Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 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 Topanga Terrace during CMS and state inspections, most recent first.
The facility failed to provide non-pharmacological interventions before administering opioid pain medication to two residents. Despite care plans and physician orders requiring such interventions, the MAR showed multiple instances where Hydrocodone-acetaminophen was given without prior non-drug methods. The DON confirmed the lack of adherence to the facility's pain assessment policy, resulting in a deficiency.
The facility failed to administer medications as prescribed for two residents, leading to potential health risks. One resident did not receive lorazepam at the prescribed time for anxiety management, and another resident was given metoprolol on dialysis days when it should have been withheld. These errors were confirmed by the nursing staff and were contrary to the facility's medication administration policies.
A facility failed to ensure non-pharmacological interventions were attempted before administering lorazepam to a resident with severe cognitive impairment and respiratory failure. Despite a care plan outlining interventions like repositioning and music therapy, documentation showed lorazepam was given without these attempts. Interviews with staff confirmed the importance of such interventions to avoid unnecessary medication and adverse effects, but the facility's policy lacked guidance on this practice.
The facility failed to develop comprehensive care plans for two residents, one with vision impairment and another using insulin for diabetes management. The first resident's visual impairment was not addressed in a care plan, despite being noted in assessments. The second resident's care plan did not reflect changes after the resident and family requested to discontinue blood sugar checks and insulin. The facility's policy on care planning was not followed, leading to deficiencies in person-centered care.
Two residents with limited English proficiency were not provided with communication boards at their bedsides, hindering their ability to communicate needs to staff. Despite facility policies ensuring access to communication aids, these residents faced challenges in expressing their needs, such as assistance when soiled, due to the absence of these aids.
A resident with visual impairment was not properly communicated to the nursing staff, resulting in a lack of care planning and increased risk of falls. Despite the resident's condition being noted in the Social Services-Admission-Evaluation, it was not shared with the Interdisciplinary Team, leading to a deficiency in care.
A resident with a history of diabetes, traumatic brain injury, and hypertension was administered Metoprolol despite a physician's order to hold the medication if the heart rate was below 60 bpm. On two occasions, the resident's heart rate was below this threshold, yet the medication was given, placing the resident at risk for bradycardia. This action was against the facility's medication administration policy.
A facility failed to follow its policy on storing and discarding leftover food brought by family for a resident. An observation revealed a resident had flan and a partially eaten enchilada on an overbed table, which were not labeled or refrigerated as required. The RN confirmed the food was unsafe and could cause foodborne illness, highlighting a lapse in adhering to food safety procedures.
The facility failed to follow infection control protocols in two cases: an LVN did not wear a gown while administering medication via a gastrostomy tube to a resident on enhanced barrier precautions, and another resident's oxygen tubing was found on the floor. These actions were contrary to the facility's policies, increasing infection risk.
A resident in an LTC facility did not receive the influenza vaccine as required by the facility's policies. The resident was admitted with several diagnoses and was dependent on staff for certain activities. The Infection Preventionist Nurse mistakenly documented the vaccine administration without obtaining informed consent from the resident or their Responsible Party. The Director of Nursing confirmed the oversight, which was contrary to the facility's policy requiring documentation and informed consent during the admission process.
A resident with chronic respiratory failure was not properly offered or documented as having received the COVID-19 vaccine, leading to uncertainty about its administration. The facility's records showed discrepancies, with the IP and DON unable to confirm the vaccine's administration. Additionally, no care plan was initiated to monitor adverse effects post-vaccination, contrary to the facility's policy.
The facility failed to report an injury of unknown source within the required two-hour timeframe to the SSA for a resident with severe cognitive impairment and an acute fracture. The DON stated the injury was considered pathological, but the resident could not describe the incident, and no witnesses were present. The facility's policy mandates immediate reporting, which was not followed.
Failure to Provide Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering as-needed opioid pain medication to two residents, Resident 204 and Resident 26. For Resident 204, the care plan initiated on 10/15/2024, indicated the use of non-pharmacological pain-relieving remedies such as positioning, relaxation therapy, and heat and cold application. However, the Medication Administration Record (MAR) showed that Hydrocodone-acetaminophen was administered multiple times without any documented attempts of non-pharmacological interventions. Licensed Vocational Nurse 1 confirmed that these interventions were not attempted, acknowledging the importance of such measures to prevent unnecessary medication and potential adverse side effects. Resident 26, who had diagnoses including chronic respiratory failure and pain in the leg, also did not receive non-pharmacological interventions prior to the administration of PRN pain medication. The care plan for Resident 26 included similar non-drug interventions, and the physician's orders required documentation of these attempts before administering medication. Despite this, the MAR indicated that Hydrocodone-acetaminophen was administered numerous times in September and October 2024 without prior non-pharmacological interventions. The Director of Nursing confirmed that the licensed staff did not offer any non-drug methods to reduce pain as ordered by the physician. The facility's policy and procedure on pain assessment, last reviewed in January 2024, emphasized the importance of assessing residents for pain and providing adequate management, including non-pharmacological interventions. The policy required documentation of the effectiveness of any interventions, whether medication or non-drug methods. The failure to adhere to these policies and procedures resulted in a deficiency, as the facility did not ensure that non-pharmacological interventions were attempted and documented before administering opioid pain medication to the residents.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to administer medications as prescribed for two residents, leading to potential health risks. For Resident 24, who was admitted with acute and chronic respiratory failure and had severely impaired cognition, the facility did not follow the physician's orders for administering lorazepam. The medication was prescribed to be given at midnight to manage anxiety, but it was administered at various other times without notifying the physician. This deviation from the prescribed schedule was acknowledged by the Licensed Vocational Nurse and the Director of Nursing, who confirmed that the nurses did not follow the physician's orders. For Resident 70, who was admitted with end-stage renal disease and other serious health conditions, the facility failed to hold doses of metoprolol as ordered on dialysis days. The medication was supposed to be withheld at 2:00 p.m. on days when the resident received dialysis, but it was administered on three occasions. This oversight was confirmed by the Licensed Vocational Nurse and the Director of Nursing, who acknowledged that administering metoprolol on dialysis days could lead to low blood pressure. The facility's policies and procedures for medication administration and care of dialysis residents were not adhered to in these cases. The policies clearly stated that medications should be administered according to the prescriber's written orders and that medications on dialysis days should only be held by physician's order. The failure to follow these guidelines resulted in the administration of medications contrary to the physician's orders, potentially compromising the residents' health.
Failure to Attempt Non-Pharmacological Interventions Before Administering Lorazepam
Penalty
Summary
The facility failed to ensure that licensed nurses attempted non-pharmacological interventions before administering as-needed lorazepam to a resident. The resident, who was admitted with acute and chronic respiratory failure and had severely impaired cognition, was dependent on staff for activities of daily living. The care plan for the resident included non-pharmacological interventions such as repositioning, deep breathing exercises, and music therapy to alleviate anxiety. However, the facility did not document attempts of these interventions before administering lorazepam on multiple occasions. During interviews, both the Licensed Vocational Nurse and the Director of Nursing acknowledged the importance of attempting non-pharmacological interventions prior to medication administration to prevent unnecessary use and potential adverse side effects. The facility's policy on psychoactive medications did not include guidance on non-pharmacological interventions, which contributed to the deficiency. This oversight had the potential to place the resident at increased risk of experiencing adverse side effects from lorazepam.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with vision impairment. The resident, admitted with diagnoses including depression and chronic respiratory failure, was found to have intact cognitive skills but was dependent on staff for various daily activities. Despite the resident's visual impairment being noted in the Social Services-Admission-Evaluation, there was no care plan initiated to address this condition. Licensed Vocational Nurse 1 confirmed the resident's inability to see clearly during an assessment, and it was acknowledged that a Change of Condition should have been triggered to assess the resident's needs and risks. The Social Services Director admitted to not discussing the resident's vision issues with the Interdisciplinary Team, resulting in a lack of a care plan to meet the resident's needs. The facility also failed to create an individualized care plan for a resident using insulin for diabetes management. The resident, admitted with type 2 diabetes and other conditions, was receiving insulin injections as per a sliding scale. However, after the resident and a family member requested to discontinue blood sugar checks and insulin administration, the facility did not update the care plan to reflect these changes. The Director of Nursing acknowledged that a care plan should have been developed to include goals and interventions for insulin use and to document the resident's refusal of blood sugar checks and insulin injections. This oversight resulted in a lack of monitoring and necessary services for the resident. The facility's policy on Interdisciplinary Team Guidelines and Care Planning, which emphasizes the inclusion of appropriate team members in the care planning process, was not followed in these cases. The policy requires that care plans include the resident's strengths, goals, life history, and preferences, and that residents and their representatives participate in establishing care goals and outcomes. The failure to adhere to these guidelines led to deficiencies in providing person-centered care for the residents involved.
Failure to Provide Communication Aids for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide communication devices or boards at the bedsides of two residents, Resident 22 and Resident 350, who had limited English proficiency. This deficiency was identified through observations, interviews, and record reviews. Resident 22, who was diagnosed with dementia and dysphagia, was noted to have a preferred language other than English and required an interpreter to communicate with healthcare staff. Despite this, no communication board was available at the resident's bedside, as confirmed by a registered nurse. The resident's care plan indicated a communication problem and the need for a communication board to maintain the current level of communication function. Similarly, Resident 350, who was admitted with type two diabetes mellitus, difficulty in walking, and spinal stenosis, also faced communication barriers due to language differences. The resident's care plan highlighted a communication problem and the need for a translator and communication board. However, during an observation, it was found that no communication board was present at the resident's bedside. The resident expressed difficulty in communicating with staff due to the language barrier, which led to unmet needs, such as being unable to verbalize the need for assistance when soiled. The facility's policy on Limited English Proficiency, last reviewed in January 2024, stated that reasonable steps would be taken to ensure meaningful access for individuals with limited English proficiency, including providing interpreters and communication aids at no cost. Despite this policy, the lack of communication boards for the two residents prevented effective communication with staff, potentially delaying necessary care and treatment.
Failure to Communicate Resident's Visual Impairment
Penalty
Summary
The facility's Interdisciplinary Care Team failed to effectively communicate and collaborate regarding a resident's visual impairment, leading to a deficiency in care. Resident 93, who was admitted with diagnoses including depression and chronic respiratory failure, was found to be visually impaired during an assessment. Despite this, the nursing staff was not informed of the resident's condition, and no care plan was developed to address the resident's visual impairment. This lack of communication and care planning was confirmed through interviews with the nursing staff and the Social Services Director, who acknowledged that the resident's visual impairment was not communicated to the Interdisciplinary Team or included in the care conference. The deficiency was further highlighted by the fact that the resident's visual impairment was noted in the Social Services-Admission-Evaluation but not communicated to the nursing staff, resulting in a lack of awareness and appropriate care planning. The facility's policies on care planning and fall/accident mitigation were not followed, as the resident's risk factors, such as potential falls due to visual impairment, were not addressed. This oversight had the potential to lead to serious injury for the resident due to the inability to see.
Failure to Adhere to Physician's Order for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the physician's order regarding the administration of Metoprolol. The resident, who was comatose and had a history of type 2 diabetes mellitus, traumatic brain injury, and hypertensive chronic disease, had a physician's order to hold Metoprolol if the heart rate was less than 60 beats per minute. However, on two occasions, the medication was administered despite the resident's heart rate being below the specified threshold. During a review of the Medication Administration Record for October 2024, it was found that the resident's heart rate was 50 bpm in the morning and 59 bpm in the evening on the same day, yet Metoprolol was administered both times. This action was contrary to the physician's order and placed the resident at risk for bradycardia, which could lead to serious health complications. The facility's policy on medication administration, which requires medications to be administered as prescribed, was not followed in this instance.
Failure to Follow Food Safety Procedures for Resident's Outside Food
Penalty
Summary
The facility failed to adhere to its policy regarding the storage and disposal of leftover food brought in by family members for a resident. During an observation and interview, it was noted that a resident had an overbed table with a clear cup containing flan and a container with a partially eaten enchilada, which were brought by the family the previous day. The Certified Nursing Assistant confirmed the presence of these food items, and the Registered Nurse verified that the food belonged to the resident. The facility's policy, last reviewed on January 17, 2024, mandates that prepared food brought in for residents must be consumed within one hour to prevent foodborne illness, with any unused food to be disposed of immediately. However, the food items in question were not labeled with a date or time, making it impossible to determine how long they had been in the resident's room. The Registered Nurse acknowledged that the food was not safe for consumption and could potentially cause foodborne illnesses, indicating a failure to follow the facility's food safety procedures.
Infection Control Lapses in Medication Administration and Oxygen Tubing Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed in two instances. In the first instance, a Licensed Vocational Nurse (LVN 3) did not don a gown before administering medications via a gastrostomy tube to a resident on enhanced barrier precautions (EBP). This resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, was readmitted with conditions including chronic respiratory failure and dependence on a ventilator. Despite a sign indicating EBP requirements and the facility's policy mandating gown use for high-contact activities, LVN 3 administered the medication without wearing a gown, acknowledging the oversight during an interview. In the second instance, the facility did not maintain proper infection control regarding a resident's oxygen tubing. The resident, admitted with atrial fibrillation and pneumonitis, was observed with their nasal cannula oxygen tubing on the floor. A Licensed Vocational Nurse (LVN 4) confirmed the observation and stated the need to replace the tubing. The Director of Nursing (DON) later affirmed that oxygen tubing should be kept off the floor to prevent infection, aligning with the facility's standard precautions policy. These deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in adherence to infection control protocols. The facility's policies on enhanced barrier precautions and standard precautions were not followed, increasing the risk of infection for the residents involved.
Failure to Administer and Document Influenza Vaccine
Penalty
Summary
The facility failed to implement its policies and procedures related to the influenza vaccine for one of the sampled residents, identified as Resident 93. The deficiency was identified during an interview and record review, which revealed that Resident 93 was admitted to the facility with diagnoses including encephalopathy, abnormal posture, and depression. The Minimum Data Set (MDS) indicated that Resident 93 had intact cognitive skills for daily decision-making but was dependent on staff for certain activities. Despite this, the resident was not in the facility during the influenza vaccination season, and there was no documentation of the influenza vaccine being administered to Resident 93 on the Medication Administration Record (MAR) for the specified date. The Infection Preventionist Nurse (IP) acknowledged that there was no informed consent obtained from Resident 93 or her Responsible Party (RP) regarding the administration of the influenza vaccine. The IP admitted to mistakenly documenting that the vaccine was administered. The Director of Nursing (DON) confirmed that licensed staff are required to offer the influenza vaccination to all residents upon admission, but Resident 93 did not receive it. The facility's policy indicated that residents or their responsible parties should be informed about the vaccinations during the admission process, and documentation should be promptly recorded in the MAR, which was not adhered to in this case.
Failure to Administer and Document COVID-19 Vaccine
Penalty
Summary
The facility failed to offer the COVID-19 vaccination to a resident, identified as Resident 43, which placed the resident at a higher risk of acquiring and transmitting the virus. Resident 43 had been admitted to the facility with chronic respiratory failure and was dependent on a respirator. The resident's cognitive skills were intact, and they were dependent on staff for daily activities. The facility's records indicated that a verbal consent for the COVID-19 vaccine was obtained from the resident's family member, and the vaccine was reportedly administered on a specific date. However, discrepancies were found in the documentation regarding the administration of the vaccine. The Immunization Record suggested that the Infection Preventionist Nurse (IP) administered the vaccine, but the Medication Administration Record (MAR) did not reflect this, and the progress notes indicated that another nurse administered the vaccine. Both the IP and the Director of Nursing (DON) were unable to confirm who administered the vaccine or if it was administered at all. The responsible party for Resident 43 also expressed uncertainty about whether the vaccine was given. Additionally, the facility failed to initiate a care plan to monitor potential adverse effects following the administration of the COVID-19 vaccine to Resident 43. The IP acknowledged that normally a care plan would be developed post-vaccine administration, but this was not done for Resident 43. The facility's policy required efforts to vaccinate unvaccinated residents within a week of admission, but it appears this was not effectively implemented for Resident 43.
Failure to Report Injury of Unknown Source Within Required Timeframe
Penalty
Summary
The facility failed to implement its policy and procedures for reporting a reasonable suspicion of a crime in accordance with Section 1150B of the Act. Specifically, the facility did not report an injury of unknown source within two hours to the State Survey Agency (SSA) for a resident who was observed with left hand swelling, purplish discoloration, and pain. The resident, who had severe cognitive impairment and required extensive assistance with daily activities, was found to have an acute fracture of the 4th metacarpal. Despite the injury being identified on 4/10/2024, the facility did not report it to the SSA until 4/16/2024, well beyond the required two-hour window. The Director of Nursing (DON) stated that the facility did not report the injury within the required timeframe because they determined it was a pathological fracture rather than a result of abuse or mistreatment. However, the resident was unable to describe what happened, and no staff or other residents witnessed the incident. The facility's policy mandates immediate reporting of any injury of unknown source to local law enforcement and the SSA within two hours, which was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Canoga Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Hills Health And Rehabilitation Center | 0.4 mi | — | 14 | 0 |
| Canyon Oaks Nursing And Rehabilitation Center | 0.8 mi | — | 5 | 0 |
| West Valley Post Acute | 1.4 mi | — | 4 | 0 |
| Holiday Manor Care Center | 1.7 mi | — | 5 | 0 |
| Stoney Point Healthcare Center | 2.5 mi | — | 2 | 0 |
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