Topanga Terrace

Inspectors wroteBased on interview and record review, the facility failed to arrange transportation for an Ophthalmology (the specialized branch of medicine focused on the comprehensive care of the eyes) appointment for one of four sampled residents (Resident 4) after the physician ordered the appointment on 6/10/2026 following the resident's admission to the facility. This deficient practice resulted in Resident 4 missing her Ophthalmology appointment resulting in a delay in services that Resident 4 need. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when there were soiled gloves on the floor in the dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) floor area. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 99 of 99 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents containing protected health information ([PHI]- any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 61 of 99 residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for three (Resident 42, Resident 118 and Resident 63) of seven residents reviewed under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) care area by failing to keep Resident 63, 42 and 118's urinary catheter tubing from coiling and allowing the contents to flow freely into the urinary catheter bag (container that connects to a urinary catheter and collects urine). This deficient practice had the increased potential for Resident 63, 42 and 118 to develop a UTI.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 2 (LVN 2) administered Midodrine (a medication used to treat hypotension [low blood pressure]) within the prescribed parameters (a set of defined limits) for one of three sampled residents (Resident 7). This deficient practice had the potential to place Resident 7 at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) which can lead to possible medical complications and/or hospitalization. 2. Ensure one of three sampled residents (Resident 57) was administered medication in accordance with the physician's orders when the resident's lidocaine patch (a patch applied to the skin that treats pain) was not removed 12 hours after application as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the recipe and did not meet the nutritional needs of residents when [NAME] 1 used water instead of warm milk for puree pasta and butter and water instead of milk, gravy, or low sodium broth for puree meat sauce. This failure had the potential to decrease in flavor and nutrient intake of protein and calories resulting in unplanned weight loss to 12 of 99 residents on puree (foods that are smooth and pudding like consistency) diet getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Ice builds up on the freezer pipes and the air curtains in the walk-in freezer. 2. Food storage racks were not six (6) inches above the floor. a. One (1) rack was four (4) inches from the floor, and the other rack was five (5) inches in the walk-in freezer. b. Two (2) racks were 5 inches from the floor in the dry storage area. 3. Kitchen equipment and utensils were not smooth and not free from cracks and chips a. One (1) green rack in the walk-in freezer and 6 green racks in the walk-in refrigerator were not smooth, had cracks and chips, orange and black discoloration and rust. b. Brown, blue and green chopping board had scratches and chips. c. Can opener blade was rusted. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 25 sampled residents (Resident 74's) diagnosis of depression was reflected in the resident's list of diagnoses in the Minimum Data Set (MDS - a resident assessment tool). This failure resulted in Resident 74 having an inaccurate MDS assessment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan based on the resident's individual assessed needs for one of 25 sampled residents (Resident 7) by failing to develop a care plan addressing Resident 7's use of Midodrine (a medication used to treat hypotension [low blood pressure]). This deficient practice had the potential to negatively affect the provision of care and services provided to Resident 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident receives 31% Fraction of Inspired Oxygen (proportion of oxygen in the air mixture that is delivered to a patient) via a mist collar (medical device that delivers humidified air or oxygen to a patient's airway through a tracheostomy [an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe]) tube as ordered by the physician for one of one resident (Resident 103). This deficient practice had the potential to cause Resident 103 to have shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood).

Inspectors wroteBased on interview and record review, the facility failed to follow their policy by failing to ensure documentation of completion of training/competency for one of three sampled hemodialysis (HD- the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) staff (Hemodialysis Technician [HD Tech]). This deficient practice violated the facility's policy and procedures (P&P), titled, Personnel Files, and had the potential for providing unsafe care to dialysis residents and as well as safety risk for both residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure by failing to ensure that providers signed telephone orders within five (5) days for two of four sampled residents (Resident 27 and Resident 92). This deficient practice resulted in a deviation from the facility's own policy and had the potential to cause delays in necessary services and continuity of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing information was posted daily (on 11/17/2025). As a result, the resident census and the actual hours worked by licensed and unlicensed nurses were not readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for two of 25 sampled residents (Residents 11 and 74) by: Failing to document Resident 11's blood pressure (the force your heart uses to send blood pumping through your body) prior to giving the resident metoprolol (a blood pressure lowering medication) on 9/9/2025 during medication review. This deficient practice resulted in inaccurate documentation in Resident 11's medical record and placed Resident 11 at risk for hypotension (low blood pressure). 2. Failing to ensure Resident 74's diagnosis of depression was reflected in the resident's list of diagnoses in the medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain appropriate infection control practices for two of two sampled residents (Resident 2 and 34) when a work computer laptop was observed placed on top of a soiled linen hamper (a large, lidded container designated for dirty linen). This deficient practice had the potential to cause cross contamination (transfer of bacteria or other microorganisms from one place to another) and the spread of infection for residents, staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to offer an updated Coronavirus Disease (COVID-19, a severe respiratory illness caused by virus and transmitted from person to person) vaccination to one of five sampled residents (Resident 2). This deficient practice placed Resident 2 at a higher risk of acquiring (to get) and transmitting (pass on) the COVID-19 virus to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid pain medication (treats moderate to severe pain) to a resident for two of 30 sampled residents (Resident 204 and 26). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview and record review, the facility failed to ensure that two of 30 sampled residents (Residents 24 and 70) were administered medications as prescribed by the physician when: 1. Lorazepam (anti-anxiety medication) was not administered to Resident 24 in accordance with physician's orders. 2. Three doses of metoprolol (a medication that treats high blood pressure, chest pain, and heart failure) were not held as ordered when Resident 70 received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). These deficient practices had the potential to place Resident 24 at increased risk of being given extra doses of lorazepam and Resident 70 to experience low blood pressure.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) lorazepam (medication used to treat anxiety disorder [intense, excessive, and persistent worry and fear about everyday situations]) to a resident for one of 30 sampled residents (Resident 24). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from lorazepam.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) addressing the resident`s vision impairment (occurs when an eye condition affects the visual system and its vision functions) for one of one sampled resident (Resident 93). 2. Develop individualized person-centered care plan for insulin (a medication used in the treatment and management of diabetes mellitus[DM- a disease that occurs when the sugar level is high in the blood]) use for one of ten sampled residents (Resident 67). These deficient practices had the potential to result in failure to deliver the necessary care and services for Resident 93 and had the potential to lead to the inadequate care of Resident 67.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) at their bedsides in the language that the residents were able to understand for two of four sampled residents (Resident 22 and Resident 350). These deficient practices prevented the residents from communicating with the staff and had the potential to delay receiving care/treatment the residents needed.

Inspectors wroteBased on observation, interview and record review, the facility`s Interdisciplinary Care Team (a group of professionals from different disciplines who work together to treat a patient's condition) failed to collaborate and communicate with the care team members the resident`s concern about her vision loss for one of one sampled resident (Resident 93). This deficient practice resulted in nurses` not being aware of the resident`s visual function status which has the potential for the resident to fall and suffer serious injury due to inability to see.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents Resident 65 was free from significant medication error by failing to ensure metoprolol (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order with parameter to hold (do not give) the medication if Resident 65's heart rate is less than 60 beats per minute (bpm-a normal resting heart rate for adults ranges from 60 to 100 beats per minute). This deficient practice placed Resident 65 at risk for bradycardia (low heart rate- can be life threatening if the heart is unable to maintain a rate that pumps enough oxygen-rich blood throughout the bod) which could lead to shortness of breath, chest pain, fatigues, and dizziness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure leftover food brought from outside was stored in the refrigerator or discarded per facility policy for one of one sampled resident (Resident 43) investigated under Food Safety Requirement. This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for Resident 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 3 (LVN 3) donned (put on) a gown prior to administering medications to a resident via gastrostomy tube (GT - a small tube that is surgically inserted into the stomach through the abdomen to provide nutrition, fluids, and medication) who was on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - bacteria that are resistant to three or more classes of antimicrobial drugs] in nursing homes) for one of 30 sampled residents (Resident 77). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures related to the influenza (a high contagious viral infection of the respiratory passages) vaccine for one of five sampled residents (Resident 93). This deficient practice placed Resident 93 at an increased risk of acquiring (to get) and transmitting (pass on) the influenza virus to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to offer the Coronavirus Disease (COVID-19, a severe respiratory illness caused by virus and transmitted from person to person) vaccination to one of five sampled residents (Resident 43). This deficient practice placed Resident 43 at a higher risk of acquiring (to get) and transmitting (pass on) the COVID-19 virus to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an injury of unknown source within two (2) hours for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' room temperatures at a range between 71 and 81 degrees Fahrenheit (° F, a measurement of temperature) for four of four sampled residents (Resident 354, 59, 105, and 104). This deficient practice resulted in increased levels of discomfort for the residents and had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Long-Term Care (LTC) Ombudsman (advocates for residents of nursing homes, board and care homes, and assisted living facilities) of the transfers and discharges from the facility for 12 of 12 sampled residents (Resident 102, 304, 306, 307, 308, 309, 310, 311, 312, 313, 76, and 91) investigated addressing the care area of discharge. These deficient practices had the potential to deny residents protection from being inappropriately discharged .

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for two of two sampled residents (Resident 81 and 32) by: 1. Failing to ensure nurses rotated injection sites when administering Lovenox (enoxaparin - medication that decreases the ability of blood to clot) for Resident 81. 2. Failing to ensure nurses rotated injection sites when administering insulin (hormone that lowers the level of glucose [sugar] in the blood) NPH Isophane (intermediate-acting insulin) and Regular suspension (short-acting insulin) 70-30 (combination of 70% NPH insulin and 30% regular insulin) for Resident 32. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%-unit of measure). Five (5) medication errors out of 36 opportunities contributed to an overall medication error rate of 13.8% affecting three of 10 sampled residents (Resident 11,35, and 46) observed for medication administration. The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Residents 11, 35, and 46 may have experienced health complications related to incorrect medication administration which could have negatively impacted their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that six of six sampled residents (Resident 54, 36, 52, 49, 47, and 2) were free from significant medication errors by: a) Failing to ensure that Amlodipine besylate (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order with a parameter to hold (do not give) the medication if Resident 54's systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart] when your heart beats) was less than 110 millimeters of mercury (mmHg-a unit of measure). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure one of six medication carts (Med Cart 5) was locked and secure and was under direct observation of authorized staff in an area where residents could access it. 2. Ensure one of five sampled residents' (Resident 314) fluticasone-salmeterol (medications to help relieve shortness of breath) and budesonide-formoterol fumarate dihydrate (medication that helps with breathing by decreasing the inflammation in the lungs) inhalers were labeled with an open date according to manufacture guidelines. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices by failing to: 1. Ensure hand hygiene (cleaning one's hands that substantially reduces potential pathogens [harmful microorganisms] on the hands) was done for two of two sampled residents (Resident 44 and 34). Hand hygiene was not performed after giving pain medication to Resident 44 and before preparing Resident 34's gastrostomy (GT-tube inserted through the belly that brings nutrition directly to the stomach) feeding. 2. Ensure hand hygiene was done for two of two sampled residents (Resident 17 and 40). Hand hygiene was not performed after turning off Resident 17's GT feeding pump and before preparing Resident 40's medications. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship (actions designed to use antibiotic [medications that fight bacterial infections] medications effectively while reducing the possibility of being prescribed an unnecessary medication) program by failing to conduct infection surveillance and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for four of five sampled residents (Residents 43, 47, 76, 87). This deficient practice had the potential for Residents 43, 47, 76 and 87 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use for future infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Certified Nursing Assistant 2 (CNA 2) was seated and at eye level while assisting a resident with feeding for one of one sampled residents (Resident 32) investigated for dignity. This deficient practice had the potential to affect Resident 32's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers [a wound that occurs as a result of prolonged pressure on a specific area of the body]) was set according to the resident's weight and comfort for one of two sampled residents (Resident 94). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure only medications that were administered were documented in the Medication Administration Record (MAR-report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) for two of ten sampled residents (Residents 11 and 35) observed for medication administration. This deficient practice resulted in residents' medical records that were not accurate and not in accordance with professional standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documented evidence that the pneumococcal vaccine (prevents infection from pneumonia [infection that infects one of both lungs]) was offered to one of five sampled residents (Resident 34). This deficient practice placed Resident 34 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility.