Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 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 Joyce Eisenberg Keefer Medical Center D/p Snf during CMS and state inspections, most recent first.
A resident with multiple chronic conditions experienced blood pressure readings both below and above their baseline, but there was no documentation of a recheck or physician notification as required by facility policy. The DON confirmed the absence of nurse-to-physician communication or notes regarding the resident's condition during this period.
The facility failed to document attempts of non-pharmacological interventions before administering PRN opioid pain medications to two residents with chronic pain conditions. Despite care plans outlining non-pharmacological strategies, these were not documented as attempted prior to medication administration. Interviews confirmed the lack of documentation and highlighted the importance of non-pharmacological methods due to opioid side effects.
A LTC facility failed to properly label and store medications, affecting several residents. An insulin pen for a resident lacked an open date, and expired medications, including eyedrops and glucose control solutions, were found in medication carts. These oversights were confirmed by staff and posed risks of administering ineffective treatments.
The facility failed to provide prescribed mechanical soft diets to four residents, leading to potential choking risks. Three residents did not receive chopped squash as required, and one resident was served the wrong meal. The facility's policies for meal identification and therapeutic diets were not followed, resulting in these deficiencies.
A facility failed to document a resident's blood sugar reading after it was taken by an LVN. The resident, diagnosed with diabetes mellitus, required blood sugar monitoring twice daily. The LVN took the reading but did not record it, citing system limitations. The DON confirmed the need for immediate documentation per policy, highlighting a lapse in professional standards.
A resident with a language barrier was not provided with a communication board as required by their care plan. The resident, who only speaks Farsi, was observed without a communication device, which was necessary for effective communication and addressing their needs. The facility's policy indicated that communication boards should be available for residents unable to communicate.
A resident with severely impaired cognition and a sacral pressure injury had their low air loss mattress (LALM) incorrectly set to 400 lbs instead of their actual weight of 94 lbs. This oversight was confirmed by nursing staff and the DON, who acknowledged the importance of correct LALM settings for wound healing. The facility's policy required pressure redistribution devices to be applied based on individual needs, which was not followed.
A resident with dysphagia and dementia was found with a cup of medications left unattended at her bedside. The resident, who required moderate assistance for daily activities, did not have an assessment for self-administration of medications. An LVN admitted to leaving the medications unattended, acknowledging the risk of choking and unauthorized access by other residents. The facility's policy required a physician's order for medications to be left at the bedside.
Two residents receiving oxygen therapy in an LTC facility were not provided care consistent with infection control standards. The facility failed to label and change oxygen tubing as per policy, increasing the risk of infection. Staff confirmed the oversight, which was not in line with the facility's procedures.
Failure to Notify Physician of Abnormal Blood Pressure Readings
Penalty
Summary
The facility failed to notify a resident's physician when the resident's blood pressure readings were outside of their baseline range. Specifically, the resident, who had a medical history including COPD, depression, lymphoma, and lung and bladder cancer, had blood pressure readings that were both below and above their baseline. On one occasion, the resident's blood pressure dropped to 89/62 mmHg, and on the following day, it rose to 172/94 mmHg. There was no documentation of a recheck of the blood pressure during the 12-hour interval between these readings, nor was there any record of communication with the physician regarding these abnormal values. During interviews and record reviews, the DON confirmed that there was no nurse-to-physician communication note or any documentation addressing the resident's condition related to these blood pressure readings. The facility's policy required physician notification when vital signs were out of range from the resident's baseline for two or more consecutive episodes, but this protocol was not followed in this instance.
Failure to Document Non-Pharmacological Interventions Before PRN Opioid Use
Penalty
Summary
The facility failed to document evidence of attempting non-pharmacological interventions before administering PRN opioid pain medications to two residents, which was a requirement according to the facility's pain management policy. Resident 126, who was admitted with conditions such as hereditary neuropathies, ankylosing spondylitis, and chronic pain syndrome, received PRN tramadol on multiple occasions without documented attempts of non-pharmacological interventions. The resident's care plan included strategies like positioning, diversional activities, and massage for pain relief, but these were not documented as attempted before administering the opioid. Similarly, Resident 65, diagnosed with cervical spinal stenosis, polyneuropathy, and chronic pain syndrome, received PRN hydrocodone-acetaminophen without documented attempts of non-pharmacological interventions. The care plan for this resident also included non-pharmacological strategies such as positioning and walking for pain relief, which were not documented as attempted prior to medication administration. Both residents had intact cognition and required assistance with activities of daily living. Interviews with the MDS Nurse and the Director of Nursing confirmed the absence of documentation for non-pharmacological interventions and emphasized the importance of attempting these methods first due to the adverse side effects associated with opioids. The facility's policy, last reviewed and revised in October 2024, clearly stated that non-pharmacological interventions must be tried and documented before administering PRN opioid medications.
Improper Drug Labeling and Storage in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, affecting six out of eight sampled residents. For Resident 219, an opened Lantus-100 insulin pen was found without an open date, which is necessary to determine its beyond-use date. This oversight was confirmed by LVN 6, who acknowledged that the pen should be labeled to prevent the administration of potentially expired medication. Similarly, Resident 36's Olopatadine HCl solution was not discarded after its beyond-use date, posing a risk of reduced efficacy in treating the resident's condition. Further deficiencies were observed with the Even Care Glucose Control Solution, which had an illegible open date, making it impossible to determine its beyond-use date. This issue was confirmed by LVN 6 and the facility pharmacist, highlighting the potential for ineffective diabetes management. Additionally, expired medications such as Opti-Fiber for Resident 4, Ativan for Resident 51, and Simethicone tablets were found in the medication cart, despite their expiration dates having passed. These medications should have been removed to prevent the administration of ineffective drugs. The facility also failed to remove expired eyedrops for Residents 214 and 111. Netarsudil and Latanoprost eyedrops were found in the medication cart beyond their use-by dates, as confirmed by LVN 2 and the facility pharmacist. The Director of Nursing emphasized the importance of not using medications past their expiration dates to avoid ineffective treatment. The facility's policy on drug storage and inventory inspection, which mandates the removal of unusable drugs, was not adhered to, leading to these deficiencies.
Failure to Provide Prescribed Mechanical Soft Diets
Penalty
Summary
The facility failed to meet the nutritional needs of four residents by not providing a mechanical soft diet as ordered by their physicians. For three residents, the kitchen staff did not place chopped squash on the tray table for those on mechanical soft and dysphagia diets. This oversight was observed during a review of the residents' tray cards, which indicated that chopped roasted squash was required. The Registered Dietician and Food Services Director confirmed that the squash was not chopped as per the menu, and the cooks did not want to chop it because it would become mushy. This failure to follow the menu placed the residents at risk for choking. Additionally, one resident was accidentally served the incorrect diet during lunch. The resident's lunch menu ticket indicated a no added salt mechanical soft diet with nectar thick liquids, but the resident received a regular diet instead. The Speech-Language Pathologist confirmed that the resident was served his wife's tray, which was not a mechanical soft diet. This mistake was acknowledged by the facility's Registered Dietician, who stated that the staff served the wrong tray, increasing the risk of choking for the resident. The facility's policies and procedures for meal identification and therapeutic diets were not followed, leading to these deficiencies. The policies indicated that dietary services should use appropriate identification to ensure residents receive their prescribed diets. However, the failure to adhere to these procedures resulted in residents not receiving the correct diet, which could lead to potential health risks such as choking and weight loss.
Failure to Document Blood Sugar Reading
Penalty
Summary
The facility failed to adhere to professional standards of practice when a Licensed Vocational Nurse (LVN 4) did not document a resident's blood sugar after taking it. This incident involved a resident who was admitted with a diagnosis of diabetes mellitus and required blood sugar monitoring twice daily as per physician's orders. On the day of the observation, LVN 4 took the resident's blood sugar at 3:25 p.m. but did not record the value, citing that the computer system only allowed documentation one hour before the scheduled time. Consequently, the resident's blood sugar was not documented before they began eating dinner at 5:32 p.m. During an interview, LVN 4 acknowledged the importance of documenting the blood sugar value to avoid confusion and admitted to not writing it down for later entry. The Director of Nursing confirmed that the blood sugar should have been documented immediately after it was taken, in line with the facility's Medication Administration policy. This policy requires that any medication or related procedure be documented before proceeding to the next resident's medication administration. The failure to document the blood sugar reading placed the resident at risk for complications related to their diabetes management.
Failure to Provide Communication Device for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication device for a resident who only speaks Farsi, which is a language barrier that was documented in the resident's care plan. The resident, who was admitted with conditions including benign prostatic hyperplasia, major depressive disorder, and chronic kidney disease, was observed in a wheelchair without a communication board in their room or attached to their wheelchair. This lack of a communication device was confirmed by a Certified Nursing Assistant who stated that the resident only speaks Farsi and had never seen a communication board in the resident's room. The Minimum Data Set Nurse reviewed the resident's care plan, which had been revised to address the language barrier by providing a communication board. However, the communication board was not in place, which the Director of Nursing acknowledged was necessary according to the care plan interventions. The facility's policy on Interpreter Services also indicated that communication boards should be available for residents unable to communicate, highlighting the deficiency in meeting the resident's communication needs.
Incorrect LALM Setting for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident's low air loss mattress (LALM) was set to the correct setting, which is crucial for preventing skin breakdown and aiding in the healing of pressure ulcers. The resident, who was admitted with pressure-induced deep tissue damage in the sacral region, had severely impaired cognition and required maximal assistance for daily activities. The resident's care plan included the use of an LALM for wound management, but during an observation, it was found that the mattress was set to 400 pounds, despite the resident weighing only 94 pounds. Interviews with the nursing staff, including a Registered Nurse (RN) and a Licensed Vocational Nurse (LVN), confirmed that the LALM should have been set according to the resident's weight. The Director of Nursing (DON) also acknowledged the importance of setting the LALM correctly to facilitate wound healing. The facility's policy on wound and skin management emphasized the need for pressure redistribution devices to be applied based on the resident's individual needs, which was not adhered to in this case.
Unattended Medications at Resident's Bedside
Penalty
Summary
The facility failed to ensure a licensed nurse did not leave a cup of medications unattended at a resident's bedside, which was identified during an observation of a resident in a wheelchair with a cup containing eight medications on the table. The resident, who had been admitted with diagnoses including dysphagia and dementia, stated she takes her medications by herself all the time. However, the resident had moderately impaired cognition and required moderate assistance for most activities of daily living, as indicated in her Minimum Data Set. Licensed Vocational Nurse 2 admitted to leaving the medications unattended and acknowledged that the resident was at risk for choking and should have been supervised while taking her medications. The resident did not have an assessment for self-administration of medications, which was confirmed by the MDS Nurse. The Director of Nursing emphasized the importance of not leaving medications unattended, as it could lead to residents not taking their medications or other residents accessing them. The facility's policy stated that medications could only be left at the bedside with a specific physician's order and must not be accessible to other residents.
Infection Control Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to adhere to professional standards of infection control practice for two residents, Resident 114 and Resident 222, who were receiving oxygen therapy. For Resident 222, the facility did not label the oxygen tubing with the date and time it was last changed, as required by the facility's policy. The resident, who was admitted with chronic obstructive pulmonary disease (COPD) and other conditions, was observed receiving oxygen therapy without the necessary labeling on the tubing. Both a registered nurse and the facility's Infection Preventionist confirmed that the tubing was not labeled, which is a requirement to prevent respiratory infections. Resident 114, who had a history of hypertensive chronic kidney disease, Alzheimer's disease, and COVID-19, also experienced a lapse in infection control practices. The facility failed to change and label the resident's oxygen tubing and nasal cannula every seven days as per the facility's policy. During an observation, it was noted that the tubing had not been changed on the scheduled date, and both a licensed vocational nurse and the Infection Preventionist acknowledged this oversight. The Director of Nursing also confirmed the requirement for weekly changes and labeling to prevent respiratory infections. The facility's policy, last reviewed in October 2024, mandates that oxygen cannulas, masks, and tubing be dated and changed every seven days. The failure to comply with this policy for both residents placed them at an increased risk of infection. The observations and interviews conducted with the facility staff highlighted these deficiencies in infection control practices, which were not in line with the established procedures for managing oxygen therapy equipment.
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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) |
|---|---|---|---|---|
| Grancell Village Of The Jewish Homes For The Aging | 0 mi | — | 5 | 0 |
| Woodland Care Center | 0.6 mi | — | 13 | 0 |
| Park View Nursing And Subacute | 0.6 mi | — | 7 | 0 |
| Northridge Care Center | 1.1 mi | — | 31 | 0 |
| Eisenberg Village | 1.1 mi | — | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.