malfunction. Licensed staff were required to monitor the LALM every shift and document this in the resident's Treatment Administration Record (TAR) or Medication Administration Record (MAR). However, there was no documentation of such monitoring for the resident, and the physician's order for the LALM was not properly recorded, leading to a lack of follow-through. The Director of Nursing confirmed that the staff did not notice the LALM was off and failed to document its monitoring, which could result in the development of pressure injuries.
Failure to Clarify Seroquel Use for Resident
Penalty
Summary
The facility failed to act upon a recommendation from the Pharmacy Consultant (PC) to clarify the behavior manifestation for the use of Seroquel for one of the residents, identified as Resident 64. The resident was admitted with diagnoses including major depressive disorder, dementia, and psychotic disorders. The Minimum Data Set (MDS) indicated that the resident's cognitive skills for daily decision-making were severely impaired, and the resident was taking antipsychotic and antidepressant medications. The physician's order for Seroquel was based on the resident's psychotic disorder with delusions due to dementia manifested by sudden verbal agitation. The Pharmacy Consultant's Monthly Regimen Review (MRR) noted that Resident 64 had been on Seroquel with a target behavior of sudden verbal agitation and recommended clarifying what the resident said and how this presented a danger to self and others. However, the facility did not follow up on this recommendation. During interviews, both LVN 5 and the Director of Nursing (DON) acknowledged that the Seroquel order did not specify the behavior to monitor, and sudden verbal agitation was not a clear indication for administering Seroquel. The lack of a clear indication and measurable target behavior led to inaccurate monitoring and potential exposure of the resident to side effects. The facility's Policies & Procedures (P&P) for psychotropic medication assessment and monitoring require that psychotropic drugs are used only when necessary and at the lowest effective dose. The P&P also state that the PC reviews the appropriateness of psychotropic medication orders and that any inappropriate orders should be clarified with the attending physician. Despite these guidelines, the facility failed to act on the PC's recommendation, resulting in a deficiency in the monitoring and administration of Seroquel for Resident 64.
Failure to Remove Discontinued Medication from Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to accepted professional principles, as evidenced by the presence of a discontinued medication in a medication cart. Specifically, a medication cart on the second floor contained a blister pack of amlodipine, a medication used to lower blood pressure, which had been discontinued for a resident. The medication was not removed from the cart after the discontinuation order was issued, which was confirmed during an observation and record review with a registered nurse. The resident involved had a history of hypertensive heart disease and was severely impaired in cognition, requiring assistance with daily activities. The physician's order for amlodipine was discontinued on a specific date, yet the medication remained in the cart, posing a risk of accidental administration. The Director of Nurses confirmed that the facility's policy required immediate removal of discontinued medications to prevent medication errors, which was not followed in this instance.
Deficiencies in Hospice Service Provision and Training
Penalty
Summary
The facility failed to ensure the provision of hospice services for two residents, leading to deficiencies in documentation and training. For Resident 1, the facility did not have documented evidence that hospice staff signed the Interdisciplinary Team Sign-in Sheet upon arrival, despite the resident being admitted to hospice care. This was confirmed during an interview and record review with the Director of Nursing (DON), who acknowledged the absence of the sign-in sheet in the resident's hospice binder. Similarly, for Resident 3, the facility did not have a hospice Interdisciplinary Team Sign-in Sheet in the resident's hospice binder, indicating a lack of documented evidence that hospice staff provided care from the date of hospice admission. The DON and the Medical Records Team Leader (MRTM) both confirmed the absence of the sign-in sheet and acknowledged that medical records should have conducted audits to ensure the presence and completion of these sheets. Additionally, the facility did not ensure that the hospice agency provided training programs in hospice care for facility staff, as required by the contractual agreement. Interviews with two Certified Nursing Assistants (CNAs) revealed that they had not received any training from the hospice agency. The DON confirmed that the hospice contract included a provision for training programs, but the facility had not been aware of or implemented this aspect of the agreement.
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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 Reseda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tarzana Health And Rehabilitation Center | 0.9 mi | — | 15 | 0 |
| Park View Nursing And Subacute | 0.9 mi | — | 7 | 0 |
| Grancell Village Of The Jewish Homes For The Aging | 1.1 mi | — | 5 | 0 |
| Joyce Eisenberg Keefer Medical Center D/p Snf | 1.1 mi | — | 28 | 0 |
| Woodland Care Center | 1.5 mi | — | 13 | 0 |
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