Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Northridge Care Center during CMS and state inspections, most recent first.
A resident with CHF, chronic pulmonary edema, and orthostatic hypotension was admitted with a physician order for fluid restriction of 750 ml per day and no bedside water pitcher. Staff documented intake and output only for an initial period and then stopped monitoring and recording I/O, despite the ongoing restriction order. During interviews, an LVN and an RN acknowledged that licensed nurses had not continued I/O monitoring as required, even though facility policies mandate daily I/O documentation for residents on fluid restrictions for at least 30 days and ongoing monitoring when hydration concerns exist.
Surveyors found that staff failed to complete fall risk evaluations accurately for two residents. One resident with CHF, pulmonary edema, and orthostatic hypotension had a fall risk tool marked as having no SBP drop between lying and standing even though the resident could not stand, and the gait/balance and medication sections were left blank, resulting in a low fall score. For another resident with CHF and HTN, the MDS nurse documented no SBP drop between lying and standing without actually obtaining lying and standing BPs, relying instead on prior BP summaries that lacked standing readings, which also produced a non–high-risk fall score. These omissions and inaccurate entries meant the fall risk tools did not reflect the residents’ true fall risk status as required by facility procedures.
A resident with CHF and chronic pulmonary edema was readmitted with a hospital report and a physician telephone order indicating a 750 ml/day fluid restriction, but the order was not properly documented or incorporated into the active physician orders. The RN who received the hospital report acknowledged missing the entry of the fluid restriction, and the telephone order form lacked the signature and title of the person who transcribed it, making it impossible to identify who took the order or confirm that the person was licensed. The ADON and Medical Records Director were unable to locate the signed copy of the telephone order or any history of the fluid restriction in current or discontinued physician orders, contrary to facility P&P requiring licensed staff to document telephone orders with signature and title and for the physician to countersign them.
A resident with a history of falls, impaired cognition, and significant physical limitations was not provided with a properly functioning bed pad alarm as ordered by the physician. Staff confirmed the alarm was not working during inspection, and the responsible manager had not checked the alarm that day, contrary to facility policy requiring daily checks.
A resident with paraplegia, anxiety, and depression, who reported trauma from a gunshot injury, did not receive a complete trauma care evaluation or a care plan addressing past trauma and triggers. Despite the resident expressing that loud noises were a trigger, the trauma assessment was left incomplete and no individualized care plan was developed, contrary to facility policy. Both the SSD and DON acknowledged these omissions.
A facility failed to provide privacy during medication administration for four residents, violating their right to dignity and respect. An LVN was observed checking blood sugar levels and administering insulin without closing privacy curtains, despite the facility's policy on treating residents with respect and dignity.
The facility failed to revise care plans for two residents' activity needs and one resident's nutritional needs. Two residents with significant dependencies did not have their activity care plans evaluated or renewed quarterly, as required. Another resident with multiple health issues had a care plan that did not account for dialysis-related weight fluctuations, despite being at risk for malnutrition. These deficiencies were identified through interviews and record reviews, indicating non-compliance with facility policies.
The facility failed to properly label and store medications, including an Aplisol vial without an open date, an insulin pen not refrigerated, and Artificial Tears labeled with room numbers instead of resident names. Additionally, medications for a discharged resident were not removed from the cart, risking administration errors.
A facility failed to follow infection control guidelines when an RN did not remove an isolation gown and gloves after administering medication to a resident on enhanced barrier precautions. The resident, who was moderately cognitively impaired and dependent on staff, was receiving treatment for discitis and a urinary tract infection. The RN's actions were against the facility's policy, which requires removing PPE before exiting a resident's room to prevent infection spread.
A facility failed to complete a resident's Quarterly MDS assessment within the required timeframe, potentially affecting care provision. The resident, with asthma and Parkinson's, had an ARD of 11/29/2024, but the assessment was completed on 12/26/2024, beyond the 14-day requirement. This delay was confirmed by the MDS Nurse during interviews and record reviews.
A facility failed to develop a comprehensive care plan for a resident using bed rails, as required by their policy. The resident, who had intact cognitive skills but was dependent on staff for daily activities, did not have a safety assessment for the bed rails attached to their bed. This oversight was confirmed by the DON, who acknowledged the potential risk of injury due to entrapment. The facility's policy requires care plans to include medical, nursing, and psychosocial needs, but this was not followed in this case.
A resident with paraplegia, anxiety, and depression was not provided with consistent access to Bible studies, an activity of choice, due to a possible COVID-19 outbreak at the religious institution. The Activity Director could not provide participant lists or contact information, and the Director of Nursing acknowledged the importance of offering activities of choice to prevent increased anxiety and depression.
A resident in an LTC facility was found storing multiple bottles of supplements and vitamins at their bedside, accessible to other residents. Despite having intact cognition, the resident's medication storage posed a risk, as confirmed by staff interviews. Facility policies indicated that such storage is only allowed when it does not present a risk to other residents, which was not adhered to in this case.
A resident with multiple health conditions, including cerebral infarction and gastrostomy malfunction, was at risk of infection due to the facility's failure to cap the enteral feeding tube after disconnection. The oversight was confirmed by an LVN, IP, and DON, who acknowledged the increased risk of healthcare-acquired infections due to this deficiency.
A facility failed to label and timely discontinue an IV site for a resident receiving Ceftriaxone for RSV pneumonia. The IV site was undated, and the completion of the antibiotic therapy was not communicated to the physician, leading to a delay in discontinuing the IV. The facility's policy requires peripheral catheters to be removed when clinically indicated, but the nursing staff did not follow the protocol, resulting in a deficiency.
A facility failed to assess a resident for the risk of entrapment from bedside rails, as required by policy. The resident, with a history of muscle weakness and falls, was observed with both rails raised without a safety assessment. The DON confirmed the absence of an assessment, acknowledging the risk of injury. Facility policy mandates a restraint assessment and physician order for side rail use.
A facility failed to label and store food brought by a resident's family, risking foodborne illness. A resident's tamales were found on an over-bed table without proper labeling or refrigeration. The DON confirmed the food should have been labeled with the resident's name and use-by date and stored in a refrigerator, as per facility policy.
The facility failed to meet the minimum room size requirements for 27 resident rooms, with each room falling short of the required square footage for two or four residents. Despite this, residents did not express concerns, and observations showed adequate space for care and mobility. A Room Variance Waiver was submitted, indicating the rooms met residents' needs.
A resident with severe cognitive impairment and multiple diagnoses experienced significant weight loss over several months. Despite the physician being aware and providing interventions, the weight loss was not documented in the progress notes, violating the facility's weight change policy.
A resident with severe cognitive impairment and frequent pain was not administered the correct dosage of Percocet as per physician's orders. Despite reporting a pain level of eight, indicating severe pain, the resident received only one tablet instead of the prescribed two. Interviews with the LVN and DON confirmed the error, highlighting a failure to follow the facility's pain management policy.
A resident's Quarterly MDS assessment inaccurately reflected their need for assistance and risk for pressure ulcers. Despite being non-ambulatory and requiring extensive assistance with ADLs, the MDS indicated only supervision was needed for eating and no risk for pressure ulcers. Interviews with staff and review of records confirmed these inaccuracies, highlighting a failure to adhere to facility policies on accurate documentation.
A resident with cognitive impairment and multiple health conditions did not have heel protectors in place as ordered by the physician, which were necessary for preventing pressure ulcers. The CNA had removed the protectors earlier, and the DON confirmed they should have been in place according to the facility's policy on pressure sore management.
A resident with anxiety disorder did not receive timely delivery of Alprazolam due to the facility's failure to reorder the medication as per policy. The last dose was administered, and the refill was delayed despite confirmation from the pharmacy. The facility's policy required reordering when five doses remained, which was not followed, leading to a deficiency.
A resident with fully intact cognition punched another resident in the face after an accidental bump in the dining room. The incident was witnessed by a CNA and confirmed by the Social Services Director and DON. The facility's policy on abuse was not upheld, resulting in a failure to protect residents from physical abuse.
A facility failed to follow its infection control policy by not placing a C. Diff positive resident in isolation upon re-admission. Instead, the resident was cohorted with another resident who did not require isolation, contrary to the facility's policy. This oversight was acknowledged by the infection preventionist and the director of nursing, who confirmed that the resident should have been isolated immediately.
The facility failed to implement its TB Infection Control Program by not conducting an annual TB Risk Assessment. The Infection Preventionist was unaware of the policy, focusing instead on Covid, leading to no documented TB risk assessments. The Director of Nursing confirmed the IP should have known the policies to implement them effectively.
Failure to Monitor and Document I/O for Resident on Fluid Restriction
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document intake and output (I/O) for a resident on physician-ordered fluid restriction, in accordance with professional standards and facility policy. The resident was originally admitted with diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension, and was dependent on staff for ADLs but cognitively intact. On readmission, the RN hospital-to-facility admission report and physician’s telephone orders specified a fluid restriction of 750 ml per day due to chronic pulmonary edema, and a subsequent physician’s order directed that no water pitcher be left at the bedside. The facility’s I/O record for this resident showed monitoring and documentation from 12/30/2025 to 1/7/2026 only. During interviews and concurrent record reviews, an LVN confirmed that licensed nurses did not monitor or document the resident’s I/O after 1/7/2026 despite the ongoing fluid restriction order. An RN similarly stated that, given the 750 ml per day fluid restriction and the order for no bedside water pitcher, licensed nurses should have continued to monitor I/O closely, particularly in light of the resident’s heart problems and history of edema. Review of facility policies titled “Fluid Intake and Output” and “Resident Hydration and Prevention of Dehydration” showed that intake and output must be recorded for residents with restricted fluids as ordered by the physician, with daily I/O documented for a minimum of 30 days, and that nursing will monitor and document fluid intake when inadequate intake or dehydration concerns are present. The facility did not follow these policies for this resident after 1/7/2026.
Inaccurate Fall Risk Evaluations for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete fall risk evaluations for two residents, contrary to its policy for promoting safety and reducing falls. For the first resident, who had diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension, the admission record showed readmission on 12/30/2025 and an MDS indicating intact cognition and dependence on staff for ADLs. The Fall Risk Evaluation dated 12/30/2025 documented that there was “no noted drop between lying and standing” for systolic blood pressure, even though the resident was not able to stand. The gait/balance section was left entirely unmarked, including the option for “not able to perform function,” and the medications section was also left blank, including the option indicating no relevant medications. The resulting fall score was four, which did not place the resident in the high-risk category. During interview and concurrent record review, the RN who completed this evaluation stated that the resident was not able to stand at the time of the assessment. The RN acknowledged marking “no noted drop between lying and standing” for systolic blood pressure because there was no “non-applicable” option, and admitted not completing the gait/balance and medication sections. The RN further stated that the total score of four, indicating no risk of fall, was not correct and confirmed that assessments are used to establish the plan of care to reduce fall risks. These statements confirmed that the fall risk evaluation for this resident was not completed thoroughly or accurately as required by the facility’s process. For the second resident, who had combined systolic and diastolic CHF and hypertension, the admission record showed readmission on 12/29/2020 and an MDS indicating intact cognition, with moderate assistance needed for oral/personal hygiene and supervision or touching assistance for toileting hygiene, dressing, and toilet transfer. The Fall Risk Evaluation dated 12/22/2025 recorded the resident as ambulatory and continent and again indicated “no noted drop between lying and standing” for systolic blood pressure, resulting in a fall score of eight, which did not meet the facility’s threshold for high fall risk. In an interview, the resident reported sometimes going to the bathroom alone and being able to self-clean. During a concurrent interview and record review, the MDS nurse who completed the evaluation stated she did not measure the resident’s systolic blood pressure in both lying and standing positions and instead relied on blood pressure summaries from other nurses, which did not include standing readings. She acknowledged that, as a result, the fall risk evaluation was not done correctly to assess the resident’s fall risks. The facility’s policy on promoting safety and reducing falls emphasized the need for caregivers to understand key fall risk factors, including gait and balance disturbances and the importance of residents rising slowly from lying or sitting positions, underscoring the expectation for accurate assessment of these parameters.
Failure to Properly Document and Countersign Physician Telephone Order for Fluid Restriction
Penalty
Summary
The facility failed to ensure that a physician telephone order for a fluid restriction was properly documented, signed, and incorporated into the resident’s active physician orders. A resident with diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension was originally admitted and later readmitted with a hospital report indicating a fluid restriction of 750 ml per day. The resident’s MDS showed intact cognition and dependence on staff for ADLs. On readmission, the RN Hospital to RN Facility admission report documented the 750 ml/day fluid restriction, and a Physician’s Telephone Order form dated the same day also indicated a fluid restriction of 750 ml/day due to chronic pulmonary edema. However, the fluid restriction was not entered into the physician’s orders or reflected in the physician order recap covering the admission period. During interviews and record reviews, RN 1 stated he became aware of the fluid restriction from the hospital report but missed inputting the restriction into the physician’s orders. When reviewing the Physician’s Telephone Orders, RN 1 stated he did not transcribe the order and could not identify who did because there was no name or signature on the form. The ADON similarly could not determine who transcribed the telephone order, whether that person was a licensed nurse, or whether the order had been entered into the charting system, and confirmed the fluid restriction was not present in the physician order summary. The Medical Records Director reported that the white copy of the Physician’s Telephone Orders, which should have been returned within five days after the physician’s signature, could not be located, and there was no history of the fluid restriction order in the current or discontinued physician orders. The facility’s P&P required that telephone orders be received only by licensed personnel, reduced to writing with date, time, signature and title of the person transcribing, and countersigned by the physician at the next visit or electronically, which was not followed in this case.
Failure to Ensure Proper Functioning Bed Pad Alarm for Resident at Fall Risk
Penalty
Summary
A deficiency occurred when a resident with a history of falls, right femur fracture, hemiplegia, morbid obesity, dementia, and moderately impaired cognition was not provided with a properly functioning bed pad alarm as ordered by the physician. The resident required significant assistance with daily activities and was dependent on staff for toileting, showering, and dressing. The physician had ordered a bed pad alarm to decrease the potential for injury, and facility policy required daily checks of such alarms for proper functioning. During an observation, a CNA attempted to demonstrate the bed pad alarm but no alert was heard, and both the CNA and DON confirmed the alarm was not working. The Central Supply Manager stated that position change alarms are typically checked daily, but on this day, the resident's alarm had not been checked. The DON acknowledged that the alarm should be operational at all times and confirmed it was not working at the time of inspection, which was inconsistent with facility policy and physician orders.
Failure to Complete Trauma Evaluation and Care Plan for Resident with Trauma History
Penalty
Summary
The facility failed to complete a thorough trauma care evaluation and develop a comprehensive, person-centered care plan addressing past trauma and triggers for one resident. The resident, who had diagnoses including complete paraplegia, anxiety disorder, and depression, reported a history of being shot in the back, which resulted in paralysis and ongoing depression. During the psychiatric intake, the resident disclosed this trauma, and during an interview, stated that loud noises, such as staff slamming doors, triggered memories of the gunshot event. Despite this, the trauma care evaluation was incomplete, with only the first question marked as declined and the remaining questions left blank. The facility's policy required further information gathering from family or medical records if the resident declined to participate, but this was not done. Additionally, a review of the resident's care plans revealed that there was no care plan addressing the resident's past trauma or potential triggers, despite staff being aware of the trauma history. The Social Services Director acknowledged that more information should have been gathered and documented, and the DON confirmed that a care plan should have been created to address the trauma and triggers. The facility's policy required individualized care plans to minimize triggers and re-traumatization, but this was not implemented for the resident in question.
Failure to Ensure Privacy During Medication Administration
Penalty
Summary
The facility failed to provide privacy to four residents during medication administration, which violated their right to dignity and respect. The incidents involved Licensed Vocational Nurse 1 (LVN1) who was observed checking the blood sugar levels of the residents and administering insulin without closing the privacy curtains in their rooms. This lack of privacy occurred despite the facility's policy that emphasizes treating residents with respect and dignity at all times. Resident 54, who was admitted with dysphagia and type 2 diabetes, had intact cognitive skills but was dependent on staff for personal care. During a medication administration observation, LVN1 checked the resident's blood sugar in the room with the privacy curtain open. Similarly, Resident 35, with impaired cognitive skills and requiring maximal assistance, had their blood sugar checked by LVN1 in bed without the privacy curtain being closed. Resident 58, with intact cognitive skills but dependent on staff for personal care, also had their blood sugar checked and insulin administered by LVN1 without privacy. Lastly, Resident 3, with severely impaired cognitive skills, experienced the same lack of privacy during their medication administration. LVN1 acknowledged the oversight and stated that residents should not be put in situations that could cause embarrassment, emphasizing the importance of providing privacy during such procedures.
Failure to Revise Care Plans for Activity and Nutritional Needs
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plans for two residents, Resident 15 and Resident 69, regarding their activity needs. Resident 15, who was diagnosed with anxiety disorder and Parkinson's disease, had an intact cognitive ability for daily decision-making but was totally dependent on staff for various activities of daily living. The care plan for Resident 15's activity needs was not evaluated or renewed on the target date, which was supposed to be done quarterly. Similarly, Resident 69, diagnosed with quadriplegia and epilepsy, had severely impaired cognitive skills and was also totally dependent on staff. The care plan for Resident 69's activity needs was not evaluated or renewed on the target date. The Director of Nursing acknowledged that the care plans were not active and should have been reviewed quarterly to ensure ongoing activities were provided to address the residents' psychosocial needs. The facility also failed to revise the comprehensive person-centered care plan addressing the nutritional needs of Resident 25. Resident 25, with diagnoses including acute respiratory failure, type 2 diabetes, and end-stage renal disease, had moderately impaired cognitive skills and required moderate assistance from staff. The nutritional assessment indicated a risk for malnutrition, and the dietary note highlighted weight loss due to fluid shifts related to dialysis. However, the care plan did not reflect the resident's dialysis treatment, which could significantly contribute to weight fluctuation. The Director of Dietary Services and the Director of Nursing both noted that the care plan should have been person-centered and included all nutritional risk factors to meet the resident's needs. The facility's policies and procedures require that resident care plans be implemented on admission and reviewed at least quarterly. However, the care plans for the residents in question were not updated as required, potentially impacting the residents' care and services related to their activity and nutritional needs. The deficiencies were identified through interviews and record reviews, highlighting the facility's failure to adhere to its own policies and procedures regarding care plan evaluations and revisions.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to several deficiencies. In Medication Room A, a multi-dose vial of Aplisol was found without an open date, which is against the facility's policy and the manufacturer's instructions. The Director of Nursing (DON) confirmed that the vial should have been labeled with an open date and discarded after 28 or 30 days to prevent inaccurate test results for tuberculosis. This oversight increased the risk of residents receiving ineffective or potentially toxic medication. In another instance, an unopened insulin pen for a resident was improperly stored in Medication Cart 2 instead of being refrigerated. The Licensed Vocational Nurse (LVN) acknowledged that the insulin pen should have been refrigerated to maintain its efficacy. The DON confirmed that improper storage could lead to the insulin losing its effectiveness, potentially causing hyperglycemia in the resident. Additionally, the facility failed to label a box of Artificial Tears with a resident's name, using a room number instead. This practice was observed during an inspection of one of the medication carts. The DON confirmed that medications should be labeled with the resident's name to prevent administration errors. Furthermore, medications for a resident who was discharged to a hospital were not removed from the medication cart, increasing the risk of another resident receiving the wrong medication.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to infection control guidelines during a medication pass observation involving a resident on enhanced barrier precautions (EBP). Registered Nurse 1 (RN 1) was observed administering Cefazolin via a central line to a resident diagnosed with discitis, a urinary tract infection, and major depressive disorder. The resident was moderately impaired in cognition and dependent on staff for daily activities. After administering the medication, RN 1 exited the resident's room without removing the isolation gown and gloves, which is against the facility's policy for EBP. The incident was confirmed through interviews with the Infection Preventionist and the Director of Nursing, both of whom stated that RN 1 should have removed the gown and gloves before leaving the resident's room to prevent the spread of infection. The facility's policy on EBP, revised in March 2024, requires the use of personal protective equipment, including gloves and gowns, during high-contact resident care activities, especially for residents with indwelling medical devices. This oversight had the potential to increase the risk of spreading infection to other residents.
Delayed Completion of Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Quarterly Minimum Data Set (MDS) was completed in a timely manner, as required by federal guidelines. The deficiency involved a resident who was admitted to the facility with diagnoses of asthma and Parkinson's disease. The resident had intact cognition and was dependent on staff for most activities of daily living. The Quarterly MDS, which is a standardized assessment and care screening tool, was not completed within the required timeframe, potentially affecting the provision of necessary care and services for the resident. During the review, it was found that the assessment reference date (ARD) was set for 11/29/2024, and the assessment should have been completed by 12/12/2024. However, the assessment was not completed until 12/26/2024, which was more than 14 days after the ARD. This delay was confirmed during interviews and record reviews with the MDS Nurse, who acknowledged the oversight and confirmed that the assessment was not completed within the required period as per the guidelines set by the Centers for Medicare and Medicaid Services (CMS) and the Omnibus Budget Reconciliation Act of 1987 (OBRA).
Failure to Develop Comprehensive Care Plan for Resident Using Bed Rails
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 58, who was investigated under accidents. The deficiency was identified during a review of the resident's admission record and Minimum Data Set (MDS), which indicated that the resident had intact cognitive skills but was dependent on staff for various activities of daily living. Despite these needs, the facility did not conduct a safety assessment for the use of bed side rails, which were attached to the resident's bed. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged the absence of a safety assessment and the potential risk of injury due to entrapment in the bed rails. The facility's policy on resident care plans, which aims to provide individualized nursing care and promote continuity of care, was not adhered to in this case. The policy requires that care plans include identification of medical, nursing, and psychosocial needs, with goals stated in measurable terms. However, the care plan for Resident 58 did not address the use of bed rails, nor did it include a timeframe for evaluating the effectiveness of this intervention. This lack of a comprehensive care plan had the potential to result in the resident not receiving necessary care and services to prevent potential injury from the bed rails.
Inconsistent Activity Provision for Resident
Penalty
Summary
The facility failed to provide appropriate and consistent activities for a resident, identified as Resident 52, which had the potential to negatively affect the resident's physical, cognitive, sense of belonging, and emotional health. Resident 52, who has diagnoses including paraplegia, anxiety, and depression, was admitted to the facility with intact cognition and required assistance for most activities of daily living. The resident expressed a preference for participating in Bible studies on Sunday afternoons, an activity that was discontinued without explanation, despite being listed on the facility's activities calendar. The Activity Director (AD) acknowledged that Bible studies had not been provided for the past 3-4 weeks due to a possible COVID-19 outbreak at the religious institution that facilitated these services. The AD was unable to provide a list of participants or contact information for the religious organization. The Director of Nursing (DON) confirmed that the facility should provide activities of choice to residents, as failing to do so could increase anxiety and depression. The facility's policy on spiritual and religious activities indicated that a variety of such activities should be available and scheduled through local religious organizations, encouraging residents to attend those of their choice.
Resident's Bedside Medication Storage Poses Hazard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing a resident to store medications at their bedside, which were readily accessible to other residents. This deficiency was identified during a review of a resident's care area for accidents. The resident, who had intact cognition and required supervision to moderate assistance for most activities of daily living, was observed with multiple bottles of supplements and vitamins stored in clear plastic drawers next to their bed. The resident confirmed that they self-administered these medications. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed concerns about the risk posed by the resident's bedside medication storage. The staff acknowledged that the presence of medications at the bedside could lead to other residents, particularly those who are confused and may wander into the room, consuming the medications and potentially experiencing adverse side effects. The facility's policy on self-administration of medication and storage of medication indicated that bedside storage is only permitted when it does not present a risk to other residents, highlighting a failure to adhere to these guidelines.
Failure to Cap Enteral Feeding Tube Increases Infection Risk
Penalty
Summary
The facility failed to ensure proper care for a resident receiving enteral feeding, leading to a potential risk of infection. The deficiency was identified when the enteral feeding tube of a resident was observed to be disconnected and hanging on a pole without a cap covering the tip. This oversight was confirmed by a Licensed Vocational Nurse (LVN) and the Infection Preventionist (IP), both of whom acknowledged that the tubing should be capped to prevent contamination and reduce the risk of healthcare-acquired infections. The resident involved had multiple diagnoses, including cerebral infarction, acute respiratory failure with hypoxia, gastrostomy malfunction, and schizophrenia. The resident was totally dependent on staff for all activities of daily living and had moderately impaired cognition. The facility's policy on enteral feeding safety precautions, last reviewed in March 2024, was not adhered to, as it required the capping of the tubing to prevent microbial growth. Interviews with the LVN, IP, and Director of Nursing (DON) confirmed the failure to cap the tubing increased the risk of infection for the resident.
Failure to Label and Discontinue IV Site as per Protocol
Penalty
Summary
The facility failed to label the insertion site of an intravenous (IV) catheter dressing for a resident, which is against the facility's protocol. This oversight was observed in one of the three sampled residents who had an IV access. The resident, identified as Resident 13, was admitted with diagnoses including hypertension and was receiving Ceftriaxone intravenously for RSV pneumonia. The IV site on the resident's left forearm was found to be undated during an observation, and there was no record of when the IV was started. The Director of Nurses (DON) and Registered Nurse 1 (RN 1) confirmed that the IV antibiotic treatment was completed by 12/29/2024, but the IV site was not discontinued until 1/06/2025. The facility's policy indicates that peripheral catheters should be removed when clinically indicated, at the completion of therapy, or if the site shows signs of complications. However, the registered nurses failed to notify the physician of the presence of the IV after the completion of the antibiotic therapy, which is a requirement to ensure the resident's safety. Interviews with the nursing staff revealed a lack of communication and documentation regarding the IV start date and the completion of the antibiotic therapy. RN 3, who administered the last dose of the antibiotic, did not notify the physician that the IV medication was completed, and the information was only endorsed to the next shift nurse. The facility's policy does not require a physician's order to remove a peripheral catheter, but the nurses are expected to notify the physician to confirm whether the IV should be discontinued or continued with a new order.
Failure to Assess Bed Rail Safety Risk
Penalty
Summary
The facility failed to ensure that a resident was assessed for the risk of entrapment from the use of bedside rails, as required by the facility's policy and procedure. Resident 58, who was originally admitted on 12/08/2021 and readmitted later, had diagnoses including muscle weakness and a history of falling. The Minimum Data Set (MDS) dated 02/08/2024 indicated that the resident's cognitive skills for daily decision-making were intact, and the resident was dependent on staff for various activities of daily living. An observation on 01/06/2024 noted that Resident 58 was lying in bed with both bedside rails raised. During a record review and interview with the Director of Nursing (DON) on 01/08/2025, it was revealed that Resident 58 did not have a safety assessment for the use of the bedside rails. The DON confirmed that a quarter bedside rail was attached to the resident's bed and acknowledged that every resident using a bed rail must be assessed for safety and risk of entrapment to prevent potential injury. The facility's policy, last reviewed on 03/15/2024, requires a physical restraint assessment form to be completed and an order from the attending physician for the use of side rails. The lack of assessment for Resident 58's use of bedside rails constituted a deficient practice with the potential for inappropriate use leading to entrapment and injury.
Improper Labeling and Storage of Food Brought by Family
Penalty
Summary
The facility failed to ensure that leftover food brought by a resident's family was properly labeled and stored, which could lead to foodborne illness. During an observation, a plastic bag containing tamales was found on a resident's over-bed table without any labeling or refrigeration. The Director of Nursing confirmed that the food should have been labeled with the resident's name and a use-by date and stored in a refrigerator to prevent potential foodborne illnesses. The resident involved was admitted with diagnoses including muscle weakness and a history of falling. The resident's cognitive skills for daily decision-making were intact, but they were dependent on staff for certain activities of daily living. The facility's policy required that food brought by family or visitors be labeled and stored separately from facility-prepared food, but this was not followed in this instance.
Room Size Deficiency in Resident Rooms
Penalty
Summary
The facility failed to provide adequate room size for residents, as required by regulations. Specifically, 27 out of 43 resident rooms did not meet the minimum square footage requirements. The rooms in question were designed to accommodate two residents each but fell short of the 160 square feet minimum requirement, with sizes ranging from 151.20 to 158.68 square feet. Additionally, two rooms intended for four residents each were also undersized, measuring 309.54 square feet instead of the required 320 square feet. This deficiency was identified through observation, interviews, and record reviews. Despite the room size deficiency, during a Resident Council meeting, no concerns were expressed by the residents regarding their room sizes. Observations indicated that residents and staff had sufficient space to move freely, and the nursing staff could safely provide care. The rooms were equipped with necessary amenities such as closets, over-bed tables, nightstands, cubicle curtains for privacy, and call lights. The facility had submitted a Room Variance Waiver application, asserting that the rooms were adequate for the residents' needs and did not impede their well-being.
Failure to Document Resident's Weight Loss in Physician's Progress Notes
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding weight change by not ensuring that a resident's physician's progress notes addressed the resident's weight loss. This deficiency was identified for one of the three sampled residents, who was admitted with diagnoses including a fracture of the first lumbar vertebra, lumbar region spondylosis, and generalized muscle weakness. The resident had severely impaired cognition, as indicated by the Admission Minimum Data Set. Over several months, the resident experienced significant weight loss, with a 10% weight variance noted over a three-month period. Despite the resident's ongoing weight loss, the physician's progress notes from July to September did not reflect this issue. The Director of Nursing confirmed that the physician was aware of the weight loss and had given orders for interventions such as supplements, diet changes, and medication. However, the physician failed to document the weight loss in the progress notes, which was a requirement of the facility's weight change policy. This oversight had the potential to delay or prevent the delivery of necessary care and services for the resident.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as per the physician's orders for a resident who was admitted with a fracture of the first lumbar vertebra, lumbar region spondylosis, and generalized muscle weakness. The resident, who had severely impaired cognition, frequently experienced pain that interfered with daily activities. The physician had prescribed Percocet 5-325 mg, with one tablet for moderate pain and two tablets for severe pain. However, on a specific occasion, the resident reported a pain level of eight, which is categorized as severe pain, but was only given one tablet instead of the prescribed two tablets. Interviews with the LVN and the DON confirmed that the resident should have received two tablets for the reported pain level of eight. The facility's policy on pain assessment and management, which was last revised in March 2020, mandates that medication regimens should be implemented as ordered. The failure to administer the correct dosage as per the physician's order resulted in the potential for the resident to be undermedicated and left in pain.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that a resident's Quarterly Minimum Data Set (MDS) assessment accurately reflected the resident's status. This deficiency was identified for one of the three sampled residents, who was admitted with diagnoses including a fracture of the first lumbar vertebra, lumbar region spondylosis, and generalized muscle weakness. The resident's Admission MDS indicated severely impaired cognition, partial/moderate assistance needed with eating, and a risk of developing pressure ulcers. However, the Quarterly MDS inaccurately reflected that the resident needed only supervision or touching assistance with eating and was not at risk for pressure ulcers. Interviews and record reviews revealed discrepancies between the resident's actual condition and the Quarterly MDS. The Interdisciplinary Team meeting notes and a Certified Nursing Assistant's (CNA) statements indicated that the resident was non-ambulatory, required extensive assistance with activities of daily living (ADLs), and was dependent on staff for all ADLs, including eating. The Director of Nursing (DON) and the MDS Coordinator confirmed the inaccuracies in the Quarterly MDS, acknowledging that it did not accurately reflect the resident's need for assistance and risk for pressure ulcers. The facility's policies emphasized the importance of accurate and complete documentation to develop appropriate care plans, which was not adhered to in this case.
Failure to Ensure Heel Protectors for Resident
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers for a resident. The resident, who was cognitively impaired and dependent on staff for various activities, was admitted with conditions including respiratory failure and type 2 diabetes mellitus. The physician had ordered heel protectors for the resident to manage skin integrity, with the order dated January 26, 2024. On October 15, 2024, during an observation and interview, it was noted that the resident was in bed without the heel protectors, which had been removed earlier that day by a CNA. The Director of Nursing confirmed that the resident should have had the heel protectors in place as per the physician's order to prevent further skin breakdown. The facility's policy on pressure sore management, dated March 2024, indicated that all available measures should be taken to reduce skin breakdown and pressure sores.
Failure to Timely Reorder Medication for Resident
Penalty
Summary
The facility failed to implement its policy and procedure on Medication Ordering and Receiving from Pharmacy, resulting in a delay in the delivery of Alprazolam for a resident with an anxiety disorder. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, hypertension, and anxiety disorder. The resident's cognition was intact, and they required supervision with certain activities of daily living. The physician's order specified Alprazolam to be administered as needed for anxiety, but the medication was not reordered in a timely manner, leading to a lapse in availability. On 8/11/2024, the last dose of Alprazolam was administered, and the need for a refill was communicated to the Registered Nurse Supervisor, who faxed the order to the pharmacy. Despite receiving confirmation of the order, the medication was not delivered until 8/12/2024. The Director of Nursing confirmed that the facility's policy required medications to be reordered when there were five doses left, which was not followed in this case. The facility's policy emphasized timely medication ordering to ensure an adequate supply, which was not adhered to, resulting in the deficiency.
Resident-to-Resident Altercation and Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident struck another in the face with a closed fist. This incident involved two residents, where Resident 1, who had moderately intact cognition and required moderate assistance with daily activities, was wheeling his wheelchair in the dining room and accidentally bumped into Resident 2's wheelchair. Resident 2, who had fully intact cognition and required varying levels of assistance with personal care, became upset and punched Resident 1 in the face. The altercation was witnessed by a Certified Nursing Assistant (CNA), who confirmed that Resident 2 yelled and struck Resident 1. Interviews with the Social Services Director and the Director of Nursing corroborated the incident, with Resident 2 admitting to hitting Resident 1 due to feeling provoked. The facility's policy on abuse and mistreatment of residents emphasizes the right of residents to be free from abuse, yet this incident demonstrated a failure to uphold that policy.
Failure to Implement Infection Control Policy for C. Diff Positive Resident
Penalty
Summary
The facility failed to implement its infection control policy and procedures for isolation and transmission-based precautions for a resident who was positive for Clostridium Difficile (C. Diff). Upon re-admission, the resident was cohorted with another resident who did not require isolation and did not have a diagnosis of C. Diff. This action was contrary to the facility's policy, which mandates that residents with transmissible infections be placed in isolation to prevent the spread of infection. The infection preventionist and the director of nursing both acknowledged that the resident should have been placed in an isolation room immediately upon re-admission. The resident in question had a history of encephalopathy, enterocolitis due to C. Diff, and cirrhosis of the liver. The resident required significant assistance from staff for daily activities, including toileting hygiene and bathing. Despite a physician's order and a care plan indicating the need for contact and spore isolation, the resident was placed in a shared room with another resident who had severe cognitive impairment and required maximum assistance from staff for daily activities. Interviews with staff revealed that the infection preventionist had instructed the registered nurse supervisor to place the resident in an isolation room, but this was not done. The registered nurse involved could not recall the specific events but admitted to possibly making an error. The director of nursing confirmed that the facility's policy on isolation was not followed, thereby placing the second resident at risk for acquiring a C. Diff infection. The facility's policy clearly states that transmission-based precautions should be initiated for residents with confirmed infections to prevent transmission to others.
Failure to Conduct Annual TB Risk Assessment
Penalty
Summary
The facility failed to implement its Tuberculosis (TB) Infection Control Program by not conducting an annual TB Risk Assessment (TBRA). During an interview and record review, the Infection Preventionist (IP) admitted to not being aware of the facility's TB Risk Assessment policy. The IP stated that his focus had been on Covid and he had not reviewed all policies related to tuberculosis. Consequently, there was no documented evidence of any TB risk assessments being conducted. The Director of Nursing (DON) confirmed that the IP should have been aware of the TB policies to implement them effectively. The facility's policy, last reviewed on 3/15/2024, emphasized the importance of an annual TB Risk Assessment to evaluate the risk of TB transmission and establish appropriate controls. The lack of awareness and implementation of this policy had the potential to place residents at risk for tuberculosis.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 2,698 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Reseda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| 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 |
| Eisenberg Village | 1.8 mi | — | 22 | 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 August 2026) and official state health department websites.