Deficiency Records for Tarzana Health and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Tarzana Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-05 | 2024-02-26 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-05 | 2024-02-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-19 | 2024-02-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-19 | 2024-02-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-17 | 2023-12-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-17 | 2023-12-10 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-07 | 2023-11-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-07 | 2023-11-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-24 | 2023-11-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-19 | 2023-10-12 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-16 | 2023-09-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-27 | 2023-08-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-27 | 2023-08-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-27 | 2023-08-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-30 | 2023-04-13 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-27 | 2023-03-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-15 | 2023-02-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-23 | 2023-02-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-05 | 2022-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-03 | 2022-08-16 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-07-24 | 2022-08-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-05 | 2022-07-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-16 | 2022-03-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-16 | 2022-03-09 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-02-22 | 2022-03-04 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-02-22 | 2022-03-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-26 | 2022-02-09 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-12-10 | 2022-01-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-05 | 2021-12-05 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-11-05 | 2021-12-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-05 | 2021-12-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-05 | 2021-12-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-05 | 2021-12-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-05 | 2021-12-05 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-11-05 | 2021-12-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-05 | 2021-12-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-05 | 2021-12-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-05 | 2021-12-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-05 | 2021-12-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-05 | 2021-12-05 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-11-05 | 2021-12-05 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-11-05 | 2021-12-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-05 | 2021-12-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-05 | 2021-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-05 | 2021-12-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-10 | 2021-11-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-10 | 2021-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-10 | 2021-11-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-09 | 2021-11-18 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-10-28 | 2021-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-10 | 2021-08-19 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-07-13 | 2021-07-30 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-07-17 | 2021-07-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-17 | 2021-07-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-07 | 2021-07-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-07 | 2021-07-16 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-06-07 | 2021-07-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-02 | 2021-06-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-07 | 2021-06-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-03 | 2021-06-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-05 | 2021-05-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-06 | 2021-05-11 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-07-02 | 2019-08-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-02 | 2019-08-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-02 | 2019-08-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-07-02 | 2019-08-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-02 | 2019-08-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-02 | 2019-08-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-02 | 2019-08-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-02 | 2019-08-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-02 | 2019-08-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-02 | 2019-08-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-02 | 2019-08-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-02 | 2019-08-23 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-07-02 | 2019-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-02 | 2019-08-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-02 | 2019-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-02 | 2019-08-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-03 | 2019-08-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Establish methods for sharing information. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-20 | 2018-08-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-07-12 | 2018-08-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-12 | 2018-08-11 | N |
| Provide activities to meet all resident's needs. | Health | 2018-07-12 | 2018-08-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-12 | 2018-08-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-07-12 | 2018-08-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-12 | 2018-08-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-07-12 | 2018-08-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-07-12 | 2018-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-12 | 2018-08-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-12 | 2018-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-12 | 2018-08-11 | N |
