Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the facility had arranged provisions of hospice (a
type of medical care for residents who are in the last stages of life) services by failing to:
1. Ensure hospice staff signed the hospice Interdisciplinary Team Sign-in Sheet upon arriving to the facility
for one of three sampled residents (Resident 1).
2. Ensure a hospice Interdisciplinary Team Sign in Sheet was placed in the chart for one of three sampled
residents (Resident 3).
3. Ensure the hospice agency provided training programs in hospice care for facility staff per contractual
agreement.
This deficient practice has the potential to negatively affect Resident 1 and Resident 3's physical comfort,
psychosocial (the state of mental, emotional, and social health of an individual) well-being, and has the
potential to delay or have a lack of necessary care and services.
Findings:
1. A review of Resident 1's Face Sheet indicated the facility originally admitted the resident on 12/2/2013
with diagnoses that included Alzheimer's disease (progressive disease that destroys memory and other
important mental functions), dementia (group of thinking and social symptoms that interferes with daily
functioning), psychotic disturbance (disconnection from reality), mood disturbance (disorder in which you
experience long periods of extreme happiness, extreme sadness or both), anxiety (intense, excessive, and
persistent worry and fear about everyday situations), and hypertensive and chronic kidney disease (high
blood pressure caused by damaged kidney ) with heart failure (condition in which the heart doesn't pump
blood as well as it should).
A review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool), dated
3/30/2024, indicated Resident 1's cognition (the mental action or process of acquiring knowledge and
understanding through thought, experience, and the senses) with skills required for daily decision making
was severely impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) with
eating, oral hygiene, toileting, and personal hygiene.
A review of Resident 1's Physician's Orders indicated an order to admit the resident to hospice care, dated
5/17/2024.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
055013
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eisenberg Village
18855 Victory Bl
Reseda, CA 91335
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview and concurrent record review with the Director of Nursing (DON) on 5/29/2024 at 6:01
p.m., the DON stated when hospice staff arrive in the facility, hospice staff are to sign-in on the hospice
sign-in sheet located in the residents' hospice binder. The DON stated that signing in in the hospice sign-in
sheet ensures that hospice staff was physically in the facility to provide hospice care to the resident.
During an interview and concurrent record review with the DON on 5/29/2024 at 6:19 p.m., the DON
reviewed Resident 1's hospice admission orders and stated that Resident 1 was admitted under hospice
care on 5/18/2024. The DON then reviewed Resident 1's hospice sign-in sheet titled Interdisciplinary Team
Sign-in Sheet that was located inside Resident 1's hospice binder. The DON stated that there was no
documented evidence that hospice staff was in the facility on 5/18/2024 when Resident 1 was admitted to
hospice.
2. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 3/1/2023 with
diagnoses that included Alzheimer's disease, dementia, and chronic (constant) pain.
A review of Resident 3's MDS dated [DATE], indicated Resident 3's cognition with skills required for daily
decision making was severely impaired. The MDS indicated Resident 3 required setup or clean-up
assistance (helper sets up or clean up; resident completes activity) with eating, oral hygiene and required
substantial or maximal assistance with toileting and personal hygiene.
A review of Resident 3's Physician's Orders indicated an order to admit the resident to hospice care, dated
4/23/2024.
During an interview and concurrent record review with the DON on 5/29/2024 at 6:30 p.m., the DON
reviewed Resident 3's hospice binder. The DON stated that there was no hospice sign-in sheet titled
Interdisciplinary Team Sign-in Sheet in Resident 3's hospice binder. The DON further stated that there was
no documented evidence that hospice staff was in the facility to provide hospice care to Resident 3 from
4/23/2024 to 5/8/2024.
During an interview and concurrent record review with the Medical Records Team Leader (MRTM) on
5/29/2024 at 6:45 p.m., the MRTM reviewed Resident 3's hospice binder and stated she was unable to find
the hospice sign-in sheet titled Interdisciplinary Team Sign-in Sheet that hospice staff is supposed to sign
upon arrival to the facility. MRTM stated that MRTM was unaware that the hospice binder had to have a
sign-in sheet for hospice staff.
During an interview with the DON on 5/29/2024 at 6:50 p.m., the DON stated that it is the responsibility of
the medical records department to ensure hospice sign-in sheets are in the hospice binder so that hospice
staff can sign in. The DON stated that medical records should have conducted audits to ensure sign-in
sheets are present and signed in all hospice binders. The DON stated that it is important to ensure hospice
sign in sheets are signed when hospice staff are in the facility because it is used to validate and confirm
hospice visits.
A review of the facility's policy and procedure titled Hospice with a revision date of 10/11/2021 indicated
that the facility is to facility hospice services for residents in accordance with state and federal law through
contracted licensed vendors.
3. During an interview with Certified Nursing Assistant 1 (CNA 1) on 5/31/2024 at 8:40 a.m., CNA 1 stated
that she (CNA 1) has cared for hospice residents in the facility. When asked if CNA 1
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055013
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eisenberg Village
18855 Victory Bl
Reseda, CA 91335
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
received any type of training from the hospice agency, CNA 1 stated that she has not received any trainings
directly from the hospice agency.
During an interview with Certified Nursing Assistant 2 (CNA 2) on 5/31/2024 at 9:35 a.m., CNA 2 stated
that she (CNA 2) has cared for hospice residents in the facility. When asked if CNA 2 received any type of
training from the hospice agency, CNA 2 stated that she has not received any trainings directly from the
hospice agency.
During an interview and concurrent record review with the DON on 5/31/2024 at 11:35 a.m., reviewed the
hospice contract signed on 7/24/2017. DON stated that the contracted hospice agency does not provide
any training programs to facility staff. The DON read the hospice contract signed on 7/24/2017. The DON
stated that the DON was not aware of the Training Program aspect of the hospice contract. When asked
what the importance of hospice training from the contracted hospice agency is, the DON stated that it is
important for the contracted hospice agency to provide training programs to the facility staff so that the
hospice agency and the facility staff can work collaboratively with the plan of care for each resident on
hospice and provide quality care.
A review of the facility's hospice contract titled Hospice and Facility Skilled Nurse Facility (SNF) Service
Agreement, addendum date signed 7/24/2017, indicated under training programs: Hospice shall provide
training programs in hospice care for facility staff involved in furnishing care to patients pursuant to this
agreement.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055013
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
FAQ · About this visit
Common questions about this visit
What happened during the May 31, 2024 survey of EISENBERG VILLAGE?
This was a inspection survey of EISENBERG VILLAGE on May 31, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EISENBERG VILLAGE on May 31, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.